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Aaltonen P, Mustonen H, Puolakkainen P, Haglund C, Peltola K, Carpén O, Lassila R, Seppänen H. Venous thromboembolism incidence and association with overall survival in pancreatic cancer: A Finnish nationwide cohort study. Cancer Med 2024; 13:e70014. [PMID: 39041308 PMCID: PMC11263919 DOI: 10.1002/cam4.70014] [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: 01/23/2024] [Revised: 05/06/2024] [Accepted: 07/04/2024] [Indexed: 07/24/2024] Open
Abstract
INTRODUCTION Pancreatic cancer (PC) is associated with a high risk of venous thromboembolic events (VTEs). We investigated the incidence of VTE before and after the diagnosis of PC and its association with overall survival. METHODS We identified PC patients diagnosed in 2013-2016 from the Finnish Cancer Registry. Data on healthcare visits and death were collected, along with follow-up data through the end of 2020. We compared patients who underwent radical-intent surgery (RIS) to those who underwent palliative treatment (PT) alone. RESULTS We identified 4086 PC patients, of whom 343 (8.4%) underwent RIS and 3743 (91.6%) received PT. VTE incidence within 1 year before a PC diagnosis was higher in the PT (4.2%, n = 156) than in the RIS group (0.6%, n = 2; p < 0.001). The cumulative incidence of VTE at 12 and 24 months after a PC diagnosis was 6% (n = 21) and 9% (n = 31), respectively, within the RIS group, and 8% (n = 286) and 8% (n = 304) within the PT group. In the PT group, a VTE within 1 year before a PC diagnosis was independently associated with a worse survival {hazard ratio, HR 1.9 [95% confidence interval (CI) 1.6-2.2]}. In both groups, VTE after a PC diagnosis was associated with a worse survival [RIS group: HR 2.6 (95%CI 1.8-3.7) vs. PT group: HR 2.2 (95%CI 1.9-2.4)]. CONCLUSIONS A VTE within 1 year before a PC diagnosis more often occurred among PT PC patients than among patients who underwent RIS. VTE might serve as a diagnostic clue to detect PC at an earlier stage.
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Affiliation(s)
- Panu Aaltonen
- Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Mustonen
- Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pauli Puolakkainen
- Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Caj Haglund
- Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Katriina Peltola
- Comprehensive Cancer Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Carpén
- Medicum, Research Program in Systems Oncology and HUSLAB, University of Helsinki, Helsinki, Finland
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit and Research Program Unit in Systems Oncology (ONCOSYS), Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Hanna Seppänen
- Department of Surgery, Translational Cancer Medicine Research Program, iCAN Digital Precision Cancer Medicine Flagship, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Bolek H, Ürün Y. Cancer-associated thrombosis and drug-drug interactions of antithrombotic and antineoplastic agents. Cancer 2023; 129:3216-3229. [PMID: 37401828 DOI: 10.1002/cncr.34937] [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: 04/01/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 07/05/2023]
Abstract
Venous thromboembolism (VTE) is often associated with malignant diseases and notably contributes to morbidity and mortality in patients with cancer. Cancer-associated thrombosis (CAT) brings additional costs to health expenditures and has a negative impact on oncological outcomes. Either the recurrence rate of VTE or bleeding complications are also higher in patients with cancer. Prophylactic anticoagulation has been recommended in peri-surgical periods, inpatient settings, and high-risk ambulatory patients. Although various risk stratification scores are used, none are ideal for identifying patients who can benefit from anticoagulant prophylaxis. New risk scoring systems or biomarkers are needed to identify patients who are more likely to benefit from prophylaxis with low bleeding risk. The questions about the patients who will be given prophylaxis and those who develop thromboembolism, with which drug, and how long they will be treated are still not fully answered. Anticoagulation is the cornerstone of the treatment, but management of CAT remains complex. Low molecular weight heparins and direct oral anticoagulants are effective and safe options for the treatment of CAT. Recognizing adverse effects, drug-drug interactions, and accompanying conditions that cause dose adjustment is crucial. Prevention and treatment of VTE in patients with cancer require a multidisciplinary and patient-based approach. PLAIN LANGUAGE SUMMARY: Cancer-associated thrombosis is a significant cause of mortality and morbidity in patients with cancer. Chemotherapy, surgery, and/or use of central venous access remarkably increase the risk of thrombosis. Prophylactic anticoagulation should be considered not only in inpatient follow-up and during peri-surgical period but also ambulatory patients with a high risk of thrombosis. Many parameters, such as drug-drug interactions, primary side of cancer, and comorbidities of patients should be considered when selecting anticoagulant drugs. More accurate risk stratification scores or biomarkers are still an unmet need.
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Affiliation(s)
- Hatice Bolek
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
| | - Yüksel Ürün
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
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3
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Thein KZ, Htut TW, Myat YM, Han MM, Win MA, Phyu EM, Oo TH. Updated meta-analysis of randomized controlled trials on primary outpatient thromboprophylaxis in patients with gastric and gastroesophageal junction cancers receiving chemotherapy. Proc AMIA Symp 2023; 36:635-640. [PMID: 37614866 PMCID: PMC10443955 DOI: 10.1080/08998280.2023.2225913] [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: 02/28/2023] [Revised: 05/25/2023] [Accepted: 06/12/2023] [Indexed: 08/25/2023] Open
Abstract
Advanced gastric cancer is a highly thrombogenic cancer per Khorana score. Recent clinical practice guidelines suggest primary outpatient thromboprophylaxis (POTP) for patients with a Khorana score ≥2. We performed an updated meta-analysis to evaluate the benefit of POTP in patients with gastric cancer and gastroesophageal junction cancers receiving chemotherapy. Randomized controlled trials with reduction in venous thromboembolism (VTE) as a primary or secondary endpoint were incorporated. A total of 631 patients from subgroups of three randomized controlled trials were included. The VTE incidence was 1.6% and 5.1% in POTP and control groups, respectively (risk ratio 0.31; confidence interval 0.11 to 0.83; P = 0.02), with a number needed to treat of 29 to prevent one VTE event. Even though the recent clinical practice guidelines suggest POTP in patients with gastric cancer and gastroesophageal junction cancers, our meta-analysis findings do not support the routine use of POTP in those patients.
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Affiliation(s)
- Kyaw Zin Thein
- Division of Hematology and Medical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, Oregon, USA
| | - Thura Win Htut
- Department of Hematology, Aberdeen Royal Infirmary, University of Aberdeen, NHS Grampian, Scotland, UK
| | | | - Myat Min Han
- Department of Internal Medicine, Interfaith Medical Center, Brooklyn, New York, USA
| | - Myint Aung Win
- Department of Internal Medicine, Lewis Gale Medical Center, Salem, Virginia, USA
| | - Ei Moe Phyu
- Department of Hospital Medicine, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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4
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Muñoz A, Ay C, Grilz E, López S, Font C, Pachón V, Castellón V, Martínez-Marín V, Salgado M, Martínez E, Calzas J, Ortega L, Rupérez A, Salas E, Pabinger I, Soria JM. A Clinical-Genetic Risk Score for Predicting Cancer-Associated Venous Thromboembolism: A Development and Validation Study Involving Two Independent Prospective Cohorts. J Clin Oncol 2023; 41:2911-2925. [PMID: 36730884 PMCID: PMC10414737 DOI: 10.1200/jco.22.00255] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. The Khorana score was developed for assessing the risk of VTE in outpatients with cancer receiving chemotherapy, but its accuracy in identifying patients at high risk has been questioned. The aim of this study was to develop and validate a clinical-genetic score that improves the assessment of VTE risk in oncology outpatients within 6 months of diagnosis. METHODS The new score was developed using the data of 364 outpatients belonging to the Spanish ONCOTHROMB 12-01 population. In this cohort, clinical data associated with the risk of VTE were collected at the time of diagnosis, including the Khorana score. These patients were also genotyped for the 51 genetic variants known to be associated with VTE. Multivariate logistic regression was performed to determine the weight of each genetic and clinical variable in relation to VTE risk, allowing a clinical-genetic risk score (the ONCOTHROMB score) to be developed. The Khorana and the ONCOTHROMB scores were then compared via the area under the receiver operating characteristic curve (AUC), calibration, and the number of patients needed to treat. The new score was then validated in a study of 263 patients in the Vienna Cancer and Thrombosis Study population. RESULTS Nine genetic variants, tumor site, TNM stage, and a body mass index of > 25 kg/m2 were found to be associated with VTE and were used to build the ONCOTHROMB score, which better predicted the overall risk of VTE than did the Khorana score (AUC, 0.781 v 0.580; P < .001). Similar AUC results were recorded in the validation study the Vienna Cancer and Thrombosis Study cohort involving patients with the same type of tumor (AUC for the ONCOTHROMB score v the Khorana score: 0.686 v 0.577; P < .001) and with all type of tumors (AUC for the ONCOTHROMB score v the Khorana score: 0.720 v 0.561; P < .0001). CONCLUSION The ONCOTHROMB score for VTE risk in outpatients with cancer, which takes into account both clinical and genetic variables, better identifies patients who might benefit from primary thromboprophylaxis than does the Khorana score.
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Affiliation(s)
- Andrés Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ella Grilz
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonia López
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Carme Font
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Vanesa Pachón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Ramón y Cajal Madrid, Madrid, Spain
| | - Victoria Castellón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Virginia Martínez-Marín
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Salgado
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Eva Martínez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Julia Calzas
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Laura Ortega
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Ana Rupérez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Fundación Jiménez Díaz, Madrid, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jose Manuel Soria
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
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5
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Voigtländer M, Langer F. [Cancer-associated coagulation disorders]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2022; 73:809-819. [PMID: 36102956 DOI: 10.1007/s00105-022-05056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Diagnosis and treatment of paraneoplastic coagulation disorders are a challenge in daily practice. While prophylactic anticoagulation to prevent venous thromboembolism (VTE) is standard of care in all surgical and acutely ill medical cancer patients, particularly careful evaluation of risks and benefits using validated risk assessment models is required during outpatient chemotherapy. Low-molecular-weight heparin and direct oral factor Xa inhibitors are available to treat established cancer-associated VTE, adhering to algorithms for bleeding risk stratification. In patients with overt disseminated intravascular coagulation, therapeutic measures should strictly follow clinical symptoms. An acquired von Willebrand syndrome may evoke a severe bleeding tendency in patients with myeloproliferative neoplasms or plasma cell dyscrasias. In 15% of cases, acquired hemophilia A, due to the formation of inhibitory autoantibodies against coagulation factor VIII, is associated with malignancy.
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Affiliation(s)
- Minna Voigtländer
- Zentrum für Onkologie - Universitäres Cancer Center Hamburg (UCCH), II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Florian Langer
- Zentrum für Onkologie - Universitäres Cancer Center Hamburg (UCCH), II. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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6
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Htut TW, Thein KZ, Quick DP, Oo TH. Meta-analysis of randomized controlled trials on primary ambulatory thromboprophylaxis in patients with nonpancreatic gastrointestinal cancers receiving chemotherapy. Proc AMIA Symp 2022; 35:51-55. [PMID: 34970032 DOI: 10.1080/08998280.2021.1973340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Primary ambulatory thromboprophylaxis (PATP) in patients with solid malignancies is not routinely indicated. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the benefit and risk of PATP in patients with nonpancreatic gastrointestinal cancers receiving chemotherapy. RCTs with venous thromboembolism (VTE) reduction as primary or secondary endpoints were included. A total of 1932 patients from subgroups of 3 RCTs were eligible. The VTE incidence was 1.26% and 2.55% in PATP and control arms, respectively (risk ratio 0.49; confidence interval 0.25 to 0.96; P = 0.04), with a number needed to treat of 78 to prevent one VTE event. In gastric and gastroesophageal junction cancer patients, the VTE incidence was 1.37% and 3.40% in PATP and control arms, respectively (risk ratio 0.40; confidence interval 0.13 to 1.24; P = 0.11). PATP should not be recommended in patients with nonpancreatic gastrointestinal cancers on chemotherapy.
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Affiliation(s)
- Thura Win Htut
- Department of Hematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kyaw Zin Thein
- Department of Investigational Cancer Therapeutics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.,Division of Hematology and Medical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, Oregon
| | - Donald Paul Quick
- Joe Arrington Cancer Research and Treatment Center, Lubbock, Texas.,Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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7
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Sandow LP, Cannon LA, Weston NR, Aung KL, Oo TH. The Clinical Applicability of Primary Thromboprophylaxis in Ambulatory Patients With Pancreatic Cancer. Pancreas 2021; 50:494-499. [PMID: 33939659 DOI: 10.1097/mpa.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
ABSTRACT Thromboembolism is a leading cause of death in ambulatory patients with cancer. Patients with pancreatic adenocarcinoma have a very high risk of developing venous thromboembolism, especially within the first 6 months of diagnosis. Although primary thromboprophylaxis could reduce this risk, there are unresolved questions concerning choice of agents for anticoagulation, duration of anticoagulation treatment, and criteria for patient selection. Furthermore, the current clinical guidelines on primary thromboprophylaxis in ambulatory patients with pancreatic cancer are ambiguous. This review seeks out to understand and critically appraise the evidence supporting the use of primary thromboprophylaxis in patients with pancreatic cancer and its clinical applicability.
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Affiliation(s)
| | | | | | - Kyaw Lwin Aung
- Department of Oncology, Livestrong Cancer Institutes and Dell Medical School, The University of Texas at Austin, Austin
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 402] [Impact Index Per Article: 134.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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9
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Cosmi B. An update on the efficacy and safety of novel anticoagulants for cancer associated thrombosis. Expert Opin Pharmacother 2020; 22:583-594. [PMID: 33243038 DOI: 10.1080/14656566.2020.1847273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: Cancer-associated thrombosis (CAT) refers to the most common thromboembolic complication of cancer which is venous thromboembolism (VTE). CAT primary prophylaxis, treatment, and secondary prevention are challenging for the complexity of cancer patients, who exhibit hypercoagulability with concomitant-heightened bleeding risk.Areas covered: In this review, the author examines the role of low molecular weight heparins (LMWH), which have been the standard of care for CAT treatment for many years. Direct oral anticoagulants (DOACS) have practical advantages over subcutaneous LMWH, especially for long-term therapy. The author then discusses the results of two RCTs which separately compared the direct oral factor Xa inhibitors, apixaban or rivaroxaban, with placebo for CAT prophylaxis in ambulatory high-risk cancer patients and found that DOACS reduced VTE but increased bleeding. Finally, the author discusses four RCTS separately comparing an oral direct factor Xa inhibitor (edoxaban, rivaroxaban, or apixaban) with LMWH for CAT treatment. DOACS showed non-inferior efficacy, although rivaroxaban and edoxaban showed higher bleeding rates, especially in gastrointestinal cancers.Expert opinion: DOACS have a convenient route of administration and do not require laboratory monitoring, although choice of anticoagulants for CAT depends on factors such as tumor type, bleeding risk, concomitant drugs, and comorbidities.
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Affiliation(s)
- Benilde Cosmi
- Division of Angiology & Blood Coagulation, Department of Specialty, Diagnostics and Experimental Medicine, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
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10
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Laporte S, Chapelle C, Trone JC, Bertoletti L, Girard P, Meyer G, Safieddine M, Cucherat M, Ollier E, Mismetti P. Early detection of the existence or absence of the treatment effect: A cumulative meta-analysis. J Clin Epidemiol 2020; 124:24-33. [DOI: 10.1016/j.jclinepi.2020.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023]
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11
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Labianca A, Bosetti T, Indini A, Negrini G, Labianca RF. Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer. Cancers (Basel) 2020; 12:E2070. [PMID: 32726933 PMCID: PMC7466093 DOI: 10.3390/cancers12082070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022] Open
Abstract
In the general population, the incidence of thromboembolic events is 117 cases/100,000 inhabitants/year, while in cancer patient incidence, it is four-fold higher, especially in patients who receive chemotherapy and who are affected by pancreatic, lung or gastric cancer. At the basis of venous thromboembolism (VTE) there is the so-called Virchow triad, but tumor cells can activate coagulation pathway by various direct and indirect mechanisms, and chemotherapy can contribute to VTE onset. For these reasons, several studies were conducted in order to assess efficacy and safety of the use of anticoagulant therapy in cancer patients, both in prophylaxis setting and in therapy setting. With this review, we aim to record principal findings and current guidelines about thromboprophylaxis in cancer patients, with particular attention to subjects with additional risk factors such as patients receiving chemotherapy or undergoing surgery, hospitalized patients for acute medical intercurrent event and patients with central venous catheters. Nonetheless we added a brief insight about acute and maintenance therapy of manifested venous thromboembolism in cancer patients.
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Affiliation(s)
- Alice Labianca
- Medical Oncology Unit, Department of Oncology and Haematology, ASST Papa Giovanni XXIII, 24121 Bergamo, Italy; (A.L.); (T.B.); (G.N.)
| | - Tommaso Bosetti
- Medical Oncology Unit, Department of Oncology and Haematology, ASST Papa Giovanni XXIII, 24121 Bergamo, Italy; (A.L.); (T.B.); (G.N.)
| | - Alice Indini
- Medical Oncology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20019 Milano, Italy;
| | - Giorgia Negrini
- Medical Oncology Unit, Department of Oncology and Haematology, ASST Papa Giovanni XXIII, 24121 Bergamo, Italy; (A.L.); (T.B.); (G.N.)
| | - Roberto Francesco Labianca
- Medical Oncology Unit, Department of Oncology and Haematology, ASST Papa Giovanni XXIII, 24121 Bergamo, Italy; (A.L.); (T.B.); (G.N.)
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12
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Primary Thromboprophylaxis in Ambulatory Pancreatic Cancer Patients Receiving Chemotherapy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cancers (Basel) 2020; 12:cancers12082028. [PMID: 32722064 PMCID: PMC7464699 DOI: 10.3390/cancers12082028] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with pancreatic cancer (PC) carry the highest risk of venous thromboembolism (VTE) amongst all cancer patients. Appropriate use of primary thromboprophylaxis might significantly and safely reduce its burden. We performed a systematic review of published studies and meeting abstracts using MEDLINE and EMBASE through July 2020 to evaluate the efficacy and safety of primary thromboprophylaxis in ambulatory PC patients receiving chemotherapy. The Mantel–Haenszel random effect model was used to estimate the pooled event-based risk ratio (RR) and the pooled absolute risk difference (RD) with a 95% confidence interval (CI). Five randomized controlled studies with 1003 PC patients were included in this meta-analysis. Compared to placebo, thromboprophylaxis significantly decreased the risk of VTE (pooled RR 0.31, 95% CI 0.19–0.51, p < 0.00001, I2 = 8%; absolute RD −0.08, 95% CI −0.12–−0.05, p < 0.00001, I2 = 0%), with an estimated number needed to treat of 11.9 patients to prevent one VTE event. Similar reductions of VTE were observed in studies with parenteral (RR 0.30, 95% CI 0.17–0.53) versus oral anticoagulants (RR 0.37, 95% CI 0.14–0.99) and in studies using prophylactic doses of anticoagulants (RR 0.34, 95% CI 0.17–0.70) versus supra-prophylactic doses of anticoagulants (RR 0.27, 95% CI 0.08–0.90). The pooled RR for major bleeding was 1.08 (95% CI 0.47–2.52, p = 0.85, I2 = 0%) and the absolute RD was 0.00 (95% CI −0.02–0.03, p = 0.85, I2 = 0%). Evidence supports a net clinical benefit of thromboprophylaxis in ambulatory PC patients receiving chemotherapy. Adequately powered randomized phase III studies assessing the most effective anticoagulant and the optimal dose, schedule and duration of thromboprophylaxis to be used are warranted.
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Vadhan-Raj S, McNamara MG, Venerito M, Riess H, O'Reilly EM, Overman MJ, Zhou X, Vijapurkar U, Kaul S, Wildgoose P, Khorana AA. Rivaroxaban thromboprophylaxis in ambulatory patients with pancreatic cancer: Results from a pre-specified subgroup analysis of the randomized CASSINI study. Cancer Med 2020; 9:6196-6204. [PMID: 32663379 PMCID: PMC7476843 DOI: 10.1002/cam4.3269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer patients are at risk for venous thromboembolism (VTE); the value of thromboprophylaxis has not been definitively established. METHODS This trial randomized cancer patients initiating a new regimen and at high risk for VTE (Khorana score ≥2) to rivaroxaban 10 mg or placebo up to day 180. This analysis examined the subset of pancreatic cancer patients. The primary efficacy endpoint was the composite of symptomatic deep-vein thrombosis (DVT), asymptomatic proximal DVT, any pulmonary embolism, and VTE-related death. The primary safety endpoint was International Society on Thrombosis and Haemostasis-defined major bleeding. RESULTS In total, 49/1080 (4.5%) patients enrolled had baseline VTE on screening, with higher rates (24/362 [6.6%]) in pancreatic cancer and they were not randomized. Of 841 randomized patients, 273 (32.5%) had pancreatic cancer; 155/273 (57% in each arm) completed the double-blind period. The primary endpoint occurred in 13/135 (9.6%) patients in the rivaroxaban group and in 18/138 (13.0%) in the placebo group (hazard ratio [HR] = 0.70; 95% CI, 0.34-1.43; P = .328) in up-to-day-180 period and 5/135 (3.7%) patients receiving rivaroxaban and 14/138 (10.1%) receiving placebo in the intervention period (HR = 0.35; 95% CI, 0.13-0.97; P = .034). Major bleeding was similar (2 [1.5%] receiving rivaroxaban and 3 [2.3%] receiving placebo). Correlative biomarker studies demonstrated significant decline in D-dimer (weeks 8 and 16) in patients randomized to rivaroxaban compared to placebo (P < .01). CONCLUSIONS In ambulatory pancreatic cancer patients, rivaroxaban did not result in significantly lower incidence of VTE or VTE-related death in the 180-day period. During the intervention period, however, rivaroxaban substantially reduced VTE without increasing major bleeding, suggesting benefit of rivaroxaban prophylaxis in this setting. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02555878.
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Affiliation(s)
- Saroj Vadhan-Raj
- The UT MD Anderson Cancer Center, Department of Sarcoma Medical Oncology, Section of Cytokines and Supportive Oncology, Houston, TX, USA
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust & Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie Universitätsklinikum, Magdeburg, Germany
| | - Hanno Riess
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | | | - Xiao Zhou
- The UT MD Anderson Cancer Center, Department of Sarcoma Medical Oncology, Section of Cytokines and Supportive Oncology, Houston, TX, USA
| | | | - Simrati Kaul
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
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14
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Thein KZ, Oo TH. 2019 international clinical practice guidelines for the treatment of venous thromboembolism. Lancet Oncol 2020; 20:e655. [PMID: 31797781 DOI: 10.1016/s1470-2045(19)30734-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 10/18/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kyaw Zin Thein
- Department of Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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15
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Frere C, Bournet B, Gourgou S, Fraisse J, Canivet C, Connors JM, Buscail L, Farge D. Incidence of Venous Thromboembolism in Patients With Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes. Gastroenterology 2020; 158:1346-1358.e4. [PMID: 31843588 DOI: 10.1053/j.gastro.2019.12.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC. METHODS We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times. RESULTS During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001). CONCLUSION In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).
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Affiliation(s)
- Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism and Nutrition, Paris, France; Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Barbara Bournet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Sophie Gourgou
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Julien Fraisse
- Université de Montpellier, Institut du Cancer de Montpellier-Unité de Biométrie, Montpellier, France
| | - Cindy Canivet
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Louis Buscail
- University of Toulouse, Toulouse, France; CHU de Toulouse, Department of Gastroenterology and Pancreatology, Toulouse, France
| | - Dominique Farge
- Université de Paris, Institut Universitaire d'Hématologie, Paris, France; Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France; Department of Medicine, McGill University, Montreal, Québec, Canada.
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16
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Farge D, Bournet B, Conroy T, Vicaut E, Rak J, Zogoulous G, Barkun J, Ouaissi M, Buscail L, Frere C. Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented. Cancers (Basel) 2020; 12:E618. [PMID: 32155940 PMCID: PMC7139861 DOI: 10.3390/cancers12030618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.
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Affiliation(s)
- Dominique Farge
- Institut Universitaire d’Hématologie, Université de Paris, EA 3518, F-75010 Paris, France
- Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, F-75010 Paris, France
- Department of Medicine, McGill University, Montreal, Québec, QC H4A 3J1, Canada
| | - Barbara Bournet
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, APEMAC, EA4360, F-54519 Vandoeuvre-lès-Nancy, France;
| | - Eric Vicaut
- Department of Biostatistics, Université de Paris, F-75010 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Biostatistics, Fernand Widal Hospital, F-75010 Paris, France
| | - Janusz Rak
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - George Zogoulous
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Jefferey Barkun
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic Transplantation, Trousseau Hospital, CHRU Trousseau, F-37170 Chambray-les-Tours, France;
| | - Louis Buscail
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Corinne Frere
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166, GRC 27 GRECO, F-75013 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, F-75013 Paris, France
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17
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Rafii H, Frère C, Benzidia I, Crichi B, Andre T, Assenat E, Bournet B, Carpentier A, Connault J, Doucet L, Durant C, Emmerich J, Gris JC, Hij A, Le Hello C, Madelaine I, Messas E, Ndour A, Villiers S, Marjanovic Z, Ait Abdallah N, Yannoutsos A, Farge D. Management of cancer-related thrombosis in the era of direct oral anticoagulants: A comprehensive review of the 2019 ITAC-CME clinical practice guidelines. On behalf of the Groupe Francophone Thrombose et Cancer (GFTC). JOURNAL DE MEDECINE VASCULAIRE 2020; 45:28-40. [PMID: 32057323 DOI: 10.1016/j.jdmv.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/06/2019] [Indexed: 06/10/2023]
Abstract
Venous thromboembolism (VTE) is a common disease complication in cancer patients and the second cause of death after cancer progression. VTE management and prophylaxis are critical in cancer patients, but effective therapy can be challenging because these patients are at higher risk of VTE recurrence and bleeding under anticoagulant treatment. Numerous published studies report inconsistent implementation of existing evidence-based clinical practice guidelines (CPG), including underutilization of thromboprophylaxis, and wide variability in clinical practice patterns across different countries and various practitioners. This review aims to summarize the 2019 ITAC-CME evidence-based CPGs for treatment and prophylaxis of cancer-related VTE, which include recommendations on the use of direct oral anticoagulants specifically in cancer patients. The guidelines underscore the gravity of developing VTE in cancer and recommend the best approaches for treating and preventing cancer-associated VTE, while minimizing unnecessary or over-treatment. Greater adherence to the 2019 ITAC guidelines could substantially decrease the burden of VTE and improve survival of cancer patients.
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Affiliation(s)
- H Rafii
- Eurocord, Équipe 3 EA3518, hôpital Saint-Louis, Université de Paris, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - C Frère
- Inserm UMRS_1166, Department of Haematology, hôpital Pitié-Salpêtrière, Université de Paris, Sorbonne Paris-Cité, AP-HP, Paris, France
| | - I Benzidia
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - B Crichi
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - T Andre
- Hôpital Saint-Antoine, AP-HP, Paris, France
| | - E Assenat
- Montpellier school of Medicine, Saint-Eloi University Hospital, Montpellier, France
| | - B Bournet
- Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | | | | | - L Doucet
- Hôpital Saint-Louis, AP-HP, Paris, France
| | | | | | | | - A Hij
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - C Le Hello
- CHU Saint-Étienne, Saint-Étienne, France
| | | | - E Messas
- Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
| | - A Ndour
- Hôpital Saint-Louis, AP-HP, Paris, France
| | - S Villiers
- Hôpital Saint-Louis, AP-HP, Paris, France
| | | | - N Ait Abdallah
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | | | - D Farge
- Internal Medicine (UF04), Équipe 3 EA 3518, Autoimmune and Vascular Disease Unit, Saint-Louis Hospital, Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, AP-HP, Sorbonne Paris-Cité, Paris, France; Department of Medicine, McGill University, Montreal, QC, Canada
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18
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Muñoz Martín AJ, Gallardo Díaz E, García Escobar I, Macías Montero R, Martínez-Marín V, Pachón Olmos V, Pérez Segura P, Quintanar Verdúguez T, Salgado Fernández M. SEOM clinical guideline of venous thromboembolism (VTE) and cancer (2019). Clin Transl Oncol 2020; 22:171-186. [PMID: 31981080 DOI: 10.1007/s12094-019-02263-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 12/05/2019] [Indexed: 12/12/2022]
Abstract
In 2011, the Spanish Society of Medical Oncology (SEOM) first published a clinical guideline of venous thromboembolism (VTE) and cancer. This guideline was updated in 2014, and since then, multiple studies and clinical trials have changed the landscape of the treatment and prophylaxis of VTE in cancer patients. To incorporate the most recent evidence, including data from direct oral anticoagulants (DOACs) randomized clinical trials, SEOM presents a new update of the guideline.
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Affiliation(s)
- A J Muñoz Martín
- Medical Oncology Department, Instituto de Investigación Sanitaria Gregorio Marañón, C/ Dr. Esquerdo, 46, 28007, Madrid, Spain.
| | - E Gallardo Díaz
- Medical Oncology Department, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - I García Escobar
- Medical Oncology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - R Macías Montero
- Medical Oncology Department, Complejo H. Universitario, Badajoz, Spain
| | - V Martínez-Marín
- Medical Oncology Department, Hospital Universitario la Paz, Madrid, Spain
| | - V Pachón Olmos
- Medical Oncology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERONC, Madrid, Spain
| | - P Pérez Segura
- Medical Oncology Department, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | - M Salgado Fernández
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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19
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2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2019; 20:e566-e581. [PMID: 31492632 DOI: 10.1016/s1470-2045(19)30336-5] [Citation(s) in RCA: 399] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023]
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20
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Capurso G. Deprescription during last year of life in patients with pancreatic cancer: Optimization or nihilism? Cancer 2019; 125:3470-3471. [PMID: 31290998 DOI: 10.1002/cncr.32389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gabriele Capurso
- Pancreato-biliary Endoscopy and EUS Division, Pancreas Translational and Clinical Research Center, San Raffaele Scientific Institute IRCCS, Milan, Italy
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21
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Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Francis CW, Gates LE, Kakkar AK, Levine MN, Liebman HA, Tempero MA, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2019; 38:496-520. [PMID: 31381464 DOI: 10.1200/jco.19.01461] [Citation(s) in RCA: 851] [Impact Index Per Article: 170.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Nigel S Key
- University of North Carolina, Chapel Hill, NC
| | | | - Nicole M Kuderer
- Advanced Cancer Research Group and University of Washington, Seattle, WA
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Agnes Y Y Lee
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | | | | | | | - Charles W Francis
- James P Wilmot Cancer Center and University of Rochester, Rochester, NY
| | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College, London, United Kingdom
| | | | - Howard A Liebman
- University of Southern California and Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA
| | - Anna Falanga
- Hospital Papa Giovanni XXIII, Bergamo; and University of Milan Bicocca, Milan, Italy
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22
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Walsh M, Moore EE, Moore H, Thomas S, Lune SV, Zimmer D, Dynako J, Hake D, Crowell Z, McCauley R, Larson EE, Miller M, Pohlman T, Achneck HE, Martin P, Nielsen N, Shariff F, Ploplis VA, Castellino FJ. Use of Viscoelastography in Malignancy-Associated Coagulopathy and Thrombosis: A Review. Semin Thromb Hemost 2019; 45:354-372. [PMID: 31108555 PMCID: PMC7707018 DOI: 10.1055/s-0039-1688497] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The relationship between malignancy and coagulopathy is one that is well documented yet incompletely understood. Clinicians have attempted to quantify the hypercoagulable state produced in various malignancies using common coagulation tests such as prothrombin time, activated partial thromboplastin time, and platelet count; however, due to these tests' focus on individual aspects of coagulation during one specific time point, they have failed to provide clinicians the complete picture of malignancy-associated coagulopathy (MAC). Viscoelastic tests (VETs), such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM), are whole blood analyses that have the advantage of providing information related to the cumulative effects of plasma clotting factors, platelets, leukocytes, and red cells during all stages of the coagulation and fibrinolytic processes. VETs have gained popularity in the care of trauma patients to objectively measure trauma-induced coagulopathy (TIC), but the utility of VETs remains yet unrealized in many other medical specialties. The authors discuss the similarities and differences between TIC and MAC, and propose a mechanism for the hypercoagulable state of MAC that revolves around the thrombomodulin-thrombin complex as it switches between activating the protein C anticoagulation pathway or the thrombin activatable fibrinolysis inhibitor coagulation pathway. Additionally, they review the current literature on the use of TEG and ROTEM in patients with various malignancies. Although limited research is currently available, early results demonstrate the utility of both TEG and ROTEM in the prediction of hypercoagulable states and thromboembolic complications in oncologic patients.
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Affiliation(s)
- Mark Walsh
- Saint Joseph Regional Medical Center, Mishawaka, Indiana
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Ernest E. Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Hunter Moore
- Ernest E. Moore Trauma Center Denver General Hospital, University of Colorado School of Medicine, Denver, Colorado
| | - Scott Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Stefani Vande Lune
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - David Zimmer
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Joseph Dynako
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Daniel Hake
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Zachary Crowell
- Chicago College of Osteopathic Medicine at Midwestern University, Downers Grove, Illinois
| | - Ross McCauley
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Emilee E. Larson
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Michael Miller
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | - Tim Pohlman
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, Indiana
| | | | - Peter Martin
- Department of Emergency Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Nathan Nielsen
- Division of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane School of Medicine, New Orleans, Louisiana
| | - Faisal Shariff
- Indiana University School of Medicine, South Bend Campus, South Bend, Indiana
| | - Victoria A. Ploplis
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
| | - Francis J. Castellino
- W.M. Keck Center for Transgene Research, The University of Notre Dame, Notre Dame, Indiana
- Department of Chemistry and Biochemistry, The University of Notre Dame, Notre Dame, Indiana
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23
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Brenner B, Hull R, Arya R, Beyer-Westendorf J, Douketis J, Elalamy I, Imberti D, Zhai Z. Evaluation of unmet clinical needs in prophylaxis and treatment of venous thromboembolism in high-risk patient groups: cancer and critically ill. Thromb J 2019; 17:6. [PMID: 31011294 PMCID: PMC6466798 DOI: 10.1186/s12959-019-0196-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 04/02/2019] [Indexed: 12/15/2022] Open
Abstract
Background Clinical practice shows that venous thromboembolism (VTE) presents a substantial burden in medical patients, and awareness and advocacy for its primary and secondary prevention remains inadequate. Specific patient populations, such as those with cancer and the critically ill, show elevated risk for VTE, bleeding or both, and significant gaps in VTE prophylaxis and treatment exist in these groups. Objective To present novel insights and consolidated evidence collected from experts, clinical practice guidelines and original studies on the unmet needs in thromboprophylaxis, and on the treatment of VTE in two high-risk patient groups: patients with cancer and the critically ill. Methodology To identify specific unmet needs in the management of VTE, a methodology was designed and implemented that assessed gaps in prophylaxis and treatment of VTE through interviews with 44 experts in the field of thrombosis and haemostasis, and through a review of current guidelines and seminal studies to substantiate the insights provided by the experts. The research findings were then analysed, discussed and consolidated by a multidisciplinary group of experts. Results The gap analysis methodology identified shortcomings in the VTE risk assessment tools, patient stratification approaches for prophylaxis, and the suboptimal use of anticoagulants for primary prophylaxis and treatment. Conclusions Specifically, patients with cancer need better VTE risk assessment tools to tailor primary thromboprophylaxis to tumour types and disease stages, and the potential for drug–drug interactions needs to be considered. In critically ill patients, unfractionated heparin is not advised as a first-line treatment option, and the strength of evidence is increasing for direct oral anticoagulants as a treatment option over low-molecular-weight heparins. Electronic supplementary material The online version of this article (10.1186/s12959-019-0196-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Benjamin Brenner
- 1Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Russell Hull
- 2Foothills Medical Centre and Thrombosis Research Unit, University of Calgary, Calgary, Canada
| | - Roopen Arya
- 3King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jan Beyer-Westendorf
- 3King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK.,4Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital 'Carl Gustav Carus' Dresden, Dresden, Germany
| | - James Douketis
- 5Department of Medicine, McMaster University, Hamilton, Ontario Canada.,6Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario Canada
| | - Ismail Elalamy
- 7Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, Paris, France
| | - Davide Imberti
- 8Haemostasis and Thrombosis Center, Hospital of Piacenza, Piacenza, Italy
| | - Zhenguo Zhai
- 9Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
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24
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Abdel-Razeq H, Mansour A. Venous thromboembolism prophylaxis for ambulatory cancer patients, can we do better? J Thromb Thrombolysis 2018; 44:399-405. [PMID: 28861758 DOI: 10.1007/s11239-017-1542-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patients with cancer are at a much higher risk of thromboembolic events. Such events are occasionally associated with significant complications that can negatively affect patients' quality of life. Thromboprophylaxis is widely practiced, but much of the emphasis is given for those admitted with acute medical illnesses or following major surgical procedures. However, a significant percentage of thrombotic events encountered in routine clinical practice are among ambulatory patients where current guidelines do not recommend routine thromboprophylaxis.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center and School of Medicine, University of Jordan, Amman, Jordan.
| | - Asem Mansour
- Department of Radiology, King Hussein Cancer Center, Amman, Jordan
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25
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Thein KZ, Yeung SCJ, Oo TH. Primary thromboprophylaxis (PTP) in ambulatory patients with lung cancer receiving chemotherapy: A systematic review and meta-analysis of randomized controlled trials (RCTs). Asia Pac J Clin Oncol 2018; 14:210-216. [DOI: 10.1111/ajco.12770] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kyaw Zin Thein
- Department of Emergency Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas USA
- Texas Tech University Health Sciences Center; Lubbock Texas USA
| | - Sai-Ching J. Yeung
- Department of Emergency Medicine; The University of Texas MD Anderson Cancer Center; Houston Texas USA
| | - Thein Hlaing Oo
- Section of Thrombosis & Benign Hematology; The University of Texas MD Anderson Cancer Center; Houston Texas USA
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26
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Biomarkers for the risk of thrombosis in pancreatic adenocarcinoma are related to cancer process. Oncotarget 2018; 9:26453-26465. [PMID: 29899870 PMCID: PMC5995170 DOI: 10.18632/oncotarget.25458] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 05/07/2018] [Indexed: 12/18/2022] Open
Abstract
Background Venous thrombo-embolic events (VTE) frequently occur in patients with pancreatic ductal adenocarcinoma (PDAC) and contribute to high morbidity and mortality. Objectives To determine whether VTE biomarkers are related to cancer, inflammation or precancerous states and to assess their relevance to predict VTE in PDAC. Patients and Methods We compared VTE biomarkers in patients with PDAC (n = 42), intraductal papillary mucinous neoplasm of the pancreas (IPMN, n = 48) or chronic pancreatitis (n = 50). PDAC patients were followed-up for 6 months. Results Factor VIII, D-dimers, von Willebrand factor, free tissue factor pathway inhibitor and microvesicle-tissue factor (MV-TF) activity were higher in PDAC patients compared to patients with IPMN or chronic pancreatitis. PDAC patients with metastasis presented higher D-dimers and MV-TF activity compared to patients with localized lesions, but elevation of D-dimers was dependent on tumor size. In multivariate analysis, elevated D-dimers (≥2.16 µg/mL) or MV-TF activity (≥2.37 pg/mL) were significant risk factors for VTE in PDAC patients, after adjustment for age and sex (HR 4.9 [1.0-23.1] or HR 10.5 [1.5-72.4], mean [interquartile range], respectively). Cumulative probability of VTE at 6 months was higher in patients with elevated D-dimers (56.3% vs 15.6%, p = 0.009) and in patients with high MV-TF activity (74.3% vs 21.7%, p = 0.01). Conclusions VTE biomarkers including D-dimers and MV-TF activity are not related to inflammation but rather to cancer process and dissemination. D-dimers and MV-TF activity are associated to future VTE in PDAC patients and could help identify patients who could benefit from thromboprophylaxis.
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27
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Utility of Viscoelastic Assays Beyond Coagulation: Can Preoperative Thrombelastography Indices Predict Tumor Histology, Nodal Disease, and Resectability in Patients Undergoing Pancreatectomy? J Am Coll Surg 2018; 227:55-62. [PMID: 29605725 DOI: 10.1016/j.jamcollsurg.2018.03.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 02/16/2018] [Accepted: 03/13/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hypercoagulability and malignancy have been linked since the 1860s. However, the impact of different neoplasms on multiple components of the coagulation system remains poorly understood. Thrombelastography (TEG) enables measurement of coagulation incorporating clotting through fibrinolysis. We hypothesize that specific TEG indices that are associated with hypercoagulability can be appreciated in patients with adenocarcinoma undergoing pancreatic resection. STUDY DESIGN Blood samples were obtained from patients undergoing pancreatic resection before surgical incision and assayed with TEG. The 4 indices of coagulation measured by TEG included in the analysis were R time, angle, maximum amplitude, and lysis at 30 minutes. Patient tumor type, nodal disease, and mass resectability were contrasted with TEG indices. RESULTS One hundred patients were enrolled over 18 months. The majority (63%) of patients had adenocarcinoma. Patients with adenocarcinoma had increased angle compared with other lesions (49 degrees [interquartile range {IQR} 37 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.011). When excluding patients that underwent neoadjuvant therapy, patients with adenocarcinoma had shorter R times (13 minutes [IQR 9 to 16 minutes] vs 14 minutes [IQR 12 to 18 minutes]; p = 0.051), steeper angles (49 degrees [IQR 40 to 59 degrees] vs 43 degrees [IQR 32 to 49 degrees]; p = 0.010), and higher maximum amplitude (67 mm [IQR 61 to 69 mm] vs 62 mm [IQR 57 to 67 mm]; p = 0.017). Nodal disease was associated with a significantly increased angle (49 degrees [IQR 42 to 59 degrees] vs 40 degrees [IQR 32 to 50 degrees]; p = 0.002) and maximum amplitude (64 mm [IQR 61 to 69 mm] vs 62 mm [IQR 56 to 67 mm]; p = 0.017). Patients who underwent successful mass resection had longer R times (14 minutes [IQR 11 to 17 minutes] vs 10 minutes [IQR 9 to 15]; p = 0.033) and shorter angles (44 degrees [IQR 35 to 55 degrees] vs 58 degrees [IQR 45 to 66 degrees]; p = 0.025). CONCLUSIONS Patients with adenocarcinoma undergoing pancreatic resection have multiple TEG abnormalities consistent with hypercoagulability. These TEG outputs are associated with tumor type, nodal disease, and probability of a successful resection. The use of preoperative TEG has the potential to aid surgeon and patient discussions on anticipated disease burden and prognosis before resection.
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