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Xu A, Sibai H, Atenafu EG, Japs K, Seki JT. Universal venous thromboembolism policy is effective but may not adequately protect hospitalized cancer patients with larger BMI. J Thromb Thrombolysis 2020; 49:113-120. [PMID: 31677148 DOI: 10.1007/s11239-019-01975-x] [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: 01/19/2023]
Abstract
Routine VTE prophylaxis is recommended for hospitalized patients, but its effectiveness and safety in cancer patients is unclear. By observation, larger patients seemed poorly covered by the prophylaxis policy. The effectiveness and safety of VTE prophylaxis policy in the hospitalized patients, their potential risk factors such as BMI were examined. A retrospective chart review was conducted to determine VTE incidences, risk factors for VTE and major bleeding events between 2007 and 2016 on the solid tumor units (STU). Patients were divided into pre-policy (Pre-2012) or post-policy implementation groups (Post-2012). Descriptive statistics were used to evaluate effectiveness and safety of prophylaxis, while propensity score matching (1:3, VTE:Non-VTE) was used to reduce selection bias. The VTE incidence per patient was 1.30% (57/4392) pre-policy and 0.56% (18/3210) post-policy (p value = 0.0013). After propensity score matching, a reduction (32.3%) of VTE cases was observed after policy implementation (OR = 0.677, p = 0.32). BMI was found to be a significant predictor of VTE (OR = 1.094, 95% CI 1.021-1.172, p = 0.011). Between July 2014 and July 2016, 1.7% (19/1091) patients who received anticoagulants had a documented bleeding event. The policy positively impacted VTE events on the STU. A significant predictor of VTE was BMI and patients with high BMI may pose a risk of breaking through standard VTE prophylaxis dosing. There was no reported major bleeding for patients who developed an VTE event despite receiving prophylaxis in either the pre-policy or post-policy phase of the study, although a low incidence of minor bleeding was documented in the post-phase.
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Affiliation(s)
- Anna Xu
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Hassan Sibai
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, ON, M5G 2M9, Canada.
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | | | - Jack T Seki
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada.,Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,Drake University, Des Moines, IA, USA
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Kakkar AK, Bauersachs R, Falanga A, Wong J, Kayani G, Kahney A, Hughes R, Levine M. Fundamental Research in Oncology and Thrombosis 2 (FRONTLINE 2): A Follow-Up Survey. Oncologist 2020; 25:e1091-e1097. [PMID: 32384216 PMCID: PMC7356678 DOI: 10.1634/theoncologist.2019-0676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 02/21/2020] [Indexed: 12/20/2022] Open
Abstract
Background Fundamental Research in Oncology and Thrombosis (FRONTLINE) is a global survey of physicians' perceptions and practice in the management of venous thromboembolism (VTE) in patients with cancer. Materials and Methods The present survey, FRONTLINE 2, follows the original FRONTLINE survey (published in The Oncologist in 2003) and provides insights into how physicians perceive risk of VTE in cancer and approach its prophylaxis and treatment. Results Between November 2015 and February 2016, 5,233 respondents participated, representing cancer physicians and surgeons. Most believed that less than one in five patients with any cancer might be at risk of VTE, with a slightly higher risk in patients with brain, pancreatic, and lung tumors. The most frequently reported reasons for giving prophylaxis were prior history of VTE (74.6%), abnormal platelet count (62.0%), and obesity (59.5%). In surgical and medical cancer patients, low‐molecular‐weight heparin (LMWH) was the most popular prophylactic measure, used by 74.2% and 80.6%, respectively. Oral anticoagulants (OACs) were given in less than one fifth of cases. In surgical patients, prophylaxis was usually provided for 1 month postoperatively. Following a diagnosis of VTE, patients initially received treatment with LMWH and were maintained long term on OACs, primarily warfarin, dabigatran, and rivaroxaban. Most surgical and medical cancer patients underwent treatment of VTE for 3–6 months. Conclusion Compared with the original FRONTLINE survey, FRONTLINE 2 reveals some differences in the management of VTE in patients with cancer. Newer anticoagulants such as fondaparinux, dabigatran, and rivaroxaban are being incorporated into the contemporary management of VTE in patients with cancer. Implications for Practice This globally conducted survey of more than 5,000 cancer clinicians revealed a number of insights into the perceived risk for venous thromboembolism as well as contemporary approaches to its prevention and treatment. Although guidelines have consistently recommended anticoagulant medications for prevention and treatment of cancer‐associated thrombosis, clinicians report substantial variation in their practice. Improvements in molecular analysis hold promise for improved identification and treatment of cancers of unknown primary. This article presents the case of a patient with a cancer of unknown primary and metastases in the brain and lung, detailing the genomic profiling performed to establish targeted therapy options.
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Affiliation(s)
- Ajay K. Kakkar
- Thrombosis Research InstituteLondonUnited Kingdom
- University College LondonLondonUnited Kingdom
| | - Rupert Bauersachs
- Klinikum Darmstadt GmbHDarmstadtGermany
- Centre of Thrombosis and Haemostasis, University of MainzMainzGermany
| | - Anna Falanga
- University of Milano‐BicoccaMilanItaly
- Hospital Papa Giovanni XXIIIBergamoItaly
| | - John Wong
- National University Health SystemSingapore
| | | | - Alex Kahney
- Thrombosis Research InstituteLondonUnited Kingdom
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Sibai H, Seki JT, Wang TQ, Sakurai N, Atenafu EG, Yee KWL, Schuh AC, Gupta V, Minden MD, Schimmer AD, Brandwein JM. Venous thromboembolism prevention during asparaginase-based therapy for acute lymphoblastic leukemia. ACTA ACUST UNITED AC 2016; 23:e355-61. [PMID: 27536184 DOI: 10.3747/co.23.3077] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Venous thromboembolism (vte) is a recognized complication in patients treated with asparaginase-containing chemotherapy regimens; the optimal preventive strategy is unclear. We assessed the safety and efficacy of prophylaxis using low-dose low molecular weight heparin in adult patients with acute lymphoblastic leukemia in complete remission treated with an asparaginase-based post-remission chemotherapy regimen. METHODS As part of the intensification phase of the Dana-Farber Cancer Institute 91-01 regimen, asparaginase was administered weekly to 41 consecutive patients for 21-30 weeks; these patients also received prophylaxis with enoxaparin 40 mg daily (60 mg for patients ≥80 kg). Outcomes were assessed against outcomes in a comparable cohort of 99 patients who received the same chemotherapy regimen without anticoagulation prophylaxis. RESULTS The overall rate of symptomatic venous thrombosis was not significantly different in the prophylaxis and non-prophylaxis cohorts (18.92% and 21.74% respectively). Among patients receiving prophylaxis, vte occurred in higher proportion in those who weighed at least 80 kg (42.86% vs. 4.35%, p = 0.0070). No major bleeding complications occurred in the prophylaxis group (minor bleeding: 8.1%). CONCLUSIONS Prophylaxis with low-dose enoxaparin during the intensification phase was safe, but was not associated with a lower overall proportion of vte.
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Affiliation(s)
- H Sibai
- Department of Medical Oncology and Hematology, University Health Network
| | - J T Seki
- Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network; Leslie Dan Faculty of Pharmacy, University of Toronto
| | - T Q Wang
- Department of Pharmacy, Princess Margaret Cancer Centre, University Health Network; Leslie Dan Faculty of Pharmacy, University of Toronto
| | - N Sakurai
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - E G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University Health Network, Toronto, ON
| | - K W L Yee
- Department of Medical Oncology and Hematology, University Health Network
| | - A C Schuh
- Department of Medical Oncology and Hematology, University Health Network
| | - V Gupta
- Department of Medical Oncology and Hematology, University Health Network
| | - M D Minden
- Department of Medical Oncology and Hematology, University Health Network
| | - A D Schimmer
- Department of Medical Oncology and Hematology, University Health Network
| | - J M Brandwein
- Division of Hematology, University of Alberta, Edmonton, AB
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ten Cate-Hoek AJ, Weitz JI, Gailani D, Meijer K, Philippou H, Bouman AC, Whitney Cheung Y, van Mens TE, Govers-Riemslag JW, Vries M, Bleker S, Biedermann JS, Stoof SCM, Buller HR. Theme 3: Non-invasive management of (recurrent) venous thromboembolism (VTE) and post thrombotic syndrome (PTS). Thromb Res 2016; 136 Suppl 1:S13-8. [PMID: 26387731 DOI: 10.1016/j.thromres.2015.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Arina J ten Cate-Hoek
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA.
| | - Jeffrey I Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Canada
| | - David Gailani
- Vanderbilt University, Department of Pathology, Microbiology and Immunology, Nashville, USA
| | - Karina Meijer
- University of Groningen, University Medical Center Groningen, Department of Hematology, Netherlands
| | - Helen Philippou
- University of Leeds, Division of Cardiovascular and Diabetes Research, The LIGHT Labs, Leeds, UK
| | - Annemieke C Bouman
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands; Thrombosis Center, USA
| | - Y Whitney Cheung
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Thijs E van Mens
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jose W Govers-Riemslag
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Minka Vries
- Maastricht University Medical Center, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht (CARIM), Netherlands
| | - Suzanne Bleker
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
| | - Jossi S Biedermann
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - S Carina M Stoof
- Erasmus University Medical Center, Rotterdam, Department of Hematology, Netherlands
| | - Harry R Buller
- University of Amsterdam, Academic Medical Center, Department of Vascular Medicine, Netherlands
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Saghazadeh A, Rezaei N. Inflammation as a cause of venous thromboembolism. Crit Rev Oncol Hematol 2016; 99:272-85. [DOI: 10.1016/j.critrevonc.2016.01.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 11/27/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
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Kelly CM, Power DG, Lichtman SM. Targeted therapy in older patients with solid tumors. J Clin Oncol 2014; 32:2635-46. [PMID: 25071113 DOI: 10.1200/jco.2014.55.4246] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The introduction of targeted therapy has ushered in the era of personalized medicine in cancer therapy. The increased understanding of tumor heterogeneity has led to the determination of specific targets that can be exploited in treatment. This review highlights approved drugs in different therapeutic classes, including tyrosine kinase inhibitors, mammalian target of rapamycin inhibitors, drugs targeted to the human epidermal growth factor receptor 2, BRAF-mutation targeted drugs, anti-epidermal growth factor receptor inhibitors, and anti-vascular endothelial growth factor therapy. There have not been elderly patient-specific trials of these therapies. Most of the data are extrapolated from larger trials in which older patients generally were a fraction of the participants. Therapeutic recommendations are made on the basis of this analysis with the recognition that the older clinical trial participants may not be representative of patients seen in daily practice. Patient selection and geriatric evaluation are critical for appropriate drug selection, dosing, and monitoring. With care, these therapies are a major step forward in the safe and effective treatment of older patients with cancer.
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Affiliation(s)
- Ciara M Kelly
- Ciara M. Kelly and Derek G. Power, Mercy University Hospital, Cork, Ireland; and Stuart M. Lichtman, Memorial Sloan Kettering Cancer Center, Commack, NY
| | - Derek G Power
- Ciara M. Kelly and Derek G. Power, Mercy University Hospital, Cork, Ireland; and Stuart M. Lichtman, Memorial Sloan Kettering Cancer Center, Commack, NY
| | - Stuart M Lichtman
- Ciara M. Kelly and Derek G. Power, Mercy University Hospital, Cork, Ireland; and Stuart M. Lichtman, Memorial Sloan Kettering Cancer Center, Commack, NY.
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Bachmeyer C, Buffo M, Soyez B. No evidence not to prescribe thromboprophylaxis in hospitalized medical patients with cancer. Am J Med 2014; 127:e33. [PMID: 24970610 DOI: 10.1016/j.amjmed.2014.01.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 01/24/2014] [Accepted: 01/24/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Claude Bachmeyer
- Department of Internal Medicine, Tenon Hospital (AP-HP), Paris, France
| | - Milène Buffo
- Department of Internal Medicine, Tenon Hospital (AP-HP), Paris, France
| | - Bérénice Soyez
- Department of Internal Medicine, Tenon Hospital (AP-HP), Paris, France
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Aprile G, Fontanella C, Lutrino ES, Ferrari L, Casagrande M, Cardellino GG, Rosati G, Fasola G. Angiogenic inhibitors for older patients with advanced colorectal cancer: Does the age hold the stage? World J Gastroenterol 2013; 19:2131-40. [PMID: 23847406 PMCID: PMC3706712 DOI: 10.3748/wjg.v19.i14.2131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2013] [Revised: 04/12/2013] [Accepted: 04/13/2013] [Indexed: 02/06/2023] Open
Abstract
Although major progress has been achieved in the treatment of advanced colorectal cancer (CRC) with the employment of antiangiogenic agents, several questions remain on the use of these drugs in older patients. Since cardiovascular, renal and other comorbidities are common in the elderly, an accurate assessment of the patients’ conditions should be performed before a treatment decision is made. Since most CRC patients enrolled in clinical trials testing antiangiogenic drugs were aged < 65 years, the efficacy and tolerability of these agents in elderly patients has not been adequately explored. Data suggest that patients with advanced CRC derive similar benefit from bevacizumab treatment regardless of age, but the advantage of other antiangiogenic drugs in the same class of patients appears more blurred. Literature data suggest that specific antiangiogenic-related toxicities such as hypertension or arterial thromboembolic events may be higher in the elderly than in the younger patients. In addition, it should be emphasized that the patients included in the clinical studies discussed herein were selected and therefore may not be representative of the usual elderly population. Advanced age alone should not discourage the use of bevacizumab. However, a careful patients’ selection and watchful monitoring of toxicities are required to optimize the use of antiangiogenics in this population.
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Nouveaux anticoagulants : ont-ils déjà une place en oncologie ? ONCOLOGIE 2012. [DOI: 10.1007/s10269-012-2232-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Oo TH. Low molecular weight heparin or semuloparin should not be recommended for thromboprophylaxis in ambulatory solid cancer patients undergoing chemotherapy. Thromb Res 2012; 130:821-2. [PMID: 22921591 DOI: 10.1016/j.thromres.2012.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 07/15/2012] [Accepted: 07/18/2012] [Indexed: 11/16/2022]
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