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Nemtut DM, Petreanu CA, Ulmeanu R, Rajnoveanu AG, Rajnoveanu RM. Life expectancy in cancer patients with pulmonary thromboembolism: From clinical prognostic biomarkers and paraclinical investigations to therapeutic approaches (Review). Exp Ther Med 2024; 28:354. [PMID: 39071911 PMCID: PMC11273361 DOI: 10.3892/etm.2024.12643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 06/19/2024] [Indexed: 07/30/2024] Open
Abstract
Pulmonary embolisms (PEs) are obstructions of the pulmonary arteries by thrombi, which are emboli and they most frequently originate from the deep venous system of the inferior limbs. Emboli can also come from the inferior vena cava, abdominal and pelvic veins, or the upper body venous system from the right atrium or ventricle of the heart. Thrombi can form in situ inside pulmonary arteries as well. A cancer patient is at a higher risk for thromboembolic phenomena given both the oncological pathological context and also due to the associated medical or surgical treatment they receive. PE is a high-risk medical emergency that is associated with an increased risk of early mortality, with sudden death occurring in 25% of patients. The long-term presence of this condition can result in thromboembolic pulmonary hypertension. The risk of mortality, both in the acute and long-term, is dependent on the severity of the acute form, the recurrence of the embolism and the associated conditions. The majority of deaths associated with PE can be prevented by early diagnosis. The aim of the present review was to describe the various biological and cellular parameters, together with known paraclinical investigations, to assist in the rapid diagnosis of PE. Mortality in patients with PE and neoplastic conditions may be reduced by initiating anticoagulant treatment as soon as possible. PE may be the first manifestation of an underlying silent malignancy or may represent a complication of an already diagnosed malignancy. Exclusion or confirmation of the diagnosis is of utmost importance to avoid unnecessary anticoagulant treatment associated with a high risk of bleeding or to start immediate anticoagulant treatment if required.
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Affiliation(s)
| | - Cornel Adrian Petreanu
- Thoracic Surgery Department, Pneumology Institute Marius Nasta, Bucharest 050159, Romania
| | - Ruxandra Ulmeanu
- Bronchoscopy Department, North Hospital, Provita Medical Group, Bucharest 020335, Romania
- Doctoral School of Biomedical Sciences, Faculty of Medicine and Pharmacy, University of Oradea, Oradea 410073, Romania
| | - Armand Gabriel Rajnoveanu
- Occupational Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca 400012, Romania
| | - Ruxandra Mioara Rajnoveanu
- Palliative Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy Cluj-Napoca 400012, Romania
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Spannbauer A, Bergler-Klein J. Cardio-Oncology: A New Discipline in Medicine and Its Relevance to Hematology. Hamostaseologie 2024; 44:255-267. [PMID: 38723641 DOI: 10.1055/a-2284-5855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024] Open
Abstract
Cardio-oncology, a burgeoning subspecialty, addresses the complex interplay between cardiology and oncology, particularly in light of increased cardiovascular (CV) disease mortality in cancer patients. This review provides a comprehensive overview of cardio-oncology with a focus on the therapies used in hematological malignancies. We explore the bidirectional relationship between heart failure and cancer, emphasizing the need for collaborative care. The review discusses risk stratification, highlighting the importance of baseline CV risk assessment and personalized surveillance regimens. Primary and secondary prevention strategies, including pharmacological interventions, are outlined. The review also delves into the cardiotoxicity associated with hematological cancer therapies, focusing on anthracyclines, Bruton kinase inhibitors, BCR-ABL tyrosine kinase inhibitors, CAR-T cell therapy, immune checkpoint inhibitors, multiple myeloma treatments, and hematopoietic stem cell transplantation. We then highlight the high risk of venous and arterial thromboembolisms in cancer patients and the challenges of anticoagulation management in cardio-oncology. Finally, the review touches on the importance of long-term follow-up and appropriate screening in cancer survivors at high risk of CV morbidity and mortality, based on their CV risk profile and the type and dose of cardiotoxic therapies they received such as anthracyclines or high radiation doses.
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Kang W, Huang C, Yan VKC, Wei Y, Shami JJP, Li STH, Yang Y, Ye X, Tang J, Lee SF, Lee VHF, Chan SL, El Helali A, Lam KO, Ngan RKC, Wong ICK, Chan EW. Effectiveness and safety of continuous low-molecular-weight heparin versus switching to direct oral anticoagulants in cancer-associated venous thrombosis. Nat Commun 2024; 15:5657. [PMID: 38969649 PMCID: PMC11229502 DOI: 10.1038/s41467-024-50037-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 06/25/2024] [Indexed: 07/07/2024] Open
Abstract
Given the existing uncertainty regarding the effectiveness and safety of switching from low-molecular-weight heparin (LMWH) to direct oral anticoagulants (DOACs) in patients with cancer-associated venous thrombosis (CAT), we conducted a comprehensive population-based cohort study utilizing electronic health database in Hong Kong. A total of 4356 patients with CAT between 2010 and 2022 were included, with 1700 (39.0%) patients switching to DOAC treatment. Compared to continuous LMWH treatment, switching to DOACs was associated with a significantly lower risk of hospitalization due to venous thromboembolism (HR: 0.49 [95% CI = 0.35-0.68]) and all-cause mortality (HR: 0.67 [95% CI = 0.61-0.74]), with no significant difference in major bleeding (HR: 1.04 [95% CI = 0.83-1.31]) within six months. These findings provide reassurance regarding the effectiveness and safety of switching from LMWH to DOACs among patients with CAT, including vulnerable patient groups.
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Affiliation(s)
- Wei Kang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Caige Huang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Vincent K C Yan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yue Wei
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Jessica J P Shami
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Silvia T H Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yu Yang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Xuxiao Ye
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Junhan Tang
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Shing Fung Lee
- Department of Radiation Oncology, National University Cancer Institute, National University Hospital, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Victor H F Lee
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Stephen L Chan
- State Key Laboratory of Translational Oncology, Department of Clinical Oncology, Hong Kong Cancer Institute, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Aya El Helali
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ka On Lam
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Clinical Oncology Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Roger K C Ngan
- Department of Clinical Oncology, School of Clinical Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China
- School of Pharmacy, Aston University, Birmingham, B4 7ET, England
- School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Macau SAR, China
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong SAR, China.
- The University of Hong Kong Shenzhen Institute of Research and Innovation, Shenzhen, China.
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
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Wee B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY, Lui B. A ten-year comparison of treatment and outcomes of cancer-associated thrombosis to non-cancer venous thromboembolism: from traditional anticoagulants to direct oral anticoagulants. J Thromb Thrombolysis 2024; 57:658-667. [PMID: 38393675 DOI: 10.1007/s11239-023-02943-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 02/25/2024]
Abstract
DOACs have emerged as first-line treatment in most cancer-associated thrombosis (CAT), representing a paradigm shift in its management. However, CAT management remains challenging and requires careful risk-benefit considerations. A retrospective analysis of CAT presentations to a tertiary referral centre from January 2011 to December 2020. Outcomes in CAT patients were compared to VTE patients without malignancy. Subgroup analysis was also conducted for CAT according to anticoagulation type. 514 CAT cases from 491 patients were identified from 3230 total VTE cases. CAT patients had higher rates of major VTE (PE and/or proximal DVT) compared to patients without malignancy (78.4% vs. 66.8%, p < 0.001). CAT patients also had higher rates of VTE recurrence (HR 1.66, 95%CI 1.23-2.26), major bleeding (HR 3.41, 95%CI 2.36-4.93), VTE-related mortality (HR 2.59, 95%CI 1.46-4.62) and bleeding-related mortality (HR 2.66, 95%CI 1.05-6.73). There were no significant differences in rates of VTE recurrence, major bleeding, VTE-related mortality or fatal bleeding between CAT patients treated with DOACs, enoxaparin or warfarin. In the subgroup of CAT treated with DOACs, there was no significant difference in rates of GI bleeding compared to the enoxaparin subgroup (HR 0.17, 95%CI 0.02-1.26). CAT was associated with a larger clot burden and higher rates of VTE recurrence, major bleeding and mortality compared to VTE patients without malignancy in this large real-world study. This study demonstrated no significant differences in complication rates for CAT patients treated with DOACs over enoxaparin, suggesting that DOACs can be safely used in most cases of CAT.
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Affiliation(s)
- Benjamin Wee
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia.
| | - Jeffrey Lai
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Zille Khattak
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | - Anna Kwok
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
| | | | - Prahlad Ho
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Hui Yin Lim
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
- Department of Medicine (Northern Health), University of Melbourne, Heidelberg, VIC, Australia
| | - Brandon Lui
- NorthErn Clinical Diagnostics and ThrombovAscular Research (NECTAR) Centre, Northern Health, 185 Cooper St, Epping, VIC, 3076, Australia
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Cohen AT, Noxon V, Dhamane AD, Shah S, Hines DM, Alfred T, Luo X. Effectiveness and safety of anticoagulants among patients with venous thromboembolism and common cancers or cancers with high venous thromboembolism risk. Future Oncol 2024; 20:521-532. [PMID: 38197229 DOI: 10.2217/fon-2022-1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Abstract
Aim: Treatment effects among anticoagulant-treated patients with venous thromboembolism (VTE) and cancer across tumor types were evaluated. Methods: Patients initiating an anticoagulant within 30 days after VTE were identified. After inverse probability treatment weighting, patients were stratified by tumor type. Interactions between treatment and tumor type on recurrent VTE, major bleeding and clinically relevant non-major bleeding were assessed using Cox proportional hazard models. Results: Treatment effects were generally not significantly different among patients with or without the following cancer types: prostate, breast, lung, pancreatic or multiple myeloma. Few significant interactions were observed for lung and pancreatic cancer. Conclusion: Anticoagulant treatment effects were generally consistent across tumor types. The significant interactions may indicate tumor-specific effects of anticoagulants, but further research is needed.
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Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, UK
| | | | - Amol D Dhamane
- Bristol Myers Squibb Company, Lawrenceville, NJ 08648, USA
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Lonnberg F, Roos A, Farm M, Heurlin A, Okas M, Gigante B, Siddiqui AJ. Causes of death after first time venous thromboembolism. Thromb J 2024; 22:16. [PMID: 38303070 PMCID: PMC10832181 DOI: 10.1186/s12959-024-00586-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/23/2024] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Causes of death after first time community-acquired venous thromboembolism (VTE) diagnosed in unselected patients at the emergency department (ED) was investigated. MATERIALS AND METHODS The study consists of all patients > 18 years of age who had a visit for any medical reason to any of 5 different ED in Stockholm County, Sweden from 1st January 2016 to 31st December 2017. We have identified all patients with a first registered incident VTE; deep vein thrombosis (DVT) and/or pulmonary embolism (PE) during the study period. Cox regression models were used to estimate hazards ratios (HR) with 95% confidence intervals (CIs) for all-cause mortality and cause-specific death in patients with DVT or PE using all other patients as the reference group. RESULTS In total, 359,884 patients had an ED visit during the study period of whom about 2.1% were diagnosed with VTE (DVT = 4,384, PE = 3,212). The patients with VTE were older compared to the control group. During a mean follow up of 2.1 years, 1567 (21%) and 23,741(6.7%) patients died within the VTE and reference group, respectively. The adjusted risk of all-cause mortality was nearly double in patients with DVT (HR 1.7; 95% CI, 1.5-1.8) and more than 3-fold in patients with PE (HR 3.4; 95% CI, 3.1-3.6). While the risk of cancer related death was nearly 3-fold in patient with DVT (HR 2.7; 95% CI, 2.4-3.1), and 5-fold in PE (HR 5.4; 95% CI, 4.9-6.0 respectively). The diagnosis of PE during the ED visit was associated with a significantly higher risk of cardiovascular death (HR 2.2; 95% CI, 1.9-2.6). CONCLUSION Patients with VTE have an elevated risk of all-cause mortality, including cardiovascular death.
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Affiliation(s)
- Frida Lonnberg
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Roos
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Farm
- Karolinska University, Solna, Sweden
- Karolinska University Hospital, Solna, Sweden
| | - André Heurlin
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Mantas Okas
- Acute Medicine, Capio. St. Görans Hospital, Stockholm, Sweden
| | - Bruna Gigante
- Department of Medicine, Karolinska Institute, Solna, Sweden
- Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
| | - Anwar J Siddiqui
- Department of Medicine, Karolinska Institute, Solna, Sweden.
- Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.
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Shoji M, Yamashita Y, Ishii M, Inoue H, Kato H, Fujita S, Matsui K, Tajiri K, Nameki M, Muraoka N, Nonaka A, Sugino H, Kono M, Oka T, Sueta D, Komuro I, Tsujita K. A Predictive Model for Cancer-Associated Thrombosis in Japanese Cancer Patients: Findings from the J-Khorana Registry. TH OPEN 2024; 8:e9-e18. [PMID: 38197014 PMCID: PMC10774015 DOI: 10.1055/a-2207-7715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
Background Although the close relationship between cancer and venous thromboembolism (VTE) has been identified, risk stratification for VTE in Japanese patients with cancer remains unclear. Objectives This study aimed to validate the Khorana VTE risk assessment score (KRS) for VTE diagnosis and establish an optimal predictive model for VTE in Japanese patients with cancer. Methods A total of 7,955 Japanese patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups according to the KRS. Using 37 explanatory variables, a total of 2,833 patients with cancer were divided into derivation and validation cohorts (5:5). A risk model for Japanese participants was developed using the derivation cohort data. Results The prevalence of VTE in low-, intermediate-, and high-score patients was 1.2, 2.5, and 4.3%, respectively. Logistic regression analysis demonstrated that cancer stage (III-IV) and KRS ≥ 2 were independent and significant predictors of VTE onset. The risk model for VTE assigned 1 point to body mass index ≥25 kg/m 2 and 2 points each to the prevalence of osteochondral cancer and D-dimer level ≥1.47 µg/mL. The areas under the curve of the risk model were 0.763 and 0.656 in the derivation and validation cohorts, respectively. Conclusion The KRS was useful in Japanese patients, and our new predictive model may be helpful for the diagnosis of VTE in Japanese patients with cancer.
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Affiliation(s)
- Masaaki Shoji
- Department of General Internal Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Hitoki Inoue
- Department of Cardiology, National Hospital Organization (NHO) Hokkaido Cancer Center, Hokkaido, Japan
| | - Hiroshi Kato
- Division of Onco-Cardiology, Miyagi Cancer Center, Miyagi, Japan
| | - Shin Fujita
- Department of Surgery, Tochigi Cancer Center, Tochigi, Japan
| | - Kazuhiro Matsui
- Department of Internal Medicine, Onco-Cardiology Unit, Saitama Cancer Center, Saitama, Japan
| | - Kazuko Tajiri
- Department of Cardiology, National Cancer Center Hospital East, Chiba, Japan
| | - Mizuo Nameki
- Division of Cardiology, Chiba Cancer Center, Chiba, Japan
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Akiko Nonaka
- Division of Onco-Cardiology, Hyogo Cancer Center, Hyogo, Japan
| | - Hiroshi Sugino
- Division of Cardiology, NHO Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Mihoko Kono
- Department of Onco-Cardiology, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Toru Oka
- Department of Internal Medicine, Onco-Cardiology Unit, Saitama Cancer Center, Saitama, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Issei Komuro
- Department of Frontier Cardiovascular Science, International University of Health and Welfare, Tokyo, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
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Tawil N, Mohammadnia A, Rak J. Oncogenes and cancer associated thrombosis: what can we learn from single cell genomics about risks and mechanisms? Front Med (Lausanne) 2023; 10:1252417. [PMID: 38188342 PMCID: PMC10769496 DOI: 10.3389/fmed.2023.1252417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
Single cell analysis of cancer cell transcriptome may shed a completely new light on cancer-associated thrombosis (CAT). CAT causes morbid, and sometimes lethal complications in certain human cancers known to be associated with high risk of venous thromboembolism (VTE), pulmonary embolism (PE) or arterial thromboembolism (ATE), all of which worsen patients' prognosis. How active cancers drive these processes has long evaded scrutiny. While "unspecific" microenvironmental effects and consequences of patient care (e.g., chemotherapy) have been implicated in pathogenesis of CAT, it has also been suggested that oncogenic pathways driven by either genetic (mutations), or epigenetic (methylation) events may influence the coagulant phenotype of cancer cells and stroma, and thereby modulate the VTE/PE risk. Consequently, the spectrum of driver events and their downstream effector mechanisms may, to some extent, explain the heterogeneity of CAT manifestations between cancer types, molecular subtypes, and individual cases, with thrombosis-promoting, or -protective mutations. Understanding this molecular causation is important if rationally designed countermeasures were to be deployed to mitigate the clinical impact of CAT in individual cancer patients. In this regard, multi-omic analysis of human cancers, especially at a single cell level, has brought a new meaning to concepts of cellular heterogeneity, plasticity, and multicellular complexity of the tumour microenvironment, with profound and still relatively unexplored implications for the pathogenesis of CAT. Indeed, cancers may contain molecularly distinct cellular subpopulations, or dynamic epigenetic states associated with different profiles of coagulant activity. In this article we discuss some of the relevant lessons from the single cell "omics" and how they could unlock new potential mechanisms through which cancer driving oncogenic lesions may modulate CAT, with possible consequences for patient stratification, care, and outcomes.
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Affiliation(s)
- Nadim Tawil
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Abdulshakour Mohammadnia
- Neuroimmunology Unit, Montreal Neurological Institute, Department of Neurology and Neurosurgery, McGill University, Rue University, Montreal, QC, Canada
| | - Janusz Rak
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
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Emilescu RA, Jinga M, Cotan HT, Popa AM, Orlov-Slavu CM, Olaru MC, Iaciu CI, Parosanu AI, Moscalu M, Nitipir C. The Role of KRAS Mutation in Colorectal Cancer-Associated Thrombosis. Int J Mol Sci 2023; 24:16930. [PMID: 38069251 PMCID: PMC10707331 DOI: 10.3390/ijms242316930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
Venous thromboembolic events (VTE) are common in patients with colorectal cancer (CRC) and represent a significant contributor to morbidity and mortality. Risk stratification is paramount in deciding the initiation of thromboprophylaxis and is calculated using scores that include tumor location, laboratory values, patient clinical characteristics, and tumor burden. Commonly used risk scores do not include the presence of molecular aberrations as a variable. This retrospective study aims to confirm the link between KRAS-activating mutations and the development of VTE in CRC. A total of 166 patients were included in this study. They were split into two cohorts based on KRAS mutational status. We evaluated the frequency and mean time to VTE development stratified by the presence of KRAS mutations. Patients with mutant KRAS had an odds ratio (OR) of 2.758 for VTE compared to KRAS wild-type patients, with an increased risk of thrombosis being maintained in KRAS mutant patients even after adjusting for other known VTE risk factors. Taking into account the results of this study, KRAS mutation represents an independent risk factor for VTE.
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Affiliation(s)
- Radu Andrei Emilescu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Mariana Jinga
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Horia Teodor Cotan
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Ana Maria Popa
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Cristina Maria Orlov-Slavu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Mihaela Cristina Olaru
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Cristian Ion Iaciu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Andreea Ioana Parosanu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
| | - Mihaela Moscalu
- Preventive Medicine and Interdisciplinarity Department, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Cornelia Nitipir
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 8 Sanitary Heroes Boulevard, 050474 Bucharest, Romania; (R.A.E.)
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Gotta J, Gruenewald LD, Eichler K, Martin SS, Mahmoudi S, Booz C, Biciusca T, Reschke P, Bernatz S, Pinto Dos Santos D, Scholtz JE, Alizadeh LS, Nour-Eldin NEA, Hammerstingl RM, Gruber-Rouh T, Mader C, Hardt SE, Sommer CM, Bucolo G, D'Angelo T, Onay M, Finkelmeier F, Leistner DM, Vogl TJ, Giannitsis E, Koch V. Unveiling the diagnostic enigma of D-dimer testing in cancer patients: Current evidence and areas of application. Eur J Clin Invest 2023; 53:e14060. [PMID: 37409393 DOI: 10.1111/eci.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 05/30/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Cancer is a well-known risk factor for venous thromboembolism (VTE). A combined strategy of D-dimer testing and clinical pre-test probability is usually used to exclude VTE. However, its effectiveness is diminished in cancer patients due to reduced specificity, ultimately leading to a decreased clinical utility. This review article seeks to provide a comprehensive summary of how to interpret D-dimer testing in cancer patients. METHODS In accordance with PRISMA standards, literature pertaining to the diagnostic and prognostic significance of D-dimer testing in cancer patients was carefully chosen from reputable sources such as PubMed and the Cochrane databases. RESULTS D-dimers have not only a diagnostic value in ruling out VTE but can also serve as an aid for rule-in if their values exceed 10-times the upper limit of normal. This threshold allows a diagnosis of VTE in cancer patients with a positive predictive value of more than 80%. Moreover, elevated D-dimers carry important prognostic information and are associated with VTE reoccurrence. A gradual increase in risk for all-cause death suggests that VTE is also an indicator of biologically more aggressive cancer types and advanced cancer stages. Considering the lack of standardization for D-dimer assays, it is essential for clinicians to carefully consider the variations in assay performance and the specific test characteristics of their institution. CONCLUSIONS Standardizing D-dimer assays and developing modified pretest probability models specifically for cancer patients, along with adjusted cut-off values for D-dimer testing, could significantly enhance the accuracy and effectiveness of VTE diagnosis in this population.
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Affiliation(s)
- Jennifer Gotta
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Katrin Eichler
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon S Martin
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Christian Booz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Teodora Biciusca
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Philipp Reschke
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Simon Bernatz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Jan-Erik Scholtz
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Leona S Alizadeh
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | | | | | - Christoph Mader
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan E Hardt
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christof M Sommer
- Clinic of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Giuseppe Bucolo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Tommaso D'Angelo
- Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Messina, Italy
| | - Melis Onay
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - David M Leistner
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Thomas J Vogl
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Evangelos Giannitsis
- Department of Cardiology, Angiology and Pulmonology, Heidelberg University Hospital, Heidelberg, Germany
| | - Vitali Koch
- Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
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11
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Götzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S, Edelman ER, Böhm M, Jaber W, Mahfoud F. Interventional therapies for pulmonary embolism. Nat Rev Cardiol 2023; 20:670-684. [PMID: 37173409 PMCID: PMC10180624 DOI: 10.1038/s41569-023-00876-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
Pulmonary embolism (PE) is the leading cause of in-hospital death and the third most frequent cause of cardiovascular death. The clinical presentation of PE is variable, and choosing the appropriate treatment for individual patients can be challenging. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis or surgery; however, a range of percutaneous interventional technologies have been developed that are under investigation in patients with intermediate-high-risk or high-risk PE. These interventional technologies include catheter-directed thrombolysis (with or without ultrasound assistance), aspiration thrombectomy and combinations of the aforementioned principles. These interventional treatment options might lead to a more rapid improvement in right ventricular function and pulmonary and/or systemic haemodynamics in particular patients. However, evidence from randomized controlled trials on the safety and efficacy of these interventions compared with conservative therapies is lacking. In this Review, we discuss the underlying pathophysiology of PE, provide assistance with decision-making on patient selection and critically appraise the available clinical evidence on interventional, catheter-based approaches for PE treatment. Finally, we discuss future perspectives and unmet needs.
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Affiliation(s)
- Felix Götzinger
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Lucas Lauder
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Andrew S P Sharp
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
- Cardiff University, Cardiff, UK
| | - Irene M Lang
- Department of Cardiology, Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stephan Rosenkranz
- Department of Cardiology - Internal Medicine III, Cologne University Heart Center, Cologne, Germany
- Cologne Cardiovascular Research Center (CCRC), Cologne University Heart Center, Cologne, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Elazer R Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michael Böhm
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany
| | - Wissam Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Felix Mahfoud
- Clinic of Cardiology, Angiology and Intensive Care Medicine, University Hospital Homburg, Saarland University, Homburg, Germany.
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
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12
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Vrotniakaite-Bajerciene K, Rütsche S, Calzavarini S, Quarroz C, Stalder O, Mean M, Righini M, Staub D, Beer JH, Frauchiger B, Osterwalder J, Kucher N, Matter CM, Husmann M, Banyai M, Aschwanden M, Mazzolai L, Hugli O, Rodondi N, Aujesky D, Angelillo-Scherrer A. Thrombin Generation Is Associated with Venous Thromboembolism Recurrence, but Not with Major Bleeding and Death in the Elderly: A Prospective Multicenter Cohort Study. J Clin Med 2023; 12:6050. [PMID: 37762997 PMCID: PMC10531633 DOI: 10.3390/jcm12186050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
It is currently unknown whether thrombin generation is associated with venous thromboembolism (VTE) recurrence, major bleeding, or mortality in the elderly. Therefore, our aim was to prospectively study the association between thrombin generation and VTE recurrence, major bleeding, and mortality in elderly patients with acute VTE. Consecutive patients aged ≥65 years with acute VTE were followed for 2 years, starting from 1 year after the index VTE. Primary outcomes were VTE recurrence, major bleeding, and mortality. Thrombin generation was assessed in 551 patients 1 year after the index VTE. At this time, 59% of the patients were still anticoagulated. Thrombin generation was discriminatory for VTE recurrence, but not for major bleeding and mortality in non-anticoagulated patients. Moreover, peak ratio (adjusted subhazard ratio 4.09, 95% CI, 1.12-14.92) and normalized peak ratio (adjusted subhazard ratio 2.18, 95% CI, 1.28-3.73) in the presence/absence of thrombomodulin were associated with VTE recurrence, but not with major bleeding and mortality after adjustment for potential confounding factors. In elderly patients, thrombin generation was associated with VTE recurrence, but not with major bleeding and/or mortality. Therefore, our study suggests the potential usefulness of thrombin generation measurement after anticoagulation completion for VTE to help identify among elderly patients those at higher risk of VTE recurrence.
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Affiliation(s)
- Kristina Vrotniakaite-Bajerciene
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sereina Rütsche
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Sara Calzavarini
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Claudia Quarroz
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
| | - Odile Stalder
- Clinical Trials Unit (CTU) Bern, University of Bern, 3010 Bern, Switzerland;
| | - Marie Mean
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Department of Medicine, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Daniel Staub
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Juerg H. Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, 5404 Baden, Switzerland;
| | - Beat Frauchiger
- Department of Internal Medicine, Cantonal Hospital of Frauenfeld, 8501 Frauenfeld, Switzerland;
| | | | - Nils Kucher
- Clinic of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Christian M. Matter
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8091 Zurich, Switzerland;
- Center for Translational and Experimental Cardiology (CTEC), Department of Cardiology, Zurich University Hospital and University of Zurich, 8091 Zurich, Switzerland
| | - Marc Husmann
- Center for Vascular Diseases, Zurich-Stadelhofen, Stadelhoferstrasse 8, 8001 Zurich, Switzerland;
| | - Martin Banyai
- Gefässpraxis Luzern Swiss AG, Pilatusstrasse 34, 6003 Lucerne, Switzerland;
| | - Markus Aschwanden
- Division of Angiology, Basel University Hospital, 4031 Basel, Switzerland; (D.S.); (M.A.)
| | - Lucia Mazzolai
- Service of Angiology, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Olivier Hugli
- Emergency Department, Lausanne University Hospital, Lausanne University, 1005 Lausanne, Switzerland;
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
- Institute of Primary Health Care (BIHAM), University of Bern, 3010 Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (M.M.); (N.R.); (D.A.)
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland; (K.V.-B.); (S.R.); (S.C.); (C.Q.)
- Department for BioMedical Research, University of Bern, 3010 Bern, Switzerland
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13
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Juul AD, Laursen CB, Christophersen A, Arshad A, Luef SM, Panou V, Larsen JG, Reimer J, Paaby J, Falster C. Endobronchial Ultrasound for the Screening of Pulmonary Embolism in Patients with Suspected Lung Cancer: A Prospective Cohort Study. Respiration 2023; 102:601-607. [PMID: 37498007 DOI: 10.1159/000531485] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND Patients with lung cancer exhibit increased risk of pulmonary embolism (PE). While the contrast phase of computed tomography of the chest in the diagnostic work-up of suspected chest malignancy does not allow reliable detection of PE, it may be feasible to screen for present PE during endobronchial ultrasound (EBUS) examination. OBJECTIVES The aim of this study was to establish if screening during EBUS for PE in patients with suspected lung cancer is feasible and if positive findings are predictive of PE. METHODS Patients undergoing EBUS due to suspicion of malignancy of the chest were prospectively enrolled. The pulmonary arteries were assessed during EBUS using a standardized protocol. Patients in whom PE suspicion was raised were referred to confirmatory imaging. RESULTS From December 2020 to August 2021, 100 patients were included. Median time for vascular assessment during EBUS was 2 min (Q1-Q3: 1-3 min). EBUS identified two suspected PEs (2%), and the number needed to scan was 50. The positive predictive value of EBUS for PE was 100%. CONCLUSION EBUS for PE screening seems feasible and with limited time use. The PPV of positive findings for the diagnosis of PE is high, but the utility is somewhat limited by a high number needed to scan even in a high-risk population. Based on our findings, we believe that EBUS assessment of the pulmonary vasculature may have a role as a routine screening tool for PE. The assessment for PE should be implemented in EBUS training programmes, as operators should be able to recognize incidental PEs.
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Affiliation(s)
- Amanda Dandanell Juul
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Arman Arshad
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Stefan Møller Luef
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Vasiliki Panou
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Jacob Reimer
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jens Paaby
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
| | - Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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14
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Li B, Lu Z, Yang Z, Zhang X, Wang M, Chu T, Wang P, Qi F, Anderson GJ, Jiang E, Song Z, Nie G, Li S. Monitoring circulating platelet activity to predict cancer-associated thrombosis. CELL REPORTS METHODS 2023; 3:100513. [PMID: 37533637 PMCID: PMC10391338 DOI: 10.1016/j.crmeth.2023.100513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/03/2023] [Accepted: 06/01/2023] [Indexed: 08/04/2023]
Abstract
A characteristic clinical complication in cancer patients is the frequent incidence of thrombotic events. Numerous studies have shown hyperactive/activated platelets to be a critical earlier trigger for cancer-associated thrombus formation. However, there currently is no viable approach to monitor specific changes in tumor-associated platelet activity. Here, we describe a chromatograph-like microfluidic device that is highly sensitive to the activity status of peripheral circulating platelets in both tumor-bearing mice and clinical cancer patients. Our results show a strongly positive correlation between platelet activation status and tumor progression. Six-month follow-up data from advanced cancer patients reveal positive links between platelet activity level and thrombus occurrence rate, with a high predictive capacity of thrombotic events (AUC = 0.842). Our findings suggest that circulating platelet activity status determined by this microfluidic device exhibits sensitive, predictive potential for thrombotic events in cancer patients for directing well-timed antithrombosis treatment.
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Affiliation(s)
- Bozhao Li
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zefang Lu
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Zhenlin Yang
- Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiuping Zhang
- Faculty of Hepato-Biliary-Pancreatic Surgery, Chinese People’s Liberation Army (PLA) General Hospital, Institute of Hepatobiliary Surgery of Chinese PLA, Key Laboratory of Digital Hepatobiliary Surgery, PLA, Beijing 100853, China
| | - Meiqi Wang
- Breast Center, Fourth Hospital of Hebei Medical University, Shijiazhuang 050035, China
| | - Tianjiao Chu
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
| | - Peina Wang
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
| | - Feilong Qi
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
- University of Chinese Academy of Sciences, Beijing 100049, China
| | - Greg J. Anderson
- QIMR Berghofer Medical Research Institute, Royal Brisbane Hospital, Brisbane, QLD 4029, Australia
| | - Ershuai Jiang
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
| | - Zhenchuan Song
- Breast Center, Fourth Hospital of Hebei Medical University, Shijiazhuang 050035, China
| | - Guangjun Nie
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
- University of Chinese Academy of Sciences, Beijing 100049, China
- Center of Materials Science and Optoelectronics Engineering, University of Chinese Academy of Sciences, Beijing 100049, China
- GBA Research Innovation Institute for Nanotechnology, Guangzhou 510530, China
| | - Suping Li
- CAS Key Laboratory for Biomedical Effects of Nanomaterials & Nanosafety, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, Beijing 100190, China
- University of Chinese Academy of Sciences, Beijing 100049, China
- Center of Materials Science and Optoelectronics Engineering, University of Chinese Academy of Sciences, Beijing 100049, China
- GBA Research Innovation Institute for Nanotechnology, Guangzhou 510530, China
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15
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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16
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Cohen A, Noxon V, Dhamane A, Bruette R, Shah S, Hines DM, Alfred T, Luo X. Effectiveness and safety of anticoagulants among venous thromboembolism cancer patients with and without brain cancer. Thromb Res 2023; 226:117-126. [PMID: 37146438 DOI: 10.1016/j.thromres.2023.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/29/2023] [Accepted: 04/10/2023] [Indexed: 05/07/2023]
Abstract
INTRODUCTION Patients with brain cancer are at a high risk of developing venous thromboembolism (VTE) and are underrepresented in clinical trials. This study compared the risk of recurrent VTE (rVTE), major bleeding (MB), and clinically relevant non-major bleeding (CRNMB) among VTE cancer patients initiating apixaban, low molecular weight heparin (LMWH), or warfarin stratified by patients with brain vs other cancer types. MATERIALS AND METHODS Active cancer patients initiating apixaban, LMWH, or warfarin within 30 days after VTE diagnosis were identified from 4 US commercial and the Medicare databases. Inverse probability of treatment weights (IPTW) was used to balance patient characteristics. Cox proportional hazards models were used to evaluate the interaction between brain cancer status and treatment on outcomes (rVTE, MB, and CRNMB), with a p-value <0.1 indicating a significant interaction. RESULTS Of 30,586 patients with active cancer (5 % had brain cancer), apixaban (vs. LMWH and warfarin) was associated with lower risk of rVTE, MB, and CRNMB. Generally, no significant interactions (P > 0.1) were found between brain cancer status and anticoagulant treatment across outcomes. The exception was MB for apixaban [vs LMWH (p-value for interaction = 0.091)] with a higher reduction among those with brain cancer (HR = 0.32) than those with (HR = 0.72) other cancer. CONCLUSIONS Among VTE patients with all types of cancer, apixaban (vs LMWH and warfarin) was associated with a lower risk of rVTE, MB, and CRNMB. In general, anticoagulant treatment effects were not significantly different between VTE patients with brain cancer and those with other cancer.
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Affiliation(s)
- Alexander Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, UK.
| | | | - Amol Dhamane
- Bristol Myers Squibb Company, Lawrenceville, NJ, USA
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Patel R, Stokes WA, Roberts C, Chung J, Fancy T, Wen S, Gao S. Preoperative low-molecular weight heparin chemoprophylaxis in head and neck free flap reconstruction. Am J Otolaryngol 2023; 44:103722. [PMID: 36527816 DOI: 10.1016/j.amjoto.2022.103722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The safety of presurgical thromboprophylaxis using low molecular weight heparin (LMWH) has not been well described in head and neck oncologic surgery with free tissue transfer (HNS-FTT). METHODS Retrospective chart review of HNS-FTT patients receiving versus not receiving presurgical subcutaneous enoxaparin (Px-LMWH) was performed. Outcomes included estimated blood loss (EBL), hematoma, flap compromise, DVT or pulmonary embolus (PE). Fisher's exact test and Wilcoxon Rank Sum test were performed to compare groups. Odds ratios and associated 95 % confidence intervals were provided as appropriate. RESULTS 43 of 128 patients (34 %) received Px-LMWH. There was no significant difference in EBL, hematoma, or flap complications between groups. Patients without Px-LMWH had higher rates of DVT and PE, although the difference did not reach statistical significance (p = 1.00, 0.095, respectively). CONCLUSION Presurgical Px-LMWH can be used in major head and neck reconstructive surgery without increased intraoperative blood loss or postoperative complications. Larger studies will need to be done to determine the impact of Px-LMWH on DVT and PE in this patient population. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Rusha Patel
- University of Oklahoma Health Sciences Center, United States of America.
| | | | | | | | - Tanya Fancy
- West Virginia University, United States of America
| | - Sijin Wen
- West Virginia University, United States of America
| | - Si Gao
- West Virginia University, United States of America
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18
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A Comprehensive Review of Risk Factors for Venous Thromboembolism: From Epidemiology to Pathophysiology. Int J Mol Sci 2023; 24:ijms24043169. [PMID: 36834580 PMCID: PMC9964264 DOI: 10.3390/ijms24043169] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023] Open
Abstract
Venous thromboembolism (VTE) is the third most common cause of death worldwide. The incidence of VTE varies according to different countries, ranging from 1-2 per 1000 person-years in Western Countries, while it is lower in Eastern Countries (<1 per 1000 person-years). Many risk factors have been identified in patients developing VTE, but the relative contribution of each risk factor to thrombotic risk, as well as pathogenetic mechanisms, have not been fully described. Herewith, we provide a comprehensive review of the most common risk factors for VTE, including male sex, diabetes, obesity, smoking, Factor V Leiden, Prothrombin G20210A Gene Mutation, Plasminogen Activator Inhibitor-1, oral contraceptives and hormonal replacement, long-haul flight, residual venous thrombosis, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, trauma and fractures, pregnancy, immobilization, antiphospholipid syndrome, surgery and cancer. Regarding the latter, the incidence of VTE seems highest in pancreatic, liver and non-small cells lung cancer (>70 per 1000 person-years) and lowest in breast, melanoma and prostate cancer (<20 per 1000 person-years). In this comprehensive review, we summarized the prevalence of different risk factors for VTE and the potential molecular mechanisms/pathogenetic mediators leading to VTE.
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19
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Gong M, Fu G, Liu Z, Zhao B, Kong J, He X, Gu J. Angiojet pharmacomechanical thrombectomy versus anticoagulant therapy alone in massive cancer-associated thrombosis: a single centre retrospective cohort study. J Thromb Thrombolysis 2023; 55:365-375. [PMID: 36630028 DOI: 10.1007/s11239-023-02770-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/12/2023]
Abstract
The therapeutic regimen option for the cancer-associated thrombosis (CAT) patients is still a major clinical challenge. The present study aimed to investigate the safety and efficacy of pharmacomechanical catheter-directed thrombolysis (PCDT) with AngioJet treatment compared with the conventional anticoagulation alone therapy in the patients with CAT. We retrospectively reviewed the patients who underwent PCDT and/or anticoagulation for the treatment of CAT between August 1, 2016 and March 1, 2022. Each patient was divided into the PCDT group or the anticoagulation alone group. The baseline demographics, comorbidities, clinical characteristics, treatment details, course data were reviewed. A total of 51 eligible patients were included, of whom 21 were in PCDT group (mean age, 60.1 ± 13.0 years; 52.4% male) and 30 in anticoagulation alone group (mean age, 66.6 ± 11.1 years; 50.0% male). No significant differences regarding age, sex, onset time, limb characteristics, cancer conditions or risk factors were detected (p > .05). After PCDT, grade III lysis was achieved in 8 and grade II lysis in 11 patients. Clinical success was achieved in 90.5% (19/21) patients. The symptoms of leg pain and swelling were significantly improved in both groups. Except for transient macroscopic hemoglobinuria occurring in PCDT group, none of all patients suffered from procedure-related and major complications. Minor complications such as bleeding events occurred in 23.8% (5/21) of patients in PCDT group compared with 10.0% (3/30) in anticoagulation alone group (p > .05). At the 6-month follow-up, iliofemoral patency was found an absolute risk reduction of 37.9% (70.0 vs. 32.1%) (95% CI: 1.183-4.008%; P = 0.010). The incidence of mild PTS was 5.0% (1/20) in PCDT group compared with 10.7% (3/28) in anticoagulation alone group (p > .05). The PCDT is a safe and effective modality in managing patients with CAT, leading to improved clinical outcomes with a low complication. The PCDT was more effective than anticoagulation alone in massive symptom relief and venous patency.
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Affiliation(s)
- Maofeng Gong
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Guanqi Fu
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Zhengli Liu
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Boxiang Zhao
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Jie Kong
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China
| | - Xu He
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China.
| | - Jianping Gu
- Department of Interventional and Vascular Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, 210006, People's Republic of China.
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20
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Imura M, Katada J, Shiga T. Epidemiological Study Regarding the Incidence of Venous Thromboembolism in Patients After Cancer Remission. Cardiol Ther 2022; 11:611-623. [PMID: 36319831 PMCID: PMC9652192 DOI: 10.1007/s40119-022-00285-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The time course of reduction in the risk of venous thromboembolism (VTE) in patients who were diagnosed with cancer, treated with anticancer therapy, and in remission is unclear. We hypothesized that the risk of VTE will decrease over time after cancer remission. METHODS We conducted a retrospective analysis using claims data for cancer remission in Japan. Background information of patients who developed VTE after cancer remission was collected, and the VTE incidence rate after cancer remission was analyzed. Subgroup analysis based on VTE history, cancer type, and the presence or absence of surgery during hospitalization was conducted. RESULTS A total of 638,908 patients were eligible for the analysis. VTE occurred in 5533 of 638,908 cases, pulmonary embolism occurred in 779 cases, and deep vein thrombosis occurred in 5084 cases after cancer remission. The mean age of patients who developed VTE was 70.1 ± 12.5 years, and the proportion of men was 47.5%. All comorbidities and medications were higher in the VTE group (P < 0.001) than in the non-VTE group after cancer remission. The incidence of VTE was 2.4% per year in the first 30 days, 1.35% per year in 31-60 days, and gradually decreased to 0.48% per year in 181-360 days, becoming almost constant (annual rate 0.3%) 2 years after cancer remission. CONCLUSION Risk of developing VTE decreased to the same level as that in patients without cancer 2 years after cancer remission. Although the guidelines do not specify the duration of anticoagulant prophylaxis for new onset or recurrent VTE after cancer remission and the appropriate duration of such prophylaxis may vary depending on VTE risk factors, determining the period of high risk of VTE for each patient and preventing VTE is considered important.
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Affiliation(s)
- Miki Imura
- Medical Affairs, Internal Medicine, Pfizer Biopharmaceuticals Group, Pfizer Japan Inc., 3-22-7 Yoyogi, Shibuya-Ku, Tokyo, 151-8589 Japan
| | - Jun Katada
- Medical Affairs, Internal Medicine, Pfizer Biopharmaceuticals Group, Pfizer Japan Inc., 3-22-7 Yoyogi, Shibuya-Ku, Tokyo, 151-8589 Japan
| | - Taro Shiga
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550 Japan
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21
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Lopez-Ruz S, Barca-Hernando M, Marin-Romero S, Elias-Hernandez T, Otero-Candelera R, Jara-Palomares L. Low-molecular-weight heparin beyond 12 months in patients with cancer-associated thrombosis. Br J Cancer 2022; 127:2234-2240. [PMID: 36241715 PMCID: PMC9727131 DOI: 10.1038/s41416-022-02007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Clinical guidelines indicate that in patients with cancer-associated thrombosis (CAT), anticoagulant treatment should be continued beyond 6 months as long as the cancer is active. We aimed to analyse the safety of low-molecular-weight heparin (LMWH) beyond 12 months in patients with CAT. METHODS We performed a post hoc analysis of consecutive CAT patients from October 2008 to December 2019. The primary outcome was the rate of clinically relevant bleeding (CRB), and we compared two periods (1-12 vs. 12-24 months). Hazard ratio (HR), competing risk analysis and sensitivity analyses were performed. RESULTS Of the 588 patients included, 30.1% (n = 177) received LMWH beyond 12 months. The rate of CRB in the first 12 months compared to the 12-24 month period was 3.2 per 100 patients/month (95% CI 2.5-4.1) vs. 0.9 per 100 patients/month (95% CI 0.4-1.5), (P < 0.0001). The competing risk analysis of CRB comparing both periods showed a lower sub-distribution hazard ratio (SHR) during the period 12-24 months (SHR: 0.5, 95% CI: 0.3-0.8, P < 0.001). CONCLUSION In patients with cancer-associated thrombosis under anticoagulant treatment with LMWH, the rate of clinically relevant bleeding and major bleeding were lower beyond 12 months.
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Affiliation(s)
- Sergio Lopez-Ruz
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Maria Barca-Hernando
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Samira Marin-Romero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Teresa Elias-Hernandez
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
| | - Remedios Otero-Candelera
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - Luis Jara-Palomares
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, 41013, España.
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
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22
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Attard LM, Gatt A, Bertoletti L, Delluc A, Riva N. Direct Oral Anticoagulants for the Prevention and Acute Treatment of Cancer-Associated Thrombosis. Vasc Health Risk Manag 2022; 18:793-807. [PMID: 36268462 PMCID: PMC9576495 DOI: 10.2147/vhrm.s271411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/05/2022] [Indexed: 12/05/2022] Open
Abstract
Cancer is a major risk factor for venous thromboembolism (VTE), and cancer-associated thrombosis (CAT) constitutes approximately 15-25% of all VTE cases. For decades, the standard treatment for CAT used to be daily subcutaneous low molecular weight heparin (LMWH). Data on the safety and efficacy of the direct oral anticoagulants (DOACs) in this population emerged only in recent years and specific DOACs were included into recent guidelines recommendations. In this narrative review of the literature, we reported the results of the phase III randomized controlled trials that evaluated the DOACs for the prevention and the acute treatment of CAT. For the acute phase treatment, the anti-Xa inhibitors (apixaban, edoxaban, rivaroxaban) showed better efficacy than LMWH in preventing VTE recurrence; however, rivaroxaban and edoxaban were also associated with an increased risk of bleeding events. For primary prevention of CAT in ambulatory cancer patients starting chemotherapy, apixaban and rivaroxaban showed better efficacy than placebo but a trend towards higher bleeding rates. Recent guidelines suggest the DOACs for the treatment of CAT in selected cancer patients (eg, low bleeding risk, no luminal gastrointestinal or genitourinary malignancies, no interfering medications). The DOACs are also suggested for primary thromboprophylaxis in selected ambulatory cancer patients at high risk of VTE (eg, Khorana score ≥2 prior to starting new chemotherapy, low bleeding risk, no interfering medications).
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Affiliation(s)
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France,INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne, France,INNOVTE, CHU de Saint-Etienne, Saint-Etienne, France
| | - Aurelien Delluc
- Ottawa Hospital Research Institute, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta,Correspondence: Nicoletta Riva, Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, MSD 2080, Malta, Email
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23
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Pulmonary Embolism in the Cancer Associated Thrombosis Landscape. J Clin Med 2022; 11:jcm11195650. [PMID: 36233519 PMCID: PMC9570910 DOI: 10.3390/jcm11195650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.
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24
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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25
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Yamashita Y, Morimoto T, Kadota K, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Inoko M, Tada T, Chen PM, Murata K, Tsuyuki Y, Nishimoto Y, Sakamoto J, Togi K, Mabuchi H, Takabayashi K, Kato T, Ono K, Kimura T. Causes of long-term mortality in patients with venous thromboembolism in the real world: From the COMMAND VTE registry. Thromb Res 2022; 219:30-39. [PMID: 36095981 DOI: 10.1016/j.thromres.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/24/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is still a scarcity of data on causes of long-term mortality in patients with venous thromboembolism (VTE). MATERIALS AND METHODS The COMMAND VTE Registry is a physician-initiated, retrospective, multicenter cohort study in which consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan were included between January 2010 and August 2014. We investigated detailed causes and risk factors for long-term mortality. RESULTS During a median observation period of 1218 days, a total of 764 patients died, and the prevalence of active cancer was higher in patients who died than in patients alive (61 % versus 10 %, P < 0.001). The cumulative incidences of cardiac death, pulmonary embolism (PE)-related death, bleeding death, cancer death, and non-cardiovascular non-cancer death were 2.2 %, 2.9 %, 2.0 %, 16.1 %, and 6.7 % at 5 years, respectively. The incidence of cancer death increased gradually, which was the most common cause of long-term death. Among patients without active cancer, the incidence of PE-related death increased rapidly and became a plateau beyond the acute phase, whereas the incidence of non-cardiovascular non-cancer death kept increasing, which became most common in the long term. The separate multivariable analysis among patient with and without active cancer identified independent risk factors of all-cause death including a few patient characteristics among patients with active cancer and several patient characteristics among patients without active cancer. CONCLUSIONS Cancer was the most common cause of long-term mortality, while non-cardiovascular non-cancer death became most common among patients without active cancer.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
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26
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Chen C, Wu C, Lyu Y, Chou Y, Chang Y, Wu C. Association between bullous pemphigoid and risk of venous thromboembolism: A nationwide population‐based cohort study. J Dermatol 2022; 49:753-761. [DOI: 10.1111/1346-8138.16412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/23/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ching‐Li Chen
- Department of Medical Education National Taiwan University Hospital Taipei Taiwan
| | - Chun‐Ying Wu
- Division of Translational Research, Department of Medical Research Taipei Veterans General Hospital Taipei Taiwan
- Institute of Biomedical Informatics National Yang Ming Chiao Tung University Taipei Taiwan
- College of Public Health China Medical University Taichung Taiwan
| | - Ying‐Syuan Lyu
- Institute of Biomedical Informatics National Yang Ming Chiao Tung University Taipei Taiwan
| | - Yiing‐Jenq Chou
- Department of Public Health, Institute of Public Health National Yang Ming Chiao Tung University Taipei Taiwan
| | - Yun‐Ting Chang
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- Department of Dermatology National Yang Ming Chiao Tung University Taipei Taiwan
| | - Chen‐Yi Wu
- Department of Public Health, Institute of Public Health National Yang Ming Chiao Tung University Taipei Taiwan
- Department of Dermatology Taipei Veterans General Hospital Taipei Taiwan
- Department of Dermatology National Yang Ming Chiao Tung University Taipei Taiwan
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27
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Chen X, Huang S, Jin Q, Ge Y, Lei J, Huang Z, Zhang L, Wang G. Thromboembolic events in idiopathic inflammatory myopathy: a retrospective study in China. Clin Rheumatol 2022; 41:2431-2438. [PMID: 35404027 DOI: 10.1007/s10067-022-06140-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/20/2022] [Accepted: 03/19/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the clinical characteristics and risk factors for thromboembolic events in patients with idiopathic inflammatory myopathy (IIM). METHODS We retrospectively analyzed 1144 consecutive patients with IIM for arterial and venous thromboses and compared them with age- and sex-matched IIM patients without thrombosis. Logistic regression analysis was used to analyze risk factors for thrombosis. RESULTS Twenty-four (2.1%) patients had arterial or venous thromboses (mean age, 62.6 ± 11.6 years; range, 33-81 years). Thromboembolic events occurred in 54.2% (13/24) of patients within 6 months before or after IIM diagnosis. Thrombosis patients had a higher Cutaneous Dermatomyositis Disease Area and Severity Index score (p = 0.028), higher myositis disease activity assessment visual analogue scale score (MYOACT) (p < 0.001), and a greater proportion of them had varicose veins (p = 0.001), surgical history in the past 3 months (p = 0.039), malignancy (p = 0.018), and infection (p < 0.001). The manual muscle test 8 score (p < 0.001) and albumin level (p = 0.003) were lower in thrombosis patients. There was no significant difference between the two groups in glucocorticoid pulse therapy; however, intravenous immunoglobulin therapy was more commonly used in thrombosis patients (p = 0.04). In multivariable regression models, malignancy, infection, longer duration of glucocorticoid treatment, and higher MYOACT were risk factors for thrombosis. The cumulative survival time of IIM patients with thrombosis was significantly shorter than that of controls. CONCLUSIONS Malignancy, infection, longer duration of glucocorticoid use, and increased myositis disease activity are risk factors for thrombosis. Patients with these risk factors should undergo screening for thrombosis. Key Points • To investigate the clinical characteristics and risk factors for thromboembolism events in patients with IIM, we performed a retrospective study with IIM patients who experienced a thromboembolic event. • We found that malignancy, infection, longer duration of glucocorticoid treatment, and a higher level of myositis disease activity were risk factors for thrombosis. • The results suggest that patients with the above risk factors should undergo screening for thrombosis.
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Affiliation(s)
- Xixia Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Sizhuang Huang
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Qiwen Jin
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, China-Japan Friendship Hospital, 2 Yinghua Road, Chaoyang District, Beijing, China
| | - Jieping Lei
- Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Huang
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Lu Zhang
- Department of Rheumatology, China-Japan Friendship Hospital, 2 Yinghua Road, Chaoyang District, Beijing, China.
| | - Guochun Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.
- Department of Rheumatology, China-Japan Friendship Hospital, 2 Yinghua Road, Chaoyang District, Beijing, China.
- The Key Laboratory of Myositis, China-Japan Friendship Hospital, Beijing, China.
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28
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Almudena FBL, Javier Jareño Esteban J, Miguel Díez JD, Zabaleta IMD, Hernández CG, Rivas MPO, Ortega CG. Evaluation of the Khorana predictive thrombotic risk and thromboprophylaxis score in cancer patients in a third level hospital. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37497323 PMCID: PMC10369566 DOI: 10.1016/j.opresp.2022.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Current clinical guidelines do not recommend the routine use of thromboprophylaxis in cancer primary unselected patients. Identifying cancer patients who could be beneficiaries of thrombotic prophylaxis is a real challenge. We aimed to analyse the application of Khorana score in cancer patients. We also tried to evaluate the prescription of primary thromboprophylaxis in cancer patients at risk of venous thromboembolic disease (VTED). Methods A retrospective observational study of survival of hospitalised patients diagnosed with pulmonary embolism (PE) at the Hospital Central de la Defensa from January 2009 to March 2018. They were stratified into tumour PE (TPE) and non-tumour PE (nTPE). A case-control study was also carried out by TPE patients and non PE cancer patients (nPEC). Results 108 patients were diagnosed with TPE, 260 nTPE and 324 nPEC. Gynaecological tumours were the most frequent (23.1%), followed by lung, digestive and urological cancer (20.4% each) in the TPE group. Death risk was 1.9 times higher in cancer patients (95% CI: 1.23-2.8) (p < 0.001). Khorana score was ≥3 points in 9.7% of TPE and 3.1% of nPEC compared to 26.2% of TPE and 9.9% of nPEC with Khorana score ≥2 points (p < 0.001). 7.4% of TPE patients received thromboprophylaxis. Khorana score in TPE patients without thromboprophylaxis was ≥3 points in the 9% and ≥2 points in the 24%. Conclusions There is an underutilisation of thromboprophylaxis in our cancer patients and mainly in those with high risk of VTED, as well as poor adherence to the Khorana score. More studies are needed to validate these findings and to optimise predictive strategies in the management of these patients.
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Venous Thromboembolism and Cancer: A Comprehensive Review from Pathophysiology to Novel Treatment. Biomolecules 2022; 12:biom12020259. [PMID: 35204760 PMCID: PMC8961522 DOI: 10.3390/biom12020259] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
Acute thrombotic events can unveil occult cancer, as they are its first manifestation in about 20 to 30% of all cases. Malignancy interacts in an intricate way with the hemostatic system, promoting both thrombosis and bleeding. The main pathway involved in these reactions involves the activation of tumor-associated procoagulant factors, which eventually results in clot formation. The clinical manifestation of cancer-related thrombotic events mainly involves the venous side, and manifests in a broad spectrum of conditions, including unusual sites of venous thrombosis. The selection of patients who have a balanced risk–benefit profile for management of anticoagulation is complex, given individual patient goals and preferences, different prognosis of specific cancers, common comorbidities, potential drug–drug interactions, underweight states, and the competing risks of morbidity and mortality. Anticoagulant treatment in cancer settings is broadly debated, considering the potential application of direct oral anticoagulants in both thromboprophylaxis and secondary prevention, having demonstrated its efficacy and safety compared to conventional treatment. This review aims to provide a brief overview of the pathophysiology and management of cancer-related thrombosis, summarizing the results obtained in recent clinical trials.
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Ruiz-Sada P, Palacios-García L, Sada-Sainz J. Venous thromboembolism treatment duration in autoimmune diseases. Research trends. Eur J Intern Med 2022; 95:100-101. [PMID: 34716077 DOI: 10.1016/j.ejim.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Pablo Ruiz-Sada
- Internal Medicine Department Hospital Reina Sofía de Tudela.
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Di W, Xu H, Xue T, Ling C. Advances in the Prediction and Risk Assessment of Lung Cancer-Associated Venous Thromboembolism. Cancer Manag Res 2021; 13:8317-8327. [PMID: 34764694 PMCID: PMC8575248 DOI: 10.2147/cmar.s328918] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
According to the most recent data from the National Cancer Center, venous thromboembolism (VTE) has unsurprisingly become one of the most common complications in lung cancer. VTE not only interferes with the equilibrium of the clotting system but it also affects tumor progression and prognosis. For the identification of high-risk patients, many clinical risk assessment models have been developed and validated based on the risk factors found in previous studies. In this review, we will summarize advances in prediction and risk assessment of VTE, with a focus on early diagnosis and therapy, reduction of mortality, and the burden of medical costs in lung cancer patients.
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Affiliation(s)
- Wenjuan Di
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People’s Republic of China
| | - Haotian Xu
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People’s Republic of China
| | - Ting Xue
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People’s Republic of China
| | - Chunhua Ling
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People’s Republic of China
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Kandemir EA, Bayraktar-Ekincioglu A, Kilickap S. Oncologists' attitudes towards prophylaxis of cancer associated venous thromboembolism: A prospective, descriptive study. J Oncol Pharm Pract 2021; 28:1560-1567. [PMID: 34559022 DOI: 10.1177/10781552211035704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cancer-associated venous thromboembolism creates a big burden on both patients and healthcare systems. Clinical guidelines have a consensus on the initiation of prophylactic treatment for hospitalised patients, however a debate still exists for ambulatory cancer patients. Therefore, this study aimed to identify attitudes and practices of medical oncologists on cancer-associated venous thromboembolism management. METHODS An online survey consisting of 22 questions was developed by researchers in the view of previous studies and delivered to 100 medical oncologists registered to the national society of medical oncology by e-mail between September and October 2018. Descriptive and statistical analyses were performed using Statistical Package for Social Science (SPSS) version 23.0 (ICM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). RESULTS A total of 62 medical oncologists (75.8% male) responded to the survey (response rate of 62%). The most critical three risk factors considered for initiating prophylaxis were prior venous thromboembolism history, immobilisation and tumour/cancer type for inpatients and outpatients (χ2 test, p < 0.001). The first choice of drug for prophylaxis was mostly low molecular weight heparins (n = 60, 96.8%). In the absence of contraindications, physicians initiate prophylaxis 'usually' for inpatients (n = 25, 40.3%) and outpatients (n = 5, 8.1%). However routine use of the Khorana score is not incorporated into the risk assessment process of cancer patients. CONCLUSION Attitudes of oncologists towards thromboprophylaxis in cancer patients are consistent with previous studies in the literature. The respondents are aware of the venous thromboembolism risk of cancer patients, however raising awareness on both cancer-associated venous thromboembolism and current guideline recommendations is needed.
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Affiliation(s)
- Esin Aysel Kandemir
- Faculty of Pharmacy, Department of Clinical Pharmacy, 113886Hacettepe University, Ankara, Turkey
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Oxley SG, Achampong YA, Sambandan N, Hughes DJ, Thomas M, Lockley M, Olaitan A. Venous thromboembolism in women with ovarian cancer undergoing neoadjuvant chemotherapy prior to cytoreductive surgery: A retrospective study. Acta Obstet Gynecol Scand 2021; 100:2091-2096. [PMID: 34486103 DOI: 10.1111/aogs.14246] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Ovarian cancer is associated with a venous thromboembolism risk of at least 7.2% by 2 years from diagnosis, and although patients undergoing surgery benefit from routine thromboprophylaxis, those undergoing neoadjuvant chemotherapy do not. This study aims to determine the venous thromboembolism incidence in patients with ovarian cancer undergoing neoadjuvant chemotherapy, and explore whether any subset is at higher risk, in order to evaluate whether thromboprophylaxis is justified in some or all of these patients. MATERIAL AND METHODS This was a retrospective review of all women undergoing neoadjuvant chemotherapy for FIGO radiological stages III and IV primary ovarian, fallopian tube, and primary peritoneal cancer, between 2000 and 2015, in a London tertiary cancer center. The primary outcome was venous thromboembolism rate among women undergoing neoadjuvant chemotherapy. The secondary outcomes were patient or treatment factors associated with venous thromboembolism risk, including age, body mass index, smoking status, performance status, and tumor stage. RESULTS We identified 278 eligible women from the ovarian cancer database. Fifty-eight women (20.9%) developed venous thromboembolism between initial presentation and the immediate postoperative period, of which 45 (77.6%) developed a pulmonary embolism. In all, 15.1% of women developed venous thromboembolism from the start of neoadjuvant chemotherapy. Age, body mass index, smoking, or other comorbidities were not significantly associated with venous thromboembolism risk. One woman died from massive pulmonary embolism, 27 women underwent inferior vena cava filter insertion, and 10 had surgery delayed. CONCLUSIONS This study demonstrates an unacceptably high rate of avoidable venous thromboembolism including pulmonary embolism in these women, which complicates and delays treatment. Thromboprophylaxis during neoadjuvant chemotherapy should now be assessed prospectively.
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Affiliation(s)
- Samuel G Oxley
- Department of Women's Health, University College London Hospital, London, UK
| | - Yaa A Achampong
- Department of Women's Health, University College London Hospital, London, UK
| | - Nikola Sambandan
- Department of Women's Health, University College London Hospital, London, UK
| | - Daniel J Hughes
- Department of Cancer Services, University College London Hospital, London, UK
| | - Mari Thomas
- Department of Haematology, University College London Hospitals NHS Foundation Trust and Cardiometabolic Programme-NIHR UCLH/UC Biomedical Research Centre, London, UK
| | - Michelle Lockley
- Department of Cancer Services, University College London Hospital, London, UK.,Centre for Cancer Cell and Molecular Biology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Adeola Olaitan
- Department of Women's Health, University College London Hospital, London, UK
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Signorelli SS, Oliveri Conti G, Carpinteri G, Lumera G, Fiore M, Dattilo G, Gaudio A, Ferrante M. Venous thromboembolism in hospital emergency room. A retrospective study on climatic effect. ENVIRONMENTAL RESEARCH 2021; 197:110950. [PMID: 33737078 DOI: 10.1016/j.envres.2021.110950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 06/12/2023]
Abstract
Several cardiovascular conditions exhibit seasonality in frequency and mortality, but little is known about the seasonality of Venous ThromboEmbolism (VTE), a very relevant medical condition, and seasonal influences are still conflicting. Patients having co-morbidities, individual suffered from dyspnea, swelling, edema of lower limb, pain (chest, lower limbs) are admitted frequently to the hospital emergency room (HER), particularly. Both mark a potential risk for VTE, that can be increased also by seasonality. A four years retrospective analysis (2016-2019) was carried out in individuals and patients admitted to the HER of the Hospital of Catania (a Mediterranean city of Sicily, Italy) to evaluate the VTE frequency and its seasonal differences, common symptoms, potential usage of some common laboratory tests. Dyspnea, swelling, edema of lower limb and pain (chest, lower limbs) were considered to suspect pulmonary embolism (PE) or for deep vein thrombosis of lower limb (DVT). Platelet count, platelet volume, fibrinogen, C-reactive protein, and D-dimer were considered. VTE frequency per year was 2.9/10,000 (2016), 4.9/10,000 (2017) 3.6/10,000 (2018), and 5.1/10,000 (2019) respectively. Dyspnea was highly frequent for PE, edema and lower limb pain were frequent in DVT patients. Fibrinogen, C reactive protein, and D-dimer values were found raised in all the VTE patients. Platelet volume was found higher in DVT than PE VTE events that occurred in warm periods were modestly greater (57 VTE: 38 DVT, 19 PE) compared to cold months (52 VTE: 34 DVT, 18 PE). Our results could be explained by the increased sweating due to the high temperatures, which in turn, can affect both on plasma concentration and on hematocrit value coupled to the reduction in atmospheric pressure determining both a hyper-coagulative condition. Climate seasonal characteristics, and environmental conditions in Catania city (Sicily) may be as reasonable items in expecting on different VTE rates in warm period compared to cold. This study highlights no specific symptoms, and confirms the common lab tests for individuals and patients admitted to HER as simple and helpful tools in initiating none or mini-invasive diagnostic strategy for the VTE. Finally, the climate/seasonality coupled with latitude can have a direct influence on the incidence of DVT.
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Affiliation(s)
- Salvatore Santo Signorelli
- Department of Clinical and Experimental Medicine. University of Catania, Italy; Internal Medicine Unit. University Hospital "G. Rodolico", Catania, Italy.
| | - Gea Oliveri Conti
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy.
| | - Giuseppe Carpinteri
- Emergengy Medicine Division. University Hospital "G. Rodolico", Catania, Italy
| | - Giovanni Lumera
- Department of Clinical and Experimental Medicine. University of Catania, Italy; Internal Medicine Unit. University Hospital "G. Rodolico", Catania, Italy
| | - Maria Fiore
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy
| | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Agostino Gaudio
- Department of Clinical and Experimental Medicine. University of Catania, Italy
| | - Margherita Ferrante
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia". University of Catania, Italy
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Lee LH, Nagarajan C, Tan CW, Ng HJ. Epidemiology of Cancer-Associated Thrombosis in Asia: A Systematic Review. Front Cardiovasc Med 2021; 8:669288. [PMID: 34095258 PMCID: PMC8175646 DOI: 10.3389/fcvm.2021.669288] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/19/2021] [Indexed: 01/03/2023] Open
Abstract
The epidemiology of cancer associated thrombosis (CAT) in Asia is less well-studied and differs from that in the western countries. Here, we systematically examine population based and hospital-based studies reported between 1995 and 2020 to understand the epidemiology of CAT in Asia. From population-based studies, the estimated incidence of VTE in cancer patients was 1.85–9.88 per 1,000 person-years. The incidence of CAT in Asia is significantly higher than non-cancer associated VTE in the general population and cancer is perhaps the most important risk factor for VTE. Hospital-based studies were heterogeneous in study designs and reveal a wide range of prevalence of VTE among cancer patients at 0.5–44.6% while the cancer prevalence rates among VTE patients ranged from 6.1 to 65.5%. The cancer sites most associated with VTE and risk factors were similar between Asian and Western studies. CAT has a major impact on the survival of patients with cancer in Asia, but thromboprophylaxis is not commonly practiced and validated risk assessment tools are lacking. This study highlights the urgent need for large multinational epidemiological studies in Asia to establish the true burden of CAT and to guide appropriate prevention strategies.
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Affiliation(s)
- Lai Heng Lee
- Singapore General Hospital, Singapore, Singapore
| | | | | | - Heng Joo Ng
- Singapore General Hospital, Singapore, Singapore
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Paredes-Ruiz D, Gómez-Cuervo C, Gómez-Martín C, Sánchez-Guerrero Á, González-Olmedo J, López-López F, Bover-Larroya M, Yarza-Barrio R, Jara-Casas DD, Castelo-Laureiro A, Revilla-Ostolaza Y, Paz-Ares L, Lumbreras-Bermejo C, Díaz-Pedroche C. Incidence of venous thromboembolism in patients with non-hematological cancer admitted for COVID-19 at a third-level hospital in Madrid. J Thromb Thrombolysis 2021; 53:471-478. [PMID: 33890200 PMCID: PMC8061713 DOI: 10.1007/s11239-021-02448-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 12/21/2022]
Abstract
An increased risk of venous thromboembolism (VTE) in hospitalized patients with COVID-19 has been reported. We aimed to describe the incidence rate of VTE on patients with non-hematological cancer who required hospitalization due to COVID-19 at our center. In this prospective study, non-hematological cancer patients hospitalized for confirmed COVID-19 at our institution from 1st March to 30th April 2020, were evaluated daily for VTE complications during their hospital stay, and after discharge until 30th June 2020. Furthermore, Doppler ultrasound of lower limbs was routinely performed in asymptomatic patients based on D-dimer levels and current active cancer therapy. The primary outcome of this study was the cumulative incidence of VTE. Secondary outcomes were the cumulative incidence of bleeding and mortality. A total of 58 hospitalized non-hematological cancer patients and confirmed COVID-19 were identified. Median follow-up since initial symptoms of COVID-19 was 91 days (IQR 19–104). Pulmonary embolism was diagnosed in three (5%) patients. Symptomatic catheter-related deep vein thrombosis (DVT) was observed in one patient. Doppler ultrasound of lower limbs was done in 11 asymptomatic patients, showing distal DVT in two of them (18%). The cumulative incidence of VTE on day 14 after admission was 10%, without new VTE events after hospital discharge and up to 90 days follow-up. No bleeding complication was observed. Seventeen patients (29%) died in the first 14 days after COVID-19 diagnosis. Four patients died after discharge due to malignancy progression. The cumulative incidence of VTE in non-hematological cancer patients under active treatment was 10% at day 14 after admission, with no further new events in the following 12 weeks.
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Affiliation(s)
- Diana Paredes-Ruiz
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Avenida Cordoba S/N 28041, Madrid, Spain.
| | - Covadonga Gómez-Cuervo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Avenida Cordoba S/N 28041, Madrid, Spain
| | - Carlos Gómez-Martín
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Jesús González-Olmedo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Avenida Cordoba S/N 28041, Madrid, Spain
| | - Flora López-López
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Mateo Bover-Larroya
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ramón Yarza-Barrio
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | - Luis Paz-Ares
- Department of Medical Oncology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Lumbreras-Bermejo
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Avenida Cordoba S/N 28041, Madrid, Spain
| | - Carmen Díaz-Pedroche
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, Avenida Cordoba S/N 28041, Madrid, Spain
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Ladha D, Mallick R, Wang TF, Caiano L, Wells PS, Carrier M. Efficacy and safety of apixaban for primary prevention in gastrointestinal cancers: A post-hoc analysis of the AVERT trial. Thromb Res 2021; 202:151-154. [PMID: 33857789 DOI: 10.1016/j.thromres.2021.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/11/2021] [Accepted: 03/15/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent trials have demonstrated that thromboprophylaxis using direct oral anticoagulants is effective but associated with a higher rate of major bleeding in intermediate-to-high risk (Khorana score ≥ 2) patients with cancer initiating systemic chemotherapy. Patients with gastrointestinal cancer may be at higher risk of major bleeding complications. We sought to assess the efficacy and safety of using thromboprophylaxis with apixaban in this patient population. METHODS This is a post-hoc analysis of the AVERT trial, which was a randomized, placebo-controlled, double-blind clinical trial. The primary efficacy outcome was objectively documented venous thromboembolism within 180 days of randomization. The primary safety outcome was a major bleeding episode. Time-to-event analyses were performed in patients with gastrointestinal cancers (upper gastrointestinal, pancreatic/hepatobiliary and colorectal cancers). RESULTS A total of 130 patients from the original AVERT trial were included, with 65 patients allocated to each of the apixaban and placebo groups. VTE occurred in 3 (4.6%) patients in the apixaban group and 13 (20%) patients in the placebo group (HR: 0.27; 95% CI: 0.13-0.54; p = 0.0002). Major bleeding occurred in 2 (3.1%) patients in the apixaban group and 1 (1.5%) patient in the placebo group (HR 2.39, 95% CI 0.29-19.78, p = 0.42). None of the major bleeding events occurred in patients with upper gastrointestinal or colorectal cancers. CONCLUSION Primary thromboprophylaxis with apixaban therapy seems to be safe and effective in patients with gastrointestinal cancers. Major bleeding complications are uncommon in our cohort. (Funded by the CIHR and Bristol-Myers Squibb-Pfizer Alliance; NCT02048865).
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Affiliation(s)
- Danyal Ladha
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ontario, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tzu-Fei Wang
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lucia Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Philip S Wells
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada.
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2083] [Impact Index Per Article: 694.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Liu Y, Wang W, Wu F, Gao G, Xu J, Li X, Zhao C, Yang S, Mao S, Pan Y, Jia K, Shao C, Chen B, Ren S, Zhou C. High discrepancy in thrombotic events in non-small cell lung cancer patients with different genomic alterations. Transl Lung Cancer Res 2021; 10:1512-1524. [PMID: 33889526 PMCID: PMC8044490 DOI: 10.21037/tlcr-20-1290] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Acute complications, such as venous thromboembolism (VTE), are common in patients with advanced severe lung cancers. However, current VTE risk scores cannot adequately identify high-risk patients with non-small cell lung cancer (NSCLC). The study proposed to elucidated the incidence of thromboembolism (TE) in patients with different oncogenic aberrations and the impact of these aberrations on the efficacy of targeted therapy in patients with NSCLC. Methods A systemic review was conducted in Web of Science, PubMed, Embase and the Cochrane Library to evaluate the incidence of TE in different molecular subtypes of NSCLC. Data from patients diagnosed of advanced NSCLC who harboring anaplastic lymphoma kinase (ALK) or ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) rearrangements since 2016 to 2019 were also retrospectively collected. A meta-analysis with random-effects model, sensitivity analysis and publication bias were performed. The principal summary measure was incidence of thrombotic events in NSCLC patients. And the efficacy of tyrosine kinase inhibitor (TKI) therapy was compared between the two subgroups. Results A total of 5,767 cases from 20 studies were included in the analysis of the incidence of thrombosis in patients with different oncogenic alterations. The pooled analysis showed a higher risk of thrombosis in ROS1-fusion types (41%, 95% CI: 35-47%) and ALK-fusion types (30%, 95% CI: 24-37%) than in EGFR-mutation (12%, 95% CI: 8-17%), KRAS-mutation (25%, 95% CI: 13-50%), and wild-type (14%, 95% CI: 10-20%) cases. A high prevalence of thrombosis (ALK: 24.4%; ROS1: 32.6%) was observed in the Shanghai Pulmonary Hospital (SPH) cohort of 224 patients with ALK or ROS1 fusion. Furthermore, patients with embolism had significantly shorter progression-free survival (PFS) after TKI therapy than those without embolism, both in the ALK+ cohort (5.6 vs. 12.9 months, P<0.0001) and in the ROS1+ cohort (9.6 vs. 17.6 months, P=0.0481). Conclusions NSCLC patients with ALK/ROS1 rearrangements are more likely to develop thrombosis than patients with other oncogenic alterations. Thrombosis may also be associated with an inferior response and PFS after TKI therapy.
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Affiliation(s)
- Yiwei Liu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wanying Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fengying Wu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guanghui Gao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Xu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuefei Li
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chao Zhao
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Yang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shiqi Mao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingying Pan
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chuchu Shao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shengxiang Ren
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Dhami SPS, Patmore S, O'Sullivan JM. Advances in the Management of Cancer-Associated Thrombosis. Semin Thromb Hemost 2021; 47:139-149. [PMID: 33636745 DOI: 10.1055/s-0041-1722863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The association between cancer and venous thromboembolism (VTE) has been established for more than 150 years. Nevertheless, cancer-associated thrombosis still remains a major clinical challenge and is associated with significant morbidity and mortality for patients with cancer. The clinical presentation of cancer-associated thrombosis can be distinct from that of a patient without an underlying malignancy. Moreover, specific cancer types, including pancreatic cancer and hematological malignancies, as well as advanced stage disease can confer a significant thrombotic risk. This risk is further augmented by specific anticancer treatment modalities. The pathophysiology of cancer-associated thrombosis is complex and multifactorial. However, understanding the biological mechanisms underpinning VTE risk may provide insight into novel targeted prophylaxis in cancer patients. Over the last decade, low-molecular-weight heparin has been the preferred anticoagulant agent for patients with cancer-associated thrombosis due to improved efficacy compared with vitamin K antagonists. However, the advent of direct oral anticoagulants (DOACs) has added to the repertoire of ammunition now at the disposal of clinicians to aid in the management of cancer-associated thrombosis. Several randomized controlled trials have now been published, demonstrating DOAC as a noninferior alternative for both the treatment and prevention of cancer-associated thrombosis. Notwithstanding this, limitations for their widespread use remain, with the potential for increased bleeding risk, drug interactions, and poor DOAC metabolism. This review discusses the evidence base for the incidence and risk factors associated with VTE in cancer, development, and refinement of risk prediction models and novel advances in the therapeutic management of cancer-associated thrombosis.
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Affiliation(s)
- Sukhraj Pal Singh Dhami
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Sean Patmore
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Jamie M O'Sullivan
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
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Maughan BC, Frueh L, McDonagh MS, Casciere B, Kline JA. Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review. Acad Emerg Med 2021; 28:226-239. [PMID: 32779290 DOI: 10.1111/acem.14108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/27/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical guidelines have supported outpatient treatment of low-risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class. METHODS We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English-language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high-quality studies assessed outcomes associated with different anticoagulation treatment classes. RESULTS Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90-day major adverse outcomes below 1%, including all-cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE-related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes. CONCLUSION Among patients with low-risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days.
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Affiliation(s)
- Brandon C. Maughan
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Lisa Frueh
- and the Department of Social and Behavioral Sciences Harvard TS Chan School of Public Health Boston MAUSA
| | - Marian S. McDonagh
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University School of Medicine Portland ORUSA
| | - Bryan Casciere
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Jeffrey A. Kline
- and the Department of Emergency Medicine Indiana University School of Medicine Indianapolis INUSA
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Nachar VR, Schepers AJ. Clinical controversies in the treatment of cancer-associated venous thromboembolism. J Oncol Pharm Pract 2021; 27:939-953. [PMID: 33435819 DOI: 10.1177/1078155220984371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cancer-associated venous thromboembolism (VTE) is a common complication of malignancy. Patients with cancer exhibit risk factors for both recurrent VTE and major or minor bleeding. Direct oral anticoagulants (DOACs) are an attractive treatment option; however, there is a lack of consensus among national guidelines for choice between DOACs and LMWH, agent selection, dosing strategy, and duration of anticoagulation. Characteristics of the thrombotic event, the malignancy, the patient, and the anticoagulant must be considered. A systematic search of online databases was performed to identify literature on the management of cancer-associated VTE. Multiple controversies remain surrounding the optimal treatment of cancer-associated VTE.
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Affiliation(s)
- Victoria R Nachar
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Allison J Schepers
- Department of Pharmacy Services and Clinical Sciences, Michigan Medicine, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Cohen A, Keshishian A, Lee T, Wygant G, Rosenblatt L, Hlavacek P, Mardekian J, Wiederkehr D, Sah J, Luo X. Effectiveness and Safety of Apixaban, Low-Molecular-Weight Heparin, and Warfarin among Venous Thromboembolism Patients with Active Cancer: A U.S. Claims Data Analysis. Thromb Haemost 2020; 121:383-395. [PMID: 33171521 PMCID: PMC7895542 DOI: 10.1055/s-0040-1718728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background
This study primarily evaluates the risk of recurrent venous thromboembolism (VTE) and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban, low-molecular-weight heparin (LMWH), or warfarin, with claims data.
Methods
Four U.S. commercial insurance claims databases were used to identify patients with VTE and active cancer who initiated apixaban, LMWH, or warfarin within 30 days following the first VTE event. Stabilized inverse-probability treatment weighting (IPTW) was used to balance treatment cohorts. Cox proportional hazard models were used to evaluate risk of recurrent VTE and MB.
Results
All eligibility criteria were fulfilled by 3,393 apixaban, 6,108 LMWH, and 4,585 warfarin patients. After IPTW, all patient characteristics were balanced. When the follow-up was censored at 6 months, apixaban patients had a lower risk of recurrent VTE (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47–0.81) and MB (HR: 0.63; 95% CI: 0.47–0.86) versus LMWH. Apixaban patients had a lower risk of recurrent VTE (HR: 0.68; 95% CI: 0.52–0.90) and similar risk of MB (HR: 0.73; 95% CI: 0.53–1.00) versus warfarin. Warfarin patients had a similar risk of recurrent VTE (HR: 0.91; 95% CI: 0.72–1.15) and MB (HR: 0.87; 95% CI: 0.68–1.12) versus LMWH. The trends were similar for the entire follow-up; however, apixaban patients had a lower risk of MB versus warfarin patients.
Conclusion
Patients with VTE and active cancer who initiated apixaban had a lower risk of recurrent VTE and MB compared with LMWH patients. Apixaban patients also had a lower risk of recurrent VTE compared with warfarin patients.
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Affiliation(s)
- Alexander Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, United Kingdom
| | | | | | - Gail Wygant
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States
| | - Lisa Rosenblatt
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States
| | | | | | | | - Janvi Sah
- SIMR, LLC, Ann Arbor, Michigan, United States
| | - Xuemei Luo
- Pfizer Inc., Groton, Connecticut, United States
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Shaw JR, Kumar V, Mallick R, Carrier M, Ilich A, Key NS, Wells P. Biomarker-enhanced VTE risk stratification in ambulatory patients with cancer. Thromb Res 2020; 196:437-443. [PMID: 33065408 DOI: 10.1016/j.thromres.2020.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/31/2020] [Accepted: 09/30/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Risk assessment models are used to stratify cancer patients according to their underlying risk of VTE. The CATS score has been shown to enhance VTE risk stratification as compared to the modified Khorana score by incorporating d-dimer and soluble p-selectin measurements. Our aim was to evaluate the performance of the CATS score with respect to VTE risk stratification. MATERIALS AND METHODS Analysis of a subset of the AVERT trial population for whom biomarker data was available. All patients included in the AVERT trial were at increased risk of VTE based on a modified Khorana score of ≥2. Patients were stratified according to the modified Khorana score and CATS score. Kaplan-Meier analysis was used to calculate the 6-month cumulative probabilities of VTE. RESULTS A total of 466 patients were included in the analysis, 229 and 237 patients in the placebo and apixaban arms, respectively. The 6-month cumulative probability of VTE among patients with a modified Khorana score ≥ 3 was 13% [95% CI 7 to 23], whereas it was 20% [95% CI 11 to 35] for patients with a CATS score ≥ 4. The absolute risk reduction achieved with apixaban VTE prophylaxis among patients with modified Khorana ≥2, modified Khorana ≥3 and CATS ≥4 was -5.9% [-10.9 to -0.8], -5.8% [-16.0 to 4.5] and -10.1% [-22.9 to 2.6], respectively. Apixaban VTE prophylaxis among patients with increasing modified Khorana or CATS scores was not associated with an increased risk of bleeding events. CONCLUSIONS The use of a CATS score of ≥4 to identify ambulatory cancer patients at very high risk of VTE could enhance the benefit/risk ratio achieved with apixaban VTE prophylaxis.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Vaibhav Kumar
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States; University of North Carolina Blood Research Center
| | - Ranjeeta Mallick
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Anton Ilich
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States; University of North Carolina Blood Research Center
| | - Nigel S Key
- Department of Medicine, University of North Carolina, Chapel Hill, NC, United States; University of North Carolina Blood Research Center
| | - Philip Wells
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Canada.
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Overvad TF, Larsen TB, Søgaard M, Albertsen IE, Ording AG, Noble S, Højen AA, Nielsen PB. Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives. Expert Rev Cardiovasc Ther 2020; 18:791-800. [PMID: 32909840 DOI: 10.1080/14779072.2020.1822167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections. AREAS COVERED This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives. EXPERT OPINION Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient's preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.
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Affiliation(s)
- Thure Filskov Overvad
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Oncology, Aalborg University Hospital , Aalborg, Denmark
| | - Torben Bjerregaard Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Mette Søgaard
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Anne Gulbech Ording
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University , Cardiff, UK
| | - Anette Arbjerg Højen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University , Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital , Aalborg, Denmark
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Sánchez-López V, Gao L, Ferrer-Galván M, Arellano-Orden E, Elías-Hernández T, Jara-Palomares L, Asensio-Cruz MI, Castro-Pérez MJ, Rodríguez-Martorell FJ, Lobo-Beristain JL, Ballaz-Quincoces A, López-Campos JL, Vila-Liante V, Otero-Candelera R. Differential biomarker profiles between unprovoked venous thromboembolism and cancer. Ann Med 2020; 52:310-320. [PMID: 32634035 PMCID: PMC7877930 DOI: 10.1080/07853890.2020.1779956] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/08/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The relationship between cancer and venous thromboembolic disease (VTD) are complex because the activated coagulation factors are not only involved in thrombosis but also in malignant processes, such as angiogenesis and metastasis. OBJECTIVE To compare phenotypes of extracellular vesicles (EVs), and levels of D-dimer, soluble P-selectin (sP-selectin) and antigenic tissue factor (TF) between unprovoked VTD patients, who did not develop cancer during one-year follow-up, and those with advanced stage of cancer but not associated with VTD. METHODS A prospective study in which we included 138 unprovoked VTD patients and 67 advanced cancer patients, who did not develop thrombosis. Levels of EVs of different cellular origin (platelet, endothelium and leukocyte), EVs positive for tissue factor (TF) and P-selectin glycoprotein ligand 1 were quantified by flow cytometry. D-dimer, soluble P-selectin (sP-selectin) and antigenic TF were determined by ELISA. RESULTS TF-positive EVs, D-dimer, and sP-selectin were markedly elevated in unprovoked VTD patients compared to cancer patients without association with thrombosis. CONCLUSIONS Levels of TF-positive EVs, D-dimer and sP-selectin are able to discriminate between unprovoked VTD patients not related to cancer and cancer patients not associated with VTD. These results could lead to the application of EVs as biomarkers of both diseases. Key messages: Circulating EVs, specifically TF-positive EVs, in combination with plasmatic markers of hypercoagulable states, such as D-dimer, sP-selectin and antigen TF, are able to discriminate between cancer patients without thrombosis and patients with unprovoked VTD. Research fields could be opened. Future studies will assess if these biomarkers together serve as predicting thrombotic events in cancer populations.
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Affiliation(s)
- V. Sánchez-López
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Seville, Spain
| | - L. Gao
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Seville, Spain
| | - M. Ferrer-Galván
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - E. Arellano-Orden
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Seville, Spain
| | - T. Elías-Hernández
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - L. Jara-Palomares
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Seville, Spain
| | - M. I. Asensio-Cruz
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - M. J. Castro-Pérez
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - F. J. Rodríguez-Martorell
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | | | | | - J. L. López-Campos
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Seville, Spain
| | - V. Vila-Liante
- Instituto de Investigación Sanitaria, Hospital Universitario y Politécnico La Fe-Valencia, Valencia, Spain
| | - R. Otero-Candelera
- Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Seville, Spain
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Abstract
Given the broad treatment options, risk stratification of pulmonary embolism is a highly desirable component of management. The ideal tool identifies patients at risk of death from the original or recurrent pulmonary embolism. Using all-cause death in the first 30-days after pulmonary embolism diagnosis as a surrogate, clinical parameters, biomarkers, and radiologic evidence of right ventricular dysfunction and strain are predictive. However, no study has demonstrated improved mortality rates after implementation of a risk stratification strategy to guide treatment. Further research should use better methodology to study prognosis and test new management strategies in patients at high risk for death.
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Affiliation(s)
- Thomas Moumneh
- Department of Emergency Medicine, University Hospital of Angers, 4 rue Larrey, 49100 Angers, France; MITOVASC Institute, UMR CNRS 6015 UMR INSERM 1083, Angers University, 28, rue Roger-Amsler, 49045 Angers, France; University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, 501 Smyth Road, Suite M1857, PO Box 206, Ottawa, Ontario K1H 8L6, Canada.
| | - Sebastien Miranda
- University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada; Department of Internal Medicine, Vascular and Thrombosis Unit, Rouen University Hospital, 37 Boulevard Gambetta, 76000 Rouen, France; Normandie University, UNIROUEN, INSERM U1096, 22 Boulevard Gambetta, 76000 Rouen, France
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Pfaundler N, Limacher A, Stalder O, Méan M, Rodondi N, Baumgartner C, Aujesky D. Prognosis in patients with cancer-associated venous thromboembolism: Comparison of the RIETE-VTE and modified Ottawa score. J Thromb Haemost 2020; 18:1154-1161. [PMID: 32124545 DOI: 10.1111/jth.14783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 01/31/2020] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The RIETE-VTE score was derived to risk-stratify patients with cancer-associated venous thromboembolism (CAT). OBJECTIVES To externally validate the RIETE-VTE score and to compare its prognostic performance with the modified Ottawa score. PATIENTS/METHODS We studied 178 elderly patients with CAT in a prospective multicenter cohort and assessed 30-day all-cause mortality, 90-day overall complications (mortality, major bleeding, or venous thromboembolism [VTE] recurrence), and 6-month VTE recurrence. Patients were stratified into RIETE-VTE and modified Ottawa score risk classes (low, intermediate, high). We compared the discriminative power (area under the receiver operating characteristic [ROC] curve) to predict mortality, overall complications, and VTE recurrence. RESULTS Fifteen patients (8.4%) died within 30 days, 42 (23.6%) experienced an overall complication by day 90, and 6 (3.4%) had recurrent VTE within 6 months. The RIETE-VTE and the modified Ottawa score classified similar proportions of patients as low risk (35.4% versus 31.5%; P = .37). No low-risk patient died within 30 days. Low-risk patients identified by the RIETE-VTE and modified Ottawa score had similar rates of overall complications (7.9% versus 8.9%) and VTE recurrence (1.6% versus 1.8%). The modified Ottawa score and the RIETE-VTE score had similar areas under the ROC curve for predicting all-cause mortality (0.84 versus 0.75; P = .21), overall complications (0.74 versus 0.68; P = .26), and VTE recurrence (0.67 versus 0.64; P = .78). CONCLUSIONS Both the RIETE-VTE and modified Ottawa score accurately identified elderly patients with CAT who are at low risk for short-term mortality and who are potential candidates for outpatient care.
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Affiliation(s)
- Nubio Pfaundler
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Limacher
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Odile Stalder
- CTU Bern, and Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Marie Méan
- Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Khorana AA, McCrae KR, Milentijevic D, Laliberté F, Lejeune D, Crivera C, Lefebvre P. Healthcare resource utilization and costs associated with venous thromboembolism recurrence in patients with cancer. J Med Econ 2020; 23:323-329. [PMID: 31818164 DOI: 10.1080/13696998.2019.1703190] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: Patients with cancer are at high risk for developing primary but also recurrent venous thromboembolism (VTE). This study examined healthcare utilization (HRU) and costs related to VTE recurrence among cancer patients.Methods: Medical and pharmacy claims from the Humana Database were used to compare HRU (outpatient visits, emergency room visits, hospitalizations, and hospitalization days) and healthcare costs among cancer patients with a single VTE event (between 01/2013 and 06/2015) and those with recurrent VTE during the follow-up period (from initiation of anticoagulant therapy until end of eligibility or data availability). All-cause and VTE-related HRU and costs were evaluated using Poisson regression, and healthcare costs were compared using mean differences reported as per-patient-per-year (PPPY).Results: Of 2,428 newly diagnosed cancer patients who developed VTE, 413 (17.1%) experienced recurrent VTE during the follow-up period (mean = 9 months). Patients with recurrent VTE had higher all-cause and VTE-related HRU and costs compared to those without recurrence. Patients with recurrent VTE also had over 3.19-times more VTE-related hospitalizations (RR [95% CI] = 3.19 [2.93-3.47]), and 3.88-times more VTE-related hospitalization days (RR [95% CI] = 3.88 [3.74-4.02]) than patients without a VTE recurrence. Total VTE-related healthcare costs were $39,641 PPPY among patients with recurrent VTE, $29,142 higher compared to those without recurrence ($10,499 PPPY). This difference was mainly driven by hospitalization costs.Conclusion: Recurrent VTE among cancer patients is associated with significant HRU and healthcare costs, notably hospitalizations. Strategies to reduce VTE recurrence in patients with cancer can contribute to reducing healthcare cost.
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Affiliation(s)
- Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith R McCrae
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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Song ZK, Cao H, Wu H, Wei Q, Tang M, Yang S, Liu Y, Qin L. Current status of rivaroxaban in elderly patients with pulmonary embolism (Review). Exp Ther Med 2020; 19:2817-2825. [PMID: 32256765 PMCID: PMC7086161 DOI: 10.3892/etm.2020.8559] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/22/2020] [Indexed: 01/14/2023] Open
Abstract
Acute pulmonary embolism (PE) occurs with a high incidence rate in elderly patients, demonstrating complex clinical manifestations, as well as a difficult anticoagulant treatment strategy. Currently, there is limited understanding of the selection criteria for anticoagulant treatment in elderly patients with PE. In fact, the vitamin K antagonist warfarin, a commonly prescribed anticoagulant, has multiple disadvantages, including a narrow therapeutic range, unpredictable pharmacokinetics, multiple food and drug interactions and genetic polymorphisms resulting in poor response to this therapy; therefore, routine laboratory monitoring is required. Most elderly patients with PE fail to adhere to the treatment regimen or even discontinue it, and clinicians are equally hesitant to initiate oral anticoagulants in elderly patients with PE. This leads to a dilemma regarding the use of anticoagulation therapies and a worse prognosis for the patients. Rivaroxaban, a direct Xa factor inhibitor, has demonstrated considerable practical and clinical advantages, exhibits fast-start action pharmacokinetic and pharmacodynamic characteristics, and has an enhanced predictable anticoagulant effect with fewer drug-drug interactions. Based on randomized controlled trials and real-world clinical practice, rivaroxaban has also been recognized as a safe and effective anticoagulant, and these advantages have improved the therapeutic compliance of elderly patients with PE. Thus, this review focused on the current status of rivaroxaban treatment for elderly patients with PE, and described its significance in changing the current anticoagulation treatment regimens for patients. It is expected that rivaroxaban will become a good choice for the treatment of PE in elderly patients.
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Affiliation(s)
- Zi-Kai Song
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Hongyan Cao
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Haidi Wu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Qi Wei
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Minglong Tang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Shuo Yang
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Yang Liu
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
| | - Ling Qin
- Department of Cardiology, The First Hospital of Jilin University, Changchun, Jilin 130000, P.R. China
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