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Khan AM, Chiasakul T, Redd R, Patell R, McCarthy EP, Neuberg D, Zwicker JI. Survival outcomes with warfarin compared with direct oral anticoagulants in cancer-associated venous thromboembolism in the United States: A population-based cohort study. PLoS Med 2022; 19:e1004012. [PMID: 35613184 PMCID: PMC9182592 DOI: 10.1371/journal.pmed.1004012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 06/09/2022] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have comparable efficacy with low-molecular-weight heparin (LMWH) for the treatment of cancer-associated venous thromboembolism (VTE). Whether there is a mortality benefit of DOACs compared with warfarin in the management of VTE in cancer is not established. METHODS AND FINDINGS Utilizing the United States' Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases from 2012 through 2016, we analyzed overall survival in individuals diagnosed with a primary gastric, colorectal, pancreas, lung, ovarian, or brain cancer and VTE who received a prescription of DOAC or warfarin within 30 days of VTE diagnosis. Patients were matched 1:2 (DOAC to warfarin) through exact matching for cancer stage and propensity score matching for age, cancer site, cancer stage, and time interval from cancer to VTE diagnosis. The analysis identified 4,274 patients who received a DOAC or warfarin for the treatment of VTE within 30 days of cancer diagnosis (1,348 in DOAC group and 2,926 in warfarin group). Patients were of median age 75 years and 56% female. Within the DOAC group, 1,188 (88%) received rivaroxaban, and 160 (12%) received apixaban. With a median follow-up of 41 months, warfarin was associated with a statistically significantly higher overall survival compared to DOACs (median overall survival 12.0 months [95% confidence interval (CI): 10.9 to 13.5] versus 9.9 months [95% CI: 8.4 to 11.2]; hazard ratio (HR) 0.85; 95% CI: 0.78 to 0.91; p < 0.001). Observed differences in survival were consistent across subgroups of cancer sites, cancer stages, and type of VTE. The study limitations include retrospective design with potential for unaccounted confounders along with issues of generalizability beyond the cancer diagnoses studied. CONCLUSIONS In this analysis of a population-based registry, warfarin was associated with prolonged overall survival compared to DOACs for treatment of cancer-associated VTE.
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Affiliation(s)
- Adeel M. Khan
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Thita Chiasakul
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Robert Redd
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Rushad Patell
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Ellen P. McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, United States of America
- Divisions of Gerontology and General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Jeffrey I. Zwicker
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Chiasakul T, Redd R, Patell R, Khan AM, McCarthy EP, Neuberg D, Zwicker JI. Overall survival with warfarin vs. low-molecular-weight heparin in cancer-associated thrombosis. J Thromb Haemost 2021; 19:2825-2834. [PMID: 34490999 PMCID: PMC8530982 DOI: 10.1111/jth.15519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND When compared with warfarin, low-molecular-weight heparin (LMWH) reduces the incidence of recurrent venous thromboembolism (VTE) in cancer. However, a survival benefit of LMWH over warfarin for the treatment of cancer-associated VTE has not been established. METHODS Using the Surveillance, Epidemiology and End Results and Medicare linked database from 2007 through 2016, we identified Medicare beneficiaries (aged ≥66 years) who were: (1) diagnosed with primary gastric, colorectal, pancreatic, lung, ovarian, or brain cancer; (2) diagnosed with cancer-associated VTE; and (3) prescribed LMWH or warfarin within 30 days. The primary outcome was overall survival (OS). Patients were matched 1:1 using exact matching for cancer stage and propensity score matching for cancer diagnosis, age, year of VTE, and time from cancer diagnosis to index VTE. Cox proportional-hazards regression was performed to estimate hazard ratios (HR) and 95% confidence intervals (95% CI). RESULTS A total of 9706 patients were included. Warfarin was associated with a significant improvement in OS compared with LMWH (median OS, 9.8 months [95% CI, 9.1-10.4] vs. 7.2 months [95% CI, 6.8-7.8]; HR, 0.86; 95% CI 0.83-0.90; p < .001). The survival advantage was most pronounced in pancreatic (HR 0.82 [95% CI, 0.74-0.90], p < .001) and gastric cancers (HR 0.82 [95% CI, 0.68-0.98], p = .03). The observed differences in survival were consistent across subgroups including cancer stage, age, comorbidity burden, and year of VTE. CONCLUSIONS In this population-based study, warfarin was associated with improved OS compared with LMWH for the treatment of cancer-associated VTE.
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Affiliation(s)
- Thita Chiasakul
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Robert Redd
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Rushad Patell
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Adeel M Khan
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ellen P McCarthy
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Divisions of Gerontology and General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jeffrey I Zwicker
- Division of Hematology and Division of Hemostasis and Thrombosis, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Childress MO. Hematologic Abnormalities in the Small Animal Cancer Patient. Vet Clin North Am Small Anim Pract 2012; 42:123-55. [DOI: 10.1016/j.cvsm.2011.09.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Amirkhosravi A, Mousa SA, Amaya M, Meyer T, Davila M, Robson T, Francis JL. Assessment of anti-metastatic effects of anticoagulant and antiplatelet agents using animal models of experimental lung metastasis. Methods Mol Biol 2010; 663:241-259. [PMID: 20617422 DOI: 10.1007/978-1-60761-803-4_10] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
It is well established that the blood coagulation system is activated in cancer. In addition, there is considerable evidence to suggest that clotting activation plays an important role in the biology of malignant tumors, including the process of blood-borne metastasis. For many years our laboratory has used experimental models of lung metastasis to study the events that follow the introduction of procoagulant-bearing tumor cells into circulating blood. This chapter focuses on the basic methods involved in assessing the anti-metastatic effects of anticoagulants and anti-platelet agents using rodent models of experimental metastasis. In addition, it summarizes our experience with these models, which collectively suggests that intravascular coagulation and platelet activation are a necessary prelude to lung tumor formation and that interruption of coagulation pathways or platelet aggregation may be an effective anti-metastatic strategy.
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Affiliation(s)
- Ali Amirkhosravi
- Florida Hospital Center for Thrombosis Research, Orlando, FL, USA
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Ingersoll SB, Langer F, Walker JM, Meyer T, Robson T, Amaya M, Desai H, Francis JL, Amirkhosravi A. Deficiencies in the CD40 and CD154 receptor-ligand system reduce experimental lung metastasis. Clin Exp Metastasis 2009; 26:829-37. [PMID: 19642003 DOI: 10.1007/s10585-009-9282-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 07/13/2009] [Indexed: 11/24/2022]
Abstract
It is established that experimental metastasis requires platelet activity. CD154 expressed on and released from activated platelets induces an inflammatory response in endothelial cells and monocytes, including tissue factor production. CD154 has also been shown to activate platelets in vitro and promote thrombus stability in vivo. These CD154 effects may be mediated, at least in part, by CD40 signaling on platelets and vascular endothelial cells. We have previously demonstrated prolonged bleeding and PFA-100 closure times in mice deficient for Cd154 or its receptor Cd40. In the present study, we hypothesized that Cd40 and Cd154 promote lung tumor formation in experimental metastasis in mice. We created mice doubly deficient in Cd40 and Cd154 (Dbl KO) and found them to be both fertile and viable. Injected tumor cells seeded poorly in mice deficient in Cd40 or Cd154, as well as Dbl KO, compared to wild-type mice. We sought to determine whether blood-borne Cd40 versus endothelial Cd40 contribute differentially to reduced experimental lung metastasis, as observed in Cd40 deficient mice. By bone marrow transplantation, we created mice deficient for Cd40 either in the blood compartment but not in the endothelium, or vice versa. We found that mice deficient in blood compartment Cd40 had fewer lung nodules compared to wild-type mice and mice deficient in endothelial Cd40. Our findings suggest an important contribution of the Cd40-Cd154 pathway to experimental lung metastasis. Furthermore, the data points to a selective role for peripheral blood cell Cd40 in this process.
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Kim SH, Lee TH, Yang DC, Kim HM, Kim JB, Park MK, Bae YS. Shiquandabutangjiaweibang inhibits tumor metastasis and angiogenesis via regulation of topoisomerase-1. JOURNAL OF ETHNOPHARMACOLOGY 2005; 98:157-162. [PMID: 15763377 DOI: 10.1016/j.jep.2005.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2004] [Revised: 12/18/2004] [Accepted: 01/14/2005] [Indexed: 05/24/2023]
Abstract
Shiquandabutangjiaweibang (SDJ) is a traditional medicine prescription used for increasing body resistance against cancer. In the present study, the effect of SDJ extract on tumor metastasis and angiogenesis was evaluated. SDJ showed cytotoxicity against P388 (leukemia cells) and B16-F10 (murine melanoma cells) to 60% of control at 1 mg. SDJ significantly inhibited lung metastasis and also restored the number of platelets in C57BL/6 mice with thrombocytopenia induced by intravenous injection of B16-F10 cells. SDJ significantly disrupted chick embryonic angiogenesis in the chorioallantoic membrane (CAM). Interestingly, SDJ suppressed DNA topoisomerase I in a concentration-dependent manner. These results suggest that SDJ can be a potent inhibitor of metastasis and angiogenesis, at least in part, via regulation of topoisomerase I.
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MESH Headings
- Animals
- Cell Survival/drug effects
- Chorioallantoic Membrane/drug effects
- DNA Topoisomerases, Type I/drug effects
- DNA Topoisomerases, Type I/metabolism
- Dose-Response Relationship, Drug
- Drug Screening Assays, Antitumor/methods
- Humans
- Leukemia P388/pathology
- Leukemia P388/prevention & control
- Lung Neoplasms/prevention & control
- Lung Neoplasms/secondary
- Male
- Medicine, East Asian Traditional
- Mice
- Mice, Inbred C57BL
- Neoplasm Metastasis/prevention & control
- Neoplasm Transplantation/methods
- Neoplasms, Experimental/drug therapy
- Neoplastic Cells, Circulating/pathology
- Neovascularization, Pathologic/prevention & control
- Plant Preparations/analysis
- Plant Preparations/chemistry
- Plant Preparations/pharmacology
- Staining and Labeling
- Thrombocytopenia/chemically induced
- Thrombocytosis/chemically induced
- Tumor Cells, Cultured
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Affiliation(s)
- Sung Hoon Kim
- Department of Oncology, Graduate School of East-West Medical Science, Kyung Hee University, 1 Seochunri, Yongin 449-701, South Korea.
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Amirkhosravi A, Mousa SA, Amaya M, Francis JL. Antimetastatic effect of tinzaparin, a low-molecular-weight heparin. J Thromb Haemost 2003; 1:1972-6. [PMID: 12941039 DOI: 10.1046/j.1538-7836.2003.00341.x] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The importance of coagulation activation in cancer patients is suggested by the clinical finding of hypercoagulability, experimental enhancement of metastasis and angiogenesis by coagulation factors such as tissue factor (TF) and thrombin and the possible antitumor effects of anticoagulant agents. Tinzaparin is a low-molecular-weight heparin (LMWH) with a relatively high molecular weight distribution and high sulfate to carboxylate ratio. In addition to its ability to inhibit thrombin and factor Xa, tinzaparin is particularly effective at releasing endothelial tissue factor pathway inhibitor (TFPI), the natural inhibitor of both procoagulant and non-coagulant effects of TF. The present study was undertaken to investigate the effect of tinzaparin on lung metastasis using a B16 melanoma model in experimental mice. Tinzaparin's anticoagulant effect in mice and its ability to release TFPI from human endothelial cells at various time points were demonstrated. Subcutaneous (s.c.) injection of tinzaparin (10 mg kg-1) 4 h before intravenous administration of melanoma cells (2.0 x 105) markedly (89%) reduced lung tumor formation (3 +/- 2) compared with controls (31 +/- 23; P < 0.001). In a second group of animals, tinzaparin (10 mg kg-1, s.c.) administered daily for 14 days following the initial (pretumor cell) dose, before assessment of lung seeding, reduced tumor formation by 96% (P < 0.001). No bleeding problems were observed in any of the tinzaparin-treated animals, despite a 4-fold prolongation of the whole blood clotting time after a single s.c. dose of tinzaparin (10 mg kg-1). Administration of tumor cells (2 x 106) caused a rapid and significant fall in platelet count 15 min after injection (a sensitive marker of intravascular coagulation) in controls (939 +/- 37 vs. 498 +/- 94 x 106 mL-1, P < 0.01), but this was prevented by tinzaparin treatment (921 +/- 104 x 106 mL-1). These data provide further experimental evidence to support the potential for LMWH as antimetastatic agents.
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Affiliation(s)
- A Amirkhosravi
- Clinical and Research Laboratories, Florida Hospital Cancer Institute, Orlando, FL 32804, USA.
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Abstract
The presence of platelets in association with cancer deposits has been recognised for over 100 years; however, the recognition of a two-way interaction has been more recent. The link between cancer spread and platelet stimulation is pivotal to understanding of the hypercoagulable state found in most cancer patients. The assistance of platelets in cancer spread may provide opportunities to interrupt this relation, thus inhibiting metastasis.
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Affiliation(s)
- G F Nash
- Imperial College, Hammersmith Hospital, London, UK
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Biggerstaff JP, Seth N, Amirkhosravi A, Amaya M, Fogarty S, Meyer TV, Siddiqui F, Francis JL. Soluble fibrin augments platelet/tumor cell adherence in vitro and in vivo, and enhances experimental metastasis. Clin Exp Metastasis 2000; 17:723-30. [PMID: 10919717 DOI: 10.1023/a:1006763827882] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
There is considerable evidence for a relationship between hemostasis and malignancy. Since platelet adhesion to tumor cells has been implicated in the metastatic process and plasma levels of fibrinogen (Fg) and soluble fibrin (sFn) monomer are increased in cancer, we hypothesized that these molecules might enhance tumor-platelet interaction. We therefore studied binding of sFn monomer to tumor cells in a static microplate adhesion assay and determined the effect of pre-treating tumor cells with sFn on tumor cell-induced thrombocytopenia and experimental metastasis. Soluble fibrin (produced by adding thrombin to FXIII- and plasminogen-free Fg in the presence of Gly-Pro-Arg-Pro-amide (GPRP-NH2) significantly increased platelet adherence to tumor cells. This effect was primarily mediated by the integrins alphaIIb beta3 on the platelet and CD 54 (ICAM-1) on the tumor cells. Platelets adhered to untreated A375 cells (28 +/- 8 platelets/tumor cell) and this was not significantly affected by pre-treatment of the tumor cells with fibrinogen or GPRP-NH2. Although thrombin treatment increased adherence, pre-incubation of the tumor cells with sFn resulted in a further increase in platelet binding to tumor cells. In contrast to untreated tumor cells, intravenous injection of sFn-treated A 375 cells reduced the platelet count in anticoagulated mice, supporting the in vitro finding that sFn enhanced tumor cell-platelet adherence. In a more aggressive model of experimental metastasis, treating tumor cells with sFn enhanced lung seeding by 65% compared to untreated cells. Extrapolation of our data to the clinical situation suggests that coagulation activation, and subsequent increase in circulating Fn monomer, may enhance platelet adhesion to circulating tumor cells and thereby facilitate metastatic spread.
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Affiliation(s)
- J P Biggerstaff
- Research and Clinical Laboratories, Walt Disney Memorial Cancer Institute at Florida Hospital, Orlando 32804, USA.
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Amirkhosravi A, Biggerstaff JP, Warnes G, Francis DA, Francis JL. Determination of tumor cell procoagulant activity by Sonoclot analysis in whole blood. Thromb Res 1996; 84:323-32. [PMID: 8948059 DOI: 10.1016/s0049-3848(96)00196-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Coagulation activation in cancer may be due to expression of procoagulant activity (PCA) by tumor cells. Some PCA activate coagulation, while others influence platelet aggregation. Thus, clotting time assessments of PCA may not reflect the potential for hypercoagulability. We therefore studied the effect of various malignant and non-malignant cells on whole blood coagulation using the Sonoclot Analyzer. Five human (HT29 colon, J82 bladder, MCF-7 breast, BT-474 breast and A375 malignant melanoma) and three rodent (MC28, WEHI-164 and Neuro2a) cell lines were used. Rat thymocytes and peritoneal macrophages and human endotoxin-stimulated mononuclear cells and umbilical vein endothelial cells (HUVEC) were used as non-malignant controls. All tumor cells markedly shortened the recalcification time of citrated blood and the most potent (HT29 and J82) also increased clot rate (P < 0.01). The breast cancer cells MCF-7 and BT-474 expressed only weak PCA and did not affect clotting rate. None of the non-malignant cells significantly affected clotting time or rate in whole blood. J82 and HT29 cells grown in serum-rich media shortened the recalcification time of both normal and FVII-deficient plasmas. However, cells grown in serum-free conditions had significantly less PCA in FVII-deficient plasma. We conclude that the Sonoclot Analyzer is useful for determining cellular PCA; significant PCA is a feature of malignant cells and cells grown in medium containing serum supplements cannot be reliably evaluated for PCA.
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Affiliation(s)
- A Amirkhosravi
- Hemostasis and Thrombosis Research Unit, Walt Disney Memorial Cancer Institute, Florida Hospital, Altamonte Springs 32701, USA
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