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Franco-Moreno, Cabezón-Gutiérrez, Ancos-Aracil. Hidden Neoplasm Detection in Patients With Venous Thromboembolism: An Unresolved Dilemma. Clin Oncol (R Coll Radiol) 2024:S0936-6555(24)00276-0. [PMID: 38991875 DOI: 10.1016/j.clon.2024.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 06/24/2024] [Indexed: 07/13/2024]
Affiliation(s)
- Franco-Moreno
- Department of Internal Medicine, Venous Thromboembolism Unit, Hospital Universitario Infanta Leonor, Madrid, Spain.
| | - Cabezón-Gutiérrez
- Department of Medical Oncology, Hospital Universitario de Torrejón, Madrid, Spain
| | - Ancos-Aracil
- Department of Internal Medicine, Venous Thromboembolism Unit, Hospital Universitario de Fuenlabrada, Madrid, Spain
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Barbarit A, Guyon C, Poupin E, Frèche B. [Thromboembolic disease and cancer: Attitude and practice of general practitioners. A qualitative study]. Bull Cancer 2023; 110:1311-1321. [PMID: 37690878 DOI: 10.1016/j.bulcan.2023.08.001] [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: 11/13/2022] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION Cancer is a major public health problem in France. Idiopathic venous thromboembolic disease may be one of the modes of discovery. Few studies have been performed on this subject in primary care. The general practitioner plays a key role in the diagnosis for which a more codified approach seems desirable. The aim was to study how general practitioners conceive the search for cancer in patients with idiopathic venous thromboembolic disease in primary care. METHOD A qualitative study, inspired by the grounded theory approach, was carried out using semi-structured interviews with 12 established general practitioners. It was conducted from May to July 2022. The interview guide was developed based on data from the literature. RESULTS Idiopathic venous thromboembolic disease as a mode of cancer discovery in primary care was a well-known topic among general practitioners but remained a difficult exercise in practice. Our study revealed similarities in their practices: a complete anamnesis, clinical examination, verification of screening tests, and finally a TAP scan. They emphasized the importance of collaboration with angiologists and asked for a more codified management. DISCUSSION The question of etiology of cancer remains unanswered. General practioners would like to be made aware of a common, codified attitude. This raises the question of the applicability of the recommendations. The aim is to avoid misdiagnosing a cancer or delaying a diagnosis, while at the same time, not unnecessarily exposing certain patients to excessive investigations when these are not needed. So, it is time to think about better dissemination of recommendations, tools to help GPs easily finding what they need among the multitude of existing recommendations and tools, to establish better collaboration between general practice and hospital medicine, and between general practice and specialist medicine in order to improve cancer diagnosis as early as possible.
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Affiliation(s)
- Andréa Barbarit
- Université de Poitiers, département de médecine générale, 86073 Poitiers, France
| | - Cyrielle Guyon
- Université de Poitiers, département de médecine générale, 86073 Poitiers, France
| | - Elodie Poupin
- Université de Poitiers, département de médecine générale, 86073 Poitiers, France; Pôle de recherche en soins primaires, université de Poitiers, Poitiers, France
| | - Bernard Frèche
- Université de Poitiers, département de médecine générale, 86073 Poitiers, France; Pôle de recherche en soins primaires, université de Poitiers, Poitiers, France; Inserm 1070, université de Poitiers, Poitiers, France.
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Lee RJ, Herlihy D, O'Neill DC, Madden-Doyle L, Morrin M, Lee MJ. CT imaging for occult malignancy in patients with unprovoked venous thromboembolism (VTE) in a tertiary centre: is it worthwhile? Ir J Med Sci 2023; 192:3081-3086. [PMID: 36849651 PMCID: PMC10692257 DOI: 10.1007/s11845-023-03317-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 02/13/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Investigating patients with unprovoked venous thromboembolism (uVTE) for occult malignancy can prove a diagnostic dilemma and imaging is often used extensively in this patient group. AIMS The primary objective of this study was to determine the incidence of malignancy on CT and other imaging over a 10-year period. A secondary objective was to evaluate the role of laboratory and other non-imaging tests performed. METHODS A retrospective key word search of our hospital's imaging system was performed to identify patients with unprovoked DVT/PE over the last 10 years. All imaging, histology, endoscopy, laboratory tests, and clinical follow-up over 2 years were analysed. Patients with provoked VTE were excluded. RESULTS 150 patients had uVTE. 9 patients were diagnosed with occult malignancy by different investigations on index hospital admission (3 patients) or subsequently on clinical follow-up (6 patients). Mean age of patients was 62 years. 116 patients had CT body imaging. The incidence of malignancy diagnosed by initial CT imaging was 1.7% with a sensitivity of 22%, specificity 87%, and PPV 12.5%. Overall incidence of malignancy identified by imaging alone during the index hospital admission was 2%. Total incidence of malignancy including index admission and follow-up was 6%. Median time to cancer diagnosis was 12 months. CONCLUSION CT imaging had a low yield for diagnosing malignancy. Extensive imaging strategies increase cost and radiation exposure without improving mortality. Clinical follow-up, history taking, and physical examination guiding appropriate investigations remain the best tool for unmasking occult malignancy in patients with uVTE.
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Affiliation(s)
- Ronan J Lee
- Beaumont Hospital, Beaumont Road, Dublin 9, Dublin, Ireland.
| | | | | | | | - Martina Morrin
- Beaumont Hospital, Beaumont Road, Dublin 9, Dublin, Ireland
| | - Michael J Lee
- Beaumont Hospital, Beaumont Road, Dublin 9, Dublin, Ireland
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Rosell A, Gautam G, Wannberg F, Ng H, Gry H, Vingbäck E, Lundström S, Mackman N, Wallén H, Westerlund E, Thålin C. Neutrophil extracellular trap formation is an independent risk factor for occult cancer in patients presenting with venous thromboembolism. J Thromb Haemost 2023; 21:3166-3174. [PMID: 37479035 DOI: 10.1016/j.jtha.2023.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE), particularly unprovoked VTE, is associated with occult cancer. The optimal screening regimen remains controversial. Neutrophil extracellular traps (NETs) are implicated in cancer-associated thrombosis, and elevated biomarkers of NET formation are associated with poor prognosis. OBJECTIVES To investigate the association between NET formation and occult cancer in patients with VTE. METHODS Blood biomarkers associated with NETs and neutrophil activation (nucleosomal citrullinated histone H3 [H3Cit-DNA], cell-free DNA, and neutrophil elastase) were quantified in patients with VTE. The primary outcome was cancer diagnosed during a one-year follow-up. RESULTS This study included 460 patients with VTE, of which 221 (48%) had isolated deep vein thrombosis. Forty-three patients had active cancer at inclusion and were excluded from the primary analysis Cancer during follow-up was diagnosed in 29 of 417 (7.0%) patients. After adjustment for age and unprovoked VTE, the hazard ratio of cancer during follow-up per 500 ng/mL increase of H3Cit-DNA was 1.79 (95% CI, 1.03-3.10). Furthermore, patients with cancer-associated VTE (known active cancer or cancer diagnosed during follow-up) had higher levels of H3Cit-DNA than cancer-free patients with VTE after adjustment for age, hemoglobin, gender, chronic obstructive pulmonary disease, previous cancer, and start of anticoagulant treatment (odds ratio 2.06 per 500 ng/mL increase of H3Cit-DNA [95% CI, 1.35-3.13]). CONCLUSIONS H3Cit-DNA is an independent predictor for occult cancer in patients with VTE and elevated in cancer-associated VTE, suggesting that H3Cit-DNA is potentially a useful diagnostic marker for cancer in patients with VTE and that elevated NET formation is a hallmark of cancer-associated VTE.
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Affiliation(s)
- Axel Rosell
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gargi Gautam
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fredrika Wannberg
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Henry Ng
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Medical Cell Biology, SciLifeLab, Uppsala University, Uppsala Sweden
| | - Hanna Gry
- Division of Radiology, Danderyd Hospital, Danderyd, Sweden
| | - Emma Vingbäck
- Division of Internal Medicine and Infectious diseases, Danderyd Hospital, Danderyd, Sweden
| | - Staffan Lundström
- Palliative Care Services and R&D-unit, Stockholms Sjukhem Foundation, Stockholm, Sweden; Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Eli Westerlund
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Charlotte Thålin
- Department of Clinical Sciences, Danderyd Hospital, Division of Internal Medicine, Karolinska Institutet, Stockholm, Sweden.
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Muacevic A, Adler JR, Rego Gonçalves C, Faria Silva J, Afonso R. Upper Extremity Deep Vein Thrombosis as the Tip of the Iceberg: Case Report and Review of Literature. Cureus 2023; 15:e33513. [PMID: 36779092 PMCID: PMC9904513 DOI: 10.7759/cureus.33513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/09/2023] Open
Abstract
Unprovoked venous thromboembolism (VTE) may be the earliest manifestation of cancer. According to recent studies, approximately 5% of patients with unprovoked VTE will be diagnosed with cancer within the first year of follow-up. Although screening extensively at the time of VTE diagnosis is attractive for clinicians, current clinical guidance documents suggest only a limited cancer screening strategy. The authors describe a rare case of Krukenberg tumor of the ovary arising from a primary gastric adenocarcinoma whose first sign was an unprovoked venous thrombosis of the upper extremity.
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Cordeanu EM, Jambert L, Tousch J, Mirea C, Delatte A, Younes W, Woehl B, Harter C, Frantz AS, Hamade A, Schini-Kerth V, Ohlmann P, Andres E, Stephan D. The Conundrum of Occult Cancer Screening in Venous Thromboembolism: Lessons from the REMOTEV Registry. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58070913. [PMID: 35888632 PMCID: PMC9317660 DOI: 10.3390/medicina58070913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/16/2022]
Abstract
(1) Background and Objectives: Venous thromboembolism (VTE) is strongly associated with cancer, and may be the first event revealing occult neoplasia. Nonetheless, the reasonable extent of the etiological assessment after an unprovoked VTE event remains debated. The main objective of this study was to evaluate the incidence of occult neoplasia one year after an episode of VTE, in consecutively hospitalized patients for VTE from the REMOTEV registry. The secondary objectives were to assess the performance of the various tests used for occult cancer screening in a real-life setting and analyze the risk factors associated with the discovery of cancer and the 1-year prognosis. (2) Methods: REMOTEV is a prospective, non-interventional cohort study of patients with acute VTE. Patients included in the registry from 23 October 2013 to 28 July 2018 were analyzed after a follow-up of 12 months. Cancer detection was performed according to local practices and consisted of a limited strategy to which an abdominal ultrasound was added. In the presence of suggestive clinical manifestations, further examinations were performed on an individual basis. (3) Results: A total of 993 patients were included in the study. At 1 year, the incidence of newly diagnosed cancer was low (5.3%). Half of the detected cancers were metastatic at discovery (51%) and had a poor global prognosis (32% of mortality at 1 year). Admission pulmonary CT scans as well as (thoracic)-abdomino-pelvic CT scans (when performed) were responsible for the majority of detected cancers. Age over 65 years and the concomitant presence of an unusual site and lower-limb deep vein thrombosis were the only factors associated with occult neoplasia in this cohort. After 1-year FU, mortality was higher in cancer patients (HR 6.0 (CI 95% 3.5−10.3, p < 0.0001)), and cancer evolution was the leading cause of death in the cancer group. (4) Conclusions: In REMOTEV, VTE-revealed occult cancer prevalence was low, but similar to recent reports and associated with higher age, multiple thrombotic sites and worse prognosis.
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Affiliation(s)
- Elena-Mihaela Cordeanu
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
- Correspondence: ; Tel.: +33-0369-551-520
| | - Lucas Jambert
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Jonathan Tousch
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Corina Mirea
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Alexandre Delatte
- Department of Cardiology, Haguenau Regional Hospital, 67500 Haguenau, France;
| | - Waël Younes
- Department of Vascular Medicine, Colmar Regional Hospital, 68000 Colmar, France;
| | - Bastien Woehl
- Department of Vascular Medicine, Mulhouse Regional Hospital, 68100 Mulhouse, France; (B.W.); (A.H.)
| | - Claire Harter
- Department of Radiology, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Anne-Sophie Frantz
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
| | - Amer Hamade
- Department of Vascular Medicine, Mulhouse Regional Hospital, 68100 Mulhouse, France; (B.W.); (A.H.)
| | - Valérie Schini-Kerth
- UMR 1260 INSERM Regenerative Nanomedecine, Faculty of Pharmacy, Strasbourg University, 67400 Illkirch, France;
| | - Patrick Ohlmann
- Cardiology Department, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Emmanuel Andres
- Internal Medicine Department, Strasbourg Regional University Hospital, 67091 Strasbourg, France;
| | - Dominique Stephan
- Department of Hypertension, Vascular Disease and Clinical Pharmacology, Strasbourg Regional University Hospital, 67091 Strasbourg, France; (L.J.); (J.T.); (C.M.); (A.-S.F.); (D.S.)
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Grainger BT, McCrea TA, Eaddy N, Ockelford P, Young L. Real‐world experience with limited screening for occult malignancy in patients presenting with spontaneous venous thromboembolism: a single‐centre, retrospective cohort study. Intern Med J 2022; 52:491-494. [DOI: 10.1111/imj.15703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/27/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Brian T. Grainger
- Department of Haematology Auckland City Hospital Auckland New Zealand
| | | | - Nicola Eaddy
- Department of Haematology Auckland City Hospital Auckland New Zealand
| | - Paul Ockelford
- Department of Haematology Auckland City Hospital Auckland New Zealand
| | - Laura Young
- Department of Haematology Auckland City Hospital Auckland New Zealand
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Robertson L, Broderick C, Yeoh SE, Stansby G. Effect of testing for cancer on cancer- or venous thromboembolism (VTE)-related mortality and morbidity in people with unprovoked VTE. Cochrane Database Syst Rev 2021; 10:CD010837. [PMID: 34597414 PMCID: PMC8486018 DOI: 10.1002/14651858.cd010837.pub5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a collective term for two conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). A proportion of people with VTE have no underlying or immediately predisposing risk factors and the VTE is referred to as unprovoked. Unprovoked VTE can often be the first clinical manifestation of an underlying malignancy. This has raised the question of whether people with an unprovoked VTE should be investigated for an underlying cancer. Treatment for VTE is different in cancer and non-cancer patients and a correct diagnosis would ensure that people received the optimal treatment for VTE to prevent recurrence and further morbidity. Furthermore, an appropriate cancer diagnosis at an earlier stage could avoid the risk of cancer progression and lead to improvements in cancer-related mortality and morbidity. This is the third update of the review first published in 2015. OBJECTIVES To determine whether testing for undiagnosed cancer in people with a first episode of unprovoked VTE (DVT of the lower limb or PE) is effective in reducing cancer- or VTE-related mortality and morbidity and to determine which tests for cancer are best at identifying treatable cancers early. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 May 2021. We also undertook reference checking to identify additional studies. SELECTION CRITERIA Randomised and quasi-randomised trials in which people with an unprovoked VTE were allocated to receive specific tests for identifying cancer or clinically indicated tests only were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias and extracted data. We assessed the certainty of the evidence using GRADE criteria. We resolved any disagreements by discussion. The main outcomes of interest were all-cause mortality, cancer-related mortality and VTE-related mortality. MAIN RESULTS No new studies were identified for this 2021 update. In total, four studies with 1644 participants are included. Two studies assessed the effect of extensive tests including computed tomography (CT) scanning versus tests at the physician's discretion, while the other two studies assessed the effect of standard testing plus positron emission tomography (PET)/CT scanning versus standard testing alone. For extensive tests including CT versus tests at the physician's discretion, the certainty of the evidence, as assessed according to GRADE, was low due to risk of bias (early termination of the studies). When comparing standard testing plus PET/CT scanning versus standard testing alone, the certainty of evidence was moderate due to a risk of detection bias. The certainty of the evidence was downgraded further as detection bias was present in one study with a low number of events. When comparing extensive tests including CT versus tests at the physician's discretion, pooled analysis on two studies showed that testing for cancer was consistent with either benefit or no benefit on cancer-related mortality (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.15 to 1.67; 396 participants; 2 studies; low-certainty evidence). One study (201 participants) showed that, overall, malignancies were less advanced at diagnosis in extensively tested participants than in participants in the control group. In total, 9/13 participants diagnosed with cancer in the extensively tested group had a T1 or T2 stage malignancy compared to 2/10 participants diagnosed with cancer in the control group (OR 5.00, 95% CI 1.05 to 23.76; low-certainty evidence). There was no clear difference in detection of advanced stages between extensive tests versus tests at the physician's discretion: one participant in the extensively tested group had stage T3 compared with four participants in the control group (OR 0.25, 95% CI 0.03 to 2.28; low-certainty evidence). In addition, extensively tested participants were diagnosed earlier than control group (mean: 1 month with extensive tests versus 11.6 months with tests at physician's discretion to cancer diagnosis from the time of diagnosis of VTE). Extensive testing did not increase the frequency of an underlying cancer diagnosis (OR 1.32, 95% CI 0.59 to 2.93; 396 participants; 2 studies; low-certainty evidence). Neither study measured all-cause mortality, VTE-related morbidity and mortality, complications of anticoagulation, adverse effects of cancer tests, participant satisfaction or quality of life. When comparing standard testing plus PET/CT screening versus standard testing alone, standard testing plus PET/CT screening was consistent with either benefit or no benefit on all-cause mortality (OR 1.22, 95% CI 0.49 to 3.04; 1248 participants; 2 studies; moderate-certainty evidence), cancer-related mortality (OR 0.55, 95% CI 0.20 to 1.52; 1248 participants; 2 studies; moderate-certainty evidence) or VTE-related morbidity (OR 1.02, 95% CI 0.48 to 2.17; 854 participants; 1 study; moderate-certainty evidence). Regarding stage of cancer, there was no clear difference for detection of early (OR 1.78, 95% 0.51 to 6.17; 394 participants; 1 study; low-certainty evidence) or advanced (OR 1.00, 95% CI 0.14 to 7.17; 394 participants; 1 study; low-certainty evidence) stages of cancer. There was also no clear difference in the frequency of an underlying cancer diagnosis (OR 1.71, 95% CI 0.91 to 3.20; 1248 participants; 2 studies; moderate-certainty evidence). Time to cancer diagnosis was 4.2 months in the standard testing group and 4.0 months in the standard testing plus PET/CT group (P = 0.88). Neither study measured VTE-related mortality, complications of anticoagulation, adverse effects of cancer tests, participant satisfaction or quality of life. AUTHORS' CONCLUSIONS Specific testing for cancer in people with unprovoked VTE may lead to earlier diagnosis of cancer at an earlier stage of the disease. However, there is currently insufficient evidence to draw definitive conclusions concerning the effectiveness of testing for undiagnosed cancer in people with a first episode of unprovoked VTE (DVT or PE) in reducing cancer- or VTE-related morbidity and mortality. The results could be consistent with either benefit or no benefit. Further good-quality large-scale randomised controlled trials are required before firm conclusions can be made.
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Affiliation(s)
| | | | - Su Ern Yeoh
- BHF Glasgow Cardiovascular Research Centre (GCRC), University of Glasgow, Glasgow, UK
| | - Gerard Stansby
- Northern Vascular Centre, Freeman Hospital, Newcastle, UK
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Thomsen L, Troelsen FS, Nagy D, Skajaa N, Körmendiné Farkas D, Erichsen R. Venous Thromboembolism and Risk of Cancer in Patients with Diverticular Disease: A Danish Population-Based Cohort Study. Clin Epidemiol 2021; 13:735-744. [PMID: 34447274 PMCID: PMC8384426 DOI: 10.2147/clep.s314350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 07/17/2021] [Indexed: 12/03/2022] Open
Abstract
Purpose Venous thromboembolism may be a harbinger of cancer. Patients with diverticular disease are suggested to have an increased risk of developing venous thromboembolism compared with the general population, but it remains unclear whether venous thromboembolism is also a marker of occult cancer in these patients. We investigated the risk of cancer after venous thromboembolism among patients with diverticular disease. Patients and Methods We used Danish health registries to conduct a nationwide, population-based cohort study during 1996–2017. We identified all venous thromboembolism patients with a diagnosis of diverticular disease and calculated absolute risks of cancer and standardized incidence ratios (SIRs) by comparing observed and expected cancer incidence based on national cancer incidence in the Danish population. Results We followed 3406 patients with venous thromboembolism and diverticular disease for a median of 3.0 years (interquartile range: 1.0–6.0). During the first year of follow-up, we observed 212 cancer cases. The corresponding one-year risk of cancer was 6.2% (95% confidence interval [CI]: 5.5–7.1) with a SIR of 2.9 (95% CI: 2.5–3.3). The SIRs were particularly elevated for cancers of the stomach, pancreas, ovary, and kidney. During the second and subsequent years of follow-up, 337 cancers were diagnosed with a SIR of 1.1 (95% CI: 1.0–1.3). Conclusion Venous thromboembolism is a harbinger of occult cancer in patients with diverticular disease. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/F_5MPyAQSAk
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Affiliation(s)
- Louise Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, 8200, Denmark
| | | | - David Nagy
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, 8200, Denmark
| | - Nils Skajaa
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, 8200, Denmark
| | - Dóra Körmendiné Farkas
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, 8200, Denmark
| | - Rune Erichsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, 8200, Denmark
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Skille H, Paulsen B, Hveem K, Severinsen MT, Gabrielsen ME, Kristensen SR, Næss IA, Hindberg K, Tjønneland A, Brækkan SK, Hansen JB. Prothrombotic genotypes and risk of venous thromboembolism in occult cancer. Thromb Res 2021; 205:17-23. [PMID: 34237679 DOI: 10.1016/j.thromres.2021.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Studies have reported that the combination of some prothrombotic genotypes and overt cancer yields a synergistic effect on VTE risk. Whether individual prothrombotic genotypes or number of risk alleles in a genetic risk score (GRS) affect VTE risk in occult cancer have not been addressed. The aim of this study was to investigate the joint effect of five prothrombotic genotypes and occult cancer on VTE risk. METHODS Cases with incident VTE (n = 1566) and a subcohort (n = 14,537) were sampled from the Scandinavian Thrombosis and Cancer Cohort (1993-2012). Five single nucleotide polymorphisms previously reported in a GRS were genotyped: ABO (rs8176719), F5 (rs6025), F2 (rs1799963), FGG (rs2066865) and F11 (rs2036914). Hazard ratios (HRs) for VTE by individual SNPs and GRS were estimated according to non-cancer and occult cancer (one year preceding a cancer diagnosis) exposure. RESULTS Occult cancer occurred in 1817 subjects, and of these, 93 experienced a VTE. The VTE risk was 4-fold higher (HR 4.05, 95% CI 3.28-5.00) in subjects with occult cancer compared with those without cancer. Among subjects with occult cancer, those with VTE had a higher proportion of prothrombotic and advanced cancers than those without VTE. The VTE risk increased according to individual prothrombotic genotypes and GRS in cancer-free subjects, while no such effect was observed in subjects with occult cancer (HR for ≥4 versus ≤1 risk alleles in GRS: 1.14, 95% CI 0.61-2.11). CONCLUSIONS Five well-established prothrombotic genotypes, individually or combined, were not associated with increased risk of VTE in individuals with occult cancer.
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Affiliation(s)
- Hanne Skille
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Benedikte Paulsen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hveem
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; HUNT Research Centre, Department of Public Health and Nursing, Norwegian University of Science and Technology, Levanger, Norway
| | - Marianne T Severinsen
- Department of Clinical Medicine, Aalborg University, Denmark; Department of Hematology, Aalborg University Hospital, Aalborg, Denmark
| | - Maiken E Gabrielsen
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; HUNT Research Centre, Department of Public Health and Nursing, Norwegian University of Science and Technology, Levanger, Norway
| | - Søren R Kristensen
- Department of Clinical Medicine, Aalborg University, Denmark; Department of Clinical Biochemistry, Aalborg University hospital, Aalborg, Denmark
| | - Inger Anne Næss
- Department of Rheumatology, Trondheim University Hospital, Trondheim, Norway
| | - Kristian Hindberg
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Anne Tjønneland
- Diet, Genes and Environment, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Sigrid K Brækkan
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway.
| | - John-Bjarne Hansen
- Thrombosis Research Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Blondon M. Screening for Cancer in Patients with Acute Venous Thromboembolic Disease. Hamostaseologie 2021; 41:42-47. [PMID: 33588454 DOI: 10.1055/a-1339-7328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Active cancer causes approximately 25% of all acute events of venous thromboembolism (VTE). While most of the cancer diagnoses are known or clinically apparent at the time of VTE, care providers and patients may be worried about the 3 to 8% risk of occult cancer occurring in the year after VTE. Several studies have compared limited to extensive cancer screening after acute VTE, especially with the addition of abdominal computed tomography (CT) or whole-body PET-CT, with the hope to shorten the time to cancer diagnosis and lead to less advanced cancer stages. These studies have not shown improved clinical outcomes with an extensive screening, and have led to current recommendations of limited screening for cancer in patients with acute VTE, including unprovoked cases. Several risk assessment models have been developed to identify patients at greatest risk of occult cancer, however, with low discriminative performances and no current clinical usefulness. Some clinical situations may empirically deserve a more thorough cancer screening, such as unprovoked upper extremity deep vein thrombosis (DVT), bilateral leg DVT, descending leg DVT, or recurrent VTE during anticoagulation.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Faculty of Medicine, Geneva University Hospitals and Faculty of Medicine, Genève, Switzerland
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Kraaijpoel N, Mulder FI, Carrier M, van Lieshout A, Würdinger T, Best MG, van Vlijmen BJ, Mohammed Y, Jara-Palomares L, Kamphuisen PW, Di Nisio M, Ageno W, Beyer-Westendorf J, Vanassche T, Klokm FA, Otten HM, Peters MJ, Cosmi B, Wolde MT, Bossuyt PM, Büller HR, van Es N. Novel biomarkers to detect occult cancer in patients with unprovoked venous thromboembolism: Rationale and design of the PLATO-VTE study. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2020.100030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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13
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Mulder FI, Carrier M, van Doormaal F, Robin P, Otten H, Salaun P, Büller HR, Le Gal G, van Es N. Risk scores for occult cancer in patients with unprovoked venous thromboembolism: Results from an individual patient data meta-analysis. J Thromb Haemost 2020; 18:2622-2628. [PMID: 32654348 PMCID: PMC7590094 DOI: 10.1111/jth.15001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/26/2020] [Accepted: 07/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Registro Informatizado de Pacientes con Enfermedad TromboEmbólica (RIETE) score and the Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) risk scores aim to identify patients with acute unprovoked venous thromboembolism (VTE) at high risk of occult cancer, but their predictive performance is unclear. METHODS The scores were evaluated in an individual patient data meta-analysis. Studies were eligible if enrolling consecutive adults with unprovoked VTE who underwent protocol-mandated screening for cancer. The primary outcome was a cancer diagnosis between 30 days and 2 years of follow-up. The discriminatory performance was evaluated by computing the area under the receiver (ROC) curve in random-effects meta-analyses. RESULTS The RIETE score could be calculated in 1753 patients, of whom 63 (3.6%) were diagnosed with cancer. The pooled area under the ROC curve was 0.59 (95% confidence interval [CI], 0.52-0.66; I2 = 0%). Of the 427 patients (24%) classified as high risk, 25 (5.9%) were diagnosed with cancer compared with 38 of 1326 (2.9%) low-risk patients (hazard ratio [HR], 2.0; 95% CI, 1.3-3.4). The SOME score was calculated in 925 patients, of whom 37 (4.0%) were diagnosed with cancer. The pooled area under the ROC curve was 0.56 (95% CI, 0.46-0.65; I2 = 46%). Of the 161 patients (17%) classified as high risk (≥2 points), eight (5.0%) were diagnosed with cancer compared with 29 of 764 (3.8%) low-risk patients (HR, 1.2; 95% CI, 0.55-2.7). CONCLUSIONS The predictive discriminatory performance of both scores is poor. When used dichotomously, the RIETE score is able to discriminate between low- and high-risk patients. Because this is largely driven by advanced age, these results do not support the use of these scores in daily clinical practice.
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Affiliation(s)
- Frits I. Mulder
- Department of Vascular MedicineAmsterdam University Medical CentersAmsterdam Cardiovascular SciencesAmsterdamThe Netherlands
- Department of Internal MedicineTergooi HospitalsHilversumThe Netherlands
| | - Marc Carrier
- Department of MedicineOttawa Hospital Research Institute at the University of OttawaOttawaONCanada
| | - Frederiek van Doormaal
- Department of Vascular MedicineAmsterdam University Medical CentersAmsterdam Cardiovascular SciencesAmsterdamThe Netherlands
| | - Philippe Robin
- Service de Médecine Nucléaire, Centre Hospitalier Régional et Universitaire de BrestEA 3878 (GETBO)Université de Bretagne OccidentaleBrestFrance
| | - Hans‐Martin Otten
- Department of Internal MedicineMeander Medical CenterAmersfoortThe Netherlands
| | - Pierre‐Yves Salaun
- Service de Médecine Nucléaire, Centre Hospitalier Régional et Universitaire de BrestEA 3878 (GETBO)Université de Bretagne OccidentaleBrestFrance
| | - Harry R. Büller
- Department of Vascular MedicineAmsterdam University Medical CentersAmsterdam Cardiovascular SciencesAmsterdamThe Netherlands
| | - Grégoire Le Gal
- Department of MedicineOttawa Hospital Research Institute at the University of OttawaOttawaONCanada
- Département de Médecine Interne et PneumologieCentre Hospitalier Régional et Universitaire de BrestUniversité de Bretagne OccidentaleBrestFrance
| | - Nick van Es
- Department of Vascular MedicineAmsterdam University Medical CentersAmsterdam Cardiovascular SciencesAmsterdamThe Netherlands
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Performance of 18F-fluorodesoxyglucose positron-emission tomography/computed tomography for cancer screening in patients with unprovoked venous thromboembolism: Results from an individual patient data meta-analysis. Thromb Res 2020; 194:153-157. [PMID: 32788108 DOI: 10.1016/j.thromres.2020.06.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/16/2020] [Accepted: 06/21/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) may be the first manifestation of cancer. We aimed at evaluating the performance of 18F-Fluorodesoxyglucose Positron-Emission Tomography/Computed Tomography (FDG PET/CT) for occult cancer screening in patients with unprovoked VTE. METHODS This was a pre-specified analysis of a systematic review and individual patient data meta-analysis including prospective studies assessing cancer screening in patients with unprovoked VTE. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FDG PET/CT were calculated based on cancer diagnosis during a 1-year follow-up period. RESULTS Four studies were identified as using FDG PET/CT as part of their extensive screening strategy. Out of the 332 patients who underwent FDG PET/CT, the scan was interpreted as positive in 67 (20.2%), as equivocal in 27 (8.1%), and as negative in 238 (71.7%). Seventeen (5.1%) patients were diagnosed with cancer at inclusion or during the 12-month follow up period. All cancers were diagnosed at initial screening. Pooled sensitivity, specificity, NPV, and PPV were 87.3% (95% CI, 55.3 to 97.4), 70.2% (95% CI, 48.2 to 85.6), 98.9% (95% CI, 94.3 to 99.7), and 17.9% (95% CI, 8.5 to 33.6), respectively. CONCLUSION FDG PET/CT appears to have satisfactory accuracy indices for cancer diagnosis in patients with unprovoked VTE. In particular, it exhibits a very high negative predictive value and could be used to rule out the presence of an underlying occult malignancy in this setting.
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Marín-Romero S, Jara-Palomares L. Screening for occult cancer: where are we in 2020? Thromb Res 2020; 191 Suppl 1:S12-S16. [PMID: 32736769 DOI: 10.1016/s0049-3848(20)30390-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/27/2019] [Accepted: 01/12/2020] [Indexed: 10/23/2022]
Abstract
The relationship between venous thromboembolism (VTE) and cancer has become an area of intense debate due to the importance and the potential benefits of the identification of occult cancer following the diagnosis of unprovoked VTE. At present, extended screening is not recommended in patients with unprovoked VTE. However, if we were able to identify a group at greater risk of presenting cancer during follow-up, these patients would benefit from extended screening. The creation of a trans-organ screening model enables the unification of metrics of quality in the screening of cancer in different localizations. Likewise, it can incorporate cancer screening for other localizations or other specific situations of risk such as unprovoked VTE. This study summarizes the contribution of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) initiative aimed at improving the cancer screening process. Likewise, we have carried out an updated review of unprovoked VTE and occult cancer. Finally, we discuss the studies currently ongoing aimed at identifying the population at greatest risk of presenting cancer during follow-up. The identification of this population at high risk could help to determine the following steps to undertake in order to implement screening in this population.
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Affiliation(s)
- Samira Marín-Romero
- Medical Surgical Unit of Respiratory Diseases, Virgen del Rocio Hospital, Seville, Spain
| | - Luis Jara-Palomares
- Medical Surgical Unit of Respiratory Diseases, Virgen del Rocio Hospital, Seville, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
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Zornitzki L, Bornstein G. Potential role for furosemide in the treatment of acute respiratory distress syndrome (ARDS) and an unusual presentation of pulmonary embolism in a complex patient. BMJ Case Rep 2020; 13:13/8/e235010. [DOI: 10.1136/bcr-2020-235010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
An 81-year-old woman was admitted to our hospital after experiencing syncope. She was diagnosed with a large pulmonary embolism and was hemodynamically unstable therefore requiring endotracheal intubation and norepinephrine support. She presented with an upper gastrointestinal bleed which prevented her from receiving tissue plasminogen activator. She was treated with enoxaparin and ceftriaxone. Her blood, sputum and urine cultures were negative. When transferred to our ward, her antibiotic treatment was changed to piperacillin–tazobactam. A lumbar puncture was not suggestive of a central nervous system infection. Chest X-rays demonstrated rapid advancement of diffuse bilateral infiltrates which were not present at first and were interpreted by radiology consultation as suggestive of acute respiratory distress syndrome. An echocardiography showed right ventricle dilatation without left-sided heart failure. Diuretics were added and with this treatment, a quick respiratory improvement was noted as she regained consciousness and extubated shortly after.
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Managing thromboembolic risk in patients with hereditary and acquired thrombophilias. Blood 2020; 135:344-350. [PMID: 31917425 DOI: 10.1182/blood.2019000917] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 11/07/2019] [Indexed: 01/03/2023] Open
Abstract
While we are now able to diagnose inherited thrombophilias in a substantial number of patients with venous thromboembolism (VTE), the initial hope that their presence would inform recurrence risk and thus decisions on anticoagulation duration has largely been disappointing. Indeed, the presence or absence of transient provoking risk factors has proven to be the most important determinant of VTE recurrence risk. Thus, particular attention to transient acquired risk factors for VTE remains paramount, as they have generally been shown to carry more prognostic weight than inherited thrombophilias. The presence of other acquired risk factors may require additional management considerations, whether pertaining to anticoagulant choice, as in antiphospholipid antibody syndrome, or to addressing a new predisposing medical condition, as in malignancy. Antithrombin deficiency or the presence of ≥1 thrombophilic defect may be exceptions that can have a role in prognostication; however, as illustrated in this review through several case vignettes, interpretation and clinical application of the results of inherited thrombophilia testing is nuanced. We have chosen to focus on cases in which patients have been identified as having thrombophilic defects rather than the indications for undertaking testing in the first place or the extent of investigation. Management decisions in such cases ultimately hinge on individualized consideration of the benefits and risks of anticoagulation along with patient preference rather than on an algorithmic pathway based on thrombophilia status.
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Lim J, Cardle C, Isles C. Patients with markedly elevated D-dimer who do not have pulmonary embolism. Postgrad Med J 2020; 97:77-82. [PMID: 32041827 DOI: 10.1136/postgradmedj-2019-137123] [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: 09/10/2019] [Revised: 11/25/2019] [Accepted: 12/31/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the cause of a markedly raised D-dimer among patients in whom a diagnosis of pulmonary embolism (PE) has been excluded by CT pulmonary angiogram (CTPA) with particular reference to new cases of cancer and aortic dissection. METHODS One thousand consecutive patients, suspected of PE, who had undergone CTPA and for whom a D-dimer had been requested, were seen between 2012 and 2016. Retrospectively we examined the case records of all those in the top quintile of the D-dimer distribution whose CTPA was negative for PE. D-dimer in the top quintile ranged from 7.5 to 260 times upper limit normal. RESULTS Eighty-five patients fulfilled our inclusion criteria. The likely causes of their very high D-dimer were infection (n=35, 41.2%), cardiovascular disease (n=12, 14.1% including two patients with previously undiagnosed aortic dissection), surgery or trauma (n=12, 14.1%), new or active cancer (n=9, 10.6% comprising six new cancers and three patients with cancers diagnosed previously that were considered to be active) and miscellaneous causes (n=17, 20.0%). Thirty-five patients (43.5%) died over a 2-year follow-up. Kaplan-Meier survival analysis showed poorer outcomes for patients with new or active cancer, when compared with those with no known cancer (p<0.001). CONCLUSIONS We have shown that a small proportion of patients suspected of PE whose D-dimers are markedly elevated have diagnoses we would not want to miss including previously unsuspected cancer and aortic dissection. Further studies will be required to define the optimal workup of patients with extremely high D-dimer who do not have venous thromboembolism.
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Affiliation(s)
- Jeren Lim
- Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
| | - Calum Cardle
- Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
| | - Chris Isles
- Department of Medicine, Dumfries and Galloway Royal Infirmary, Dumfriesshire, UK
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Kalinin R, Suchkov I, Zemlyanukhin S. Idiopathic Deep Vein Thrombosis: Choosing a Screening Strategy for Detecting Occult Cancer. ACTA ACUST UNITED AC 2020. [DOI: 10.17116/flebo202014021142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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A clinical practice-based evaluation of the RIETE score in predicting occult cancer in patients with venous thromboembolism. J Thromb Thrombolysis 2019; 48:111-118. [PMID: 30739306 PMCID: PMC6556156 DOI: 10.1007/s11239-019-01822-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The association between venous thromboembolism (VTE) and occult cancer is well established. However, the benefit of cancer screening in all VTE patients remains controversial. The Registro Informatizado Enfermedad TromboEmbólica (RIETE) score is a recently proposed risk score to identify VTE patients at high risk of occult cancer. We evaluated the performance of the RIETE score in a routine clinical setting comprising patients presenting with VTE between January 1 and December 31, 2014, at Danderyd University hospital. Out of 488 VTE patients, 47 (9.6%) patients received a new cancer diagnosis during a 24-month follow-up. After exclusion of patients with cancer diagnosed at baseline (≤ 10 days after VTE, n = 16), 472 patients were considered eligible for cancer screening. Among these 472 patients, 31 (6.6%) received a cancer diagnosis during follow-up. The cumulative incidence was high after both unprovoked (8.5%) and provoked (4.8%) VTE. The RIETE score was evaluated in 467 of these patients. Interestingly, a high RIETE score was not significantly associated with cancer diagnosis during follow-up (OR 1.78; 95% CI 0.85-3.63), which was mainly due to a poor performance in women (OR 1.04; 95% CI 0.30-2.83). In summary, we observed a relatively high incidence of occult cancer in both unprovoked and provoked VTE. The RIETE score performed poorly in identifying patients at high risk of occult cancer in our VTE population. Additional risk assessment models are warranted to identify VTE patients who would benefit from extensive cancer screening.
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Elmoamly S, Mattar M, Yacoub MF, Afif A. Can Biomarkers of Coagulation, Platelet Activation, and Inflammation Predict Venous Thromboembolism in Patients with Haematological Malignancies? Acta Haematol 2019; 141:245-253. [PMID: 30965330 DOI: 10.1159/000496914] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) in haematological malignancies varies according to the type and grade of the disease and clinical variables, and there is a need to develop a tool to predict the occurrence of VTE in cancer patients at diagnosis to tailor prophylactic anticoagulation use during treatment. OBJECTIVE To study the incidence of VTE in haematological malignancies and clarify whether vascular and inflammatory biomarkers could be used as predictors of VTE in those patients. METHODS This was a prospective observational cohort study. Hypercoagulability and inflammatory biomarkers were assayed in a group of 171 patients with haematological malignancies at diagnosis. These markers included (1) coagulation and fibrinolysis activation markers (D-dimer, fibrinogen, antithrombin, plasminogen activator inhibitor 1), (2) endothelial and platelet activation markers (von Willebrand factor and soluble P-selectin), and (3) inflammatory markers (tumour necrosis factor αand interleukin 6). The end point was mortality or symptomatic VTE. RESULTS/CONCLUSION The incidence of symptomatic VTE was 7%. None of the tested biomarkers showed statistical significance as predictors for the occurrence of VTE in haematological malignancies. However, there were statistically significant associations between the occurrence of VTE and central venous access device insertion, the prothrombin time, and the erythrocyte sedimentation rate. An ESR above 106.5 mm/h is associated with increased VTE occurrence.
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Affiliation(s)
- Shereef Elmoamly
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt,
| | - Mervat Mattar
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maha F Yacoub
- Department of Internal Medicine and Clinical Haematology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Afif
- Department of Chemical Pathology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Relationship between type of unprovoked venous thromboembolism and cancer location: An individual patient data meta-analysis. Thromb Res 2019; 176:79-84. [DOI: 10.1016/j.thromres.2019.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/03/2019] [Accepted: 02/11/2019] [Indexed: 11/23/2022]
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Yannoutsos A, Lazareth I, Priollet P. Occult cancer screening and idiopathic venous thromboembolic disease: Where do we stand? JOURNAL DE MEDECINE VASCULAIRE 2018; 43:339-341. [PMID: 30522704 DOI: 10.1016/j.jdmv.2018.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 09/10/2018] [Indexed: 06/09/2023]
Affiliation(s)
- A Yannoutsos
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
| | - I Lazareth
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
| | - P Priollet
- Service de médecine vasculaire, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France
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Usefulness of abdominal ultrasound and biomarkers in screening for occult cancer in patients with idiopathic venous thromboembolism. Med Clin (Barc) 2018; 151:418-419. [PMID: 29496245 DOI: 10.1016/j.medcli.2017.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/14/2017] [Accepted: 12/21/2017] [Indexed: 11/23/2022]
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Robertson L, Yeoh SE, Broderick C, Stansby G, Agarwal R. Effect of testing for cancer on cancer- or venous thromboembolism (VTE)-related mortality and morbidity in people with unprovoked VTE. Cochrane Database Syst Rev 2018; 11:CD010837. [PMID: 30407621 PMCID: PMC6517248 DOI: 10.1002/14651858.cd010837.pub4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a collective term for two conditions: deep vein thrombosis (DVT) and pulmonary embolism (PE). A proportion of people with VTE have no underlying or immediately predisposing risk factors and the VTE is referred to as unprovoked. Unprovoked VTE can often be the first clinical manifestation of an underlying malignancy. This has raised the question of whether people with an unprovoked VTE should be investigated for an underlying cancer. Treatment for VTE is different in cancer and non-cancer patients and a correct diagnosis would ensure that people received the optimal treatment for VTE to prevent recurrence and further morbidity. Furthermore, an appropriate cancer diagnosis at an earlier stage could avoid the risk of cancer progression and lead to improvements in cancer-related mortality and morbidity. This is an update of a review first published in 2015. OBJECTIVES To determine whether testing for undiagnosed cancer in people with a first episode of unprovoked VTE (DVT of the lower limb or PE) is effective in reducing cancer or VTE-related mortality and morbidity and to determine which tests for cancer are best at identifying treatable cancers early. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 11 July 2018. We also undertook reference checking to identify additional studies. SELECTION CRITERIA Randomised and quasi-randomised trials in which people with an unprovoked VTE were allocated to receive specific tests for identifying cancer or clinically indicated tests only were eligible for inclusion. Primary outcomes included all-cause mortality, cancer-related mortality and VTE-related mortality. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias and extracted data. We resolved any disagreements by discussion. MAIN RESULTS No new studies were identified for this 2018 update. In total, four studies with 1644 participants are included. Two studies assessed the effect of extensive tests including computed tomography (CT) scanning versus tests at the physician's discretion, while the other two studies assessed the effect of standard testing plus positron emission tomography (PET)/CT scanning versus standard testing alone. For extensive tests including CT versus tests at the physician's discretion, the quality of the evidence, as assessed according to GRADE, was low due to risk of bias (early termination of the studies). When comparing standard testing plus PET/CT scanning versus standard testing alone, the quality of evidence was moderate due to a risk of detection bias. The quality of the evidence was downgraded further as detection bias was present in one study with a low number of events.When comparing extensive tests including CT versus tests at the physician's discretion, pooled analysis on two studies showed that testing for cancer was consistent with either benefit or no benefit on cancer-related mortality (odds ratio (OR) 0.49, 95% confidence interval (CI) 0.15 to 1.67; 396 participants; 2 studies; P = 0.26; low-quality evidence). One study (201 participants) showed that, overall, malignancies were less advanced at diagnosis in extensively tested participants than in participants in the control group. In total, 9/13 participants diagnosed with cancer in the extensively tested group had a T1 or T2 stage malignancy compared to 2/10 participants diagnosed with cancer in the control group (OR 5.00, 95% CI 1.05 to 23.76; P = 0.04; low-quality evidence). There was no clear difference in detection of advanced stages between extensive tests versus tests at the physician's discretion: one participant in the extensively tested group had stage T3 compared with four participants in the control group (OR 0.25, 95% CI 0.03 to 2.28; P = 0.22; low-quality evidence). In addition, extensively tested participants were diagnosed earlier than control group (mean: 1 month with extensive tests versus 11.6 months with tests at physician's discretion to cancer diagnosis from the time of diagnosis of VTE). Extensive testing did not increase the frequency of an underlying cancer diagnosis (OR 1.32, 95% CI 0.59 to 2.93; 396 participants; 2 studies; P = 0.50; low-quality evidence). Neither study measured all-cause mortality, VTE-related morbidity and mortality, complications of anticoagulation, adverse effects of cancer tests, participant satisfaction or quality of life.When comparing standard testing plus PET/CT screening versus standard testing alone, standard testing plus PET/CT screening was consistent with either benefit or no benefit on all-cause mortality (OR 1.22, 95% CI 0.49 to 3.04; 1248 participants; 2 studies; P = 0.66; moderate-quality evidence), cancer-related mortality (OR 0.55, 95% CI 0.20 to 1.52; 1248 participants; 2 studies; P = 0.25; moderate-quality evidence) or VTE-related morbidity (OR 1.02, 95% CI 0.48 to 2.17; 854 participants; 1 study; P = 0.96; moderate-quality evidence). Regarding stage of cancer, there was no clear difference for detection of early (OR 1.78, 95% 0.51 to 6.17; 394 participants; 1 study; P = 0.37; low-quality evidence) or advanced (OR 1.00, 95% CI 0.14 to 7.17; 394 participants; 1 study; P = 1.00; low-quality evidence) stages of cancer. There was also no clear difference in the frequency of an underlying cancer diagnosis (OR 1.71, 95% CI 0.91 to 3.20; 1248 participants; 2 studies; P = 0.09; moderate-quality evidence). Time to cancer diagnosis was 4.2 months in the standard testing group and 4.0 months in the standard testing plus PET/CT group (P = 0.88). Neither study measured VTE-related mortality, complications of anticoagulation, adverse effects of cancer tests, participant satisfaction or quality of life. AUTHORS' CONCLUSIONS Specific testing for cancer in people with unprovoked VTE may lead to earlier diagnosis of cancer at an earlier stage of the disease. However, there is currently insufficient evidence to draw definitive conclusions concerning the effectiveness of testing for undiagnosed cancer in people with a first episode of unprovoked VTE (DVT or PE) in reducing cancer- or VTE-related morbidity and mortality. The results could be consistent with either benefit or no benefit. Further good-quality large-scale randomised controlled trials are required before firm conclusions can be made.
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Affiliation(s)
- Lindsay Robertson
- University of YorkCochrane Common Mental Disorders Group, Centre for Reviews and DisseminationHeslingtonYorkUKYO10 5DD
| | - Su Ern Yeoh
- University of EdinburghCollege of Medicine and Veterinary MedicineEdinburghUKEH16 4TJ
| | - Cathryn Broderick
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsTeviot PlaceEdinburghUKEH8 9AG
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
| | - Roshan Agarwal
- Northampton General Hospital NHS TrustDepartment of OncologyCliftonvilleDu Cane RoadNorthamptonUKNN1 5BD
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Effect of occult cancer screening on mortality in patients with unprovoked venous thromboembolism. Thromb Res 2018; 171:92-96. [DOI: 10.1016/j.thromres.2018.09.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/19/2018] [Accepted: 09/21/2018] [Indexed: 11/20/2022]
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Robin P, Carrier M. Revisiting occult cancer screening in patients with unprovoked venous thromboembolism. Thromb Res 2018; 164 Suppl 1:S7-S11. [PMID: 29703487 DOI: 10.1016/j.thromres.2017.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/29/2017] [Indexed: 10/17/2022]
Abstract
Unprovoked venous thromboembolism (VTE) can be the first manifestation of an unknown cancer. A recently published individual patient data meta-analysis (IPDMA) reported a prevalence of occult cancer detection of 5.2% (95% CI, 4.1% to 6.5%) over a one-year follow-up period, approximately 50% lower than the previously reported 12-month period prevalence. Although an extensive screening strategy was associated with a 2-fold higher probability of cancer detection at initial screening in the IPDMA, not enough evidence exists yet to support the routine use of these tests in patients with unprovoked VTE. It is likely that a subgroup of patients with unprovoked VTE is at higher risk of occult cancer detection and might benefit from closer clinical surveillance. A newly derived and validated clinical predictive rule seems to be able to stratify patients with unprovoked VTE accordingly to their underlying risk of occult cancer detection. The low incidence of occult cancer detection (<3%) in the low-risk group is reassuring for clinicians. Future studies are required to better define the risks and benefits of an extensive occult cancer screening strategy in high risk patients sub-group with unprovoked VTE. To date, the Scientific and Standardized Committee from the International Society of Thrombosis and Haemostasis suggests that patients with unprovoked VTE should only undergo a limited cancer screening including thorough medical history and physical examination, basic laboratory investigations, chest X-ray as well as age- and gender-specific cancer screening according to national guidelines.
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Affiliation(s)
- Philippe Robin
- Service de Médecine Nucléaire, CHRU de Brest, GETBO, EA 3878, Université de Bretagne Occidentale, Brest, France
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa.
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Duvillard C, De Magalhaes E, Moulin N, Accassat S, Mismetti P, Bertoletti L. Screening cancer after venous thromboembolism: How many abnormal tests before diagnosing cancer? An analysis of practice. Presse Med 2018; 47:e99-e106. [PMID: 30075951 DOI: 10.1016/j.lpm.2018.01.026] [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] [Received: 01/13/2017] [Revised: 12/12/2017] [Accepted: 01/15/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Since Trousseau, we knows that venous thrombemboembolism (VTE) can reveal occult cancer. Different strategies of cancer screening have been evaluated: they are often time-consuming, cause stress and anxiety, and frequently require second-look examinations (due to the risk of false positives), with ultimately a very low yield (about 5%). We evaluated the number of suspect cancer tests before reporting them to the number of cancers finally diagnosed, after a VTE, in the setting of practice's analysis. METHODS We studied retrospectively patients hospitalized for a VTE and with a cancer screening, between 2011 and 2012. Screening cancer was defined by performing at least one of the following tests: PSA, fecal occult blood test, mammography, abdominopelvic iconography (abdominal ultrasound and/or abdominal CT scan). We recorded the suspected cancer tests, the cancers diagnosed, their stage and the survival. These results were expressed as a percentage with a 95% confidence interval. RESULTS Out of the 491 patients treated for a VTE, screening cancer was performed on 295 patients (median age 66.2 years). Nineteen PSA (16.7%, 95% CI [10.3-25]) were abnormal, with 2 localized prostate cancers. Nineteen fecal occult blood tests (15.3%, 95% CI [9.5-23]) were positive, with 2 local cancers. Five mammograms suspected cancer (4.7% 95% CI [1.6-10.8]) for one confirmed. Thirty-eight abdomino-pelvic iconographies (14.4% 95% CI [10.4-19.2]) were suspect, with 7 confirmed cancers, 6 being metastatic at times of diagnostic. CONCLUSION Among the 607 tests performed, 81 were suspected of cancer (13.3%) for only 12 cancers confirmed (2.0%). Screening cancer exposes patients to several false positive tests.
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Affiliation(s)
- Cécile Duvillard
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France.
| | - Elodie De Magalhaes
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, CHU de St-Étienne, centre d'investigation clinique CIC 1401, avenue Albert-Raimond, 42055 St-Étienne cedex, France
| | - Nathalie Moulin
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France
| | - Sandrine Accassat
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, CHU de St-Étienne, centre d'investigation clinique CIC 1401, avenue Albert-Raimond, 42055 St-Étienne cedex, France
| | - Patrick Mismetti
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, CHU de St-Étienne, centre d'investigation clinique CIC 1401, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, Campus santé innovation, UMR 1059 SAINBIOSE, équipe dysfonctions vasculaires et hémostase, 10, rue de la Marandière, 42270 St-Priest-en-Jarez, France
| | - Laurent Bertoletti
- CHU de St-Étienne, hôpital Nord, service de médecine vasculaire et thérapeutique, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, CHU de St-Étienne, centre d'investigation clinique CIC 1401, avenue Albert-Raimond, 42055 St-Étienne cedex, France; Inserm, Campus santé innovation, UMR 1059 SAINBIOSE, équipe dysfonctions vasculaires et hémostase, 10, rue de la Marandière, 42270 St-Priest-en-Jarez, France
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Christensen DH, Veres K, Ording AG, Jørgensen JOL, Cannegieter SC, Thomsen RW, Sørensen HT. Risk of cancer in patients with thyroid disease and venous thromboembolism. Clin Epidemiol 2018; 10:907-915. [PMID: 30123003 PMCID: PMC6080866 DOI: 10.2147/clep.s158869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective Risk of venous thromboembolism (VTE) is increased in patients with hypo/hyperthyroidism. It is unknown whether VTE may be a presenting symptom of occult cancer in these patients. Design Nationwide population-based cohort study based on Danish medical registry data. Methods We identified all patients diagnosed with VTE during 1978–2013 who had a previous or concurrent diagnosis of hypothyroidism (N=1481) or hyperthyroidism (N=1788). We followed them until a first-time cancer diagnosis, death, emigration, or study end, whichever came first. We calculated 1-year absolute cancer risk and standardized incidence ratios (SIRs) for cancer incidence in the study population compared with national cancer incidence in the general population. Results During the first year after a VTE diagnosis, the 1-year absolute cancer risk was 3.0% among patients with hypothyroidism and 3.9% among those with hyperthyroidism. During the first year of follow-up, SIRs for cancer in the study population compared with the general population were 1.96 (95% CI: 1.42–2.64) among patients with hypothyroidism and 2.67 (95% CI: 2.07–3.39) among those with hyperthyroidism. SIRs declined substantially after 1 year but remained increased during the remainder of the follow-up period (up to 36 years) (SIR for hypothyroidism=1.16 [95% CI: 0.97–1.39]; SIR for hyperthyroidism=1.26 [95% CI: 1.08–1.46]). Conclusion VTE may be a marker of underlying occult cancer in patients with hypothyroidism or hyperthyroidism.
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Affiliation(s)
- Diana H Christensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Katalin Veres
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Anne G Ording
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Jens Otto L Jørgensen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Reimar W Thomsen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
| | - Henrik T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark,
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Riess H, Ay C, Bauersachs R, Becattini C, Beyer-Westendorf J, Cajfinger F, Chau I, Cohen AT, Khorana AA, Maraveyas A, Renni M, Young AM. Use of Direct Oral Anticoagulants in Patients with Cancer: Practical Considerations for the Management of Patients with Nausea or Vomiting. Oncologist 2018; 23:822-839. [PMID: 29650686 PMCID: PMC6058321 DOI: 10.1634/theoncologist.2017-0473] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/23/2018] [Indexed: 01/14/2023] Open
Abstract
Direct oral anticoagulants (DOACs) have proven efficacy and safety and are approved for use in the prevention and treatment of thromboembolic events in patients with venous thromboembolism (VTE) and those with atrial fibrillation (AF). There is no clear guidance on the use of DOACs in the significant proportion of these patients who have or will develop concomitant cancer. The occurrence of nausea and vomiting in these patients, despite implementation of guideline-recommended antiemetic strategies, is a particular concern because it may affect oral drug intake and consequently outcomes with anticoagulation therapy.Here, we review recent data on the incidence and management of cancer-associated nausea and vomiting and the current evidence and guidance relating to the use of DOACs in patients with cancer. On the basis of this evidence, an international working group of experts in the fields of cancer-associated thrombosis/hemostasis, hematology, and oncology discussed key issues related to the use of DOACs in patients with VTE or AF and cancer who are at risk of nausea and vomiting and developed some consensus recommendations. We present these consensus recommendations, which outline strategies for the use and management of anticoagulants, including DOACs, in patients with VTE or AF and cancer for whom oral drug intake may pose challenges. Guidance is provided on managing patients with gastrointestinal obstruction or nausea and vomiting that is caused by cancer treatments or other cancer-related factors.The recommendations outlined in this review provide a useful reference for health care professionals and will help to improve the management of anticoagulation in patients with VTE or AF and cancer. IMPLICATIONS FOR PRACTICE Direct oral anticoagulants (DOACs) offer several advantages over traditional anticoagulants, including ease of administration and the lack of need for routine monitoring. However, the management of patients with an indication for anticoagulation and concomitant cancer, who are at high risk of thromboembolic events, presents several challenges for administering oral therapies, particularly with regard to the risk of nausea and vomiting. In the absence of robust data from randomized trials and specific guidelines, consensus recommendations were developed for healthcare professionals regarding the use of DOACs in patients with cancer, with a focus on the management of patients who are at risk of nausea and vomiting.
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Affiliation(s)
- Hanno Riess
- Department of Hematology, Oncology, and Tumor Immunology, Charité, University Hospital, Berlin, Germany
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Rupert Bauersachs
- Department of Vascular Medicine, Darmstadt Hospital, Darmstadt, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Frankfurt, Germany
| | | | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division of Haematology, University Hospital "Carl Gustav Carus" Dresden, Germany
- King's Thrombosis Service, Department of Haematology, King's College London, London, UK
| | | | - Ian Chau
- Gastrointestinal Unit, Department of Medicine, Royal Marsden Hospital, Sutton, UK
| | - Alexander T Cohen
- Thrombosis and Thrombophilia Unit, Department of Haematology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Maraveyas
- Joint Centre of Cancer Studies, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Marcos Renni
- National Institute of Cancer, Ministry of Health, Rio de Janeiro, Brazil
| | - Annie M Young
- Cancer Research Centre, Warwick Medical School, University of Warwick, Coventry, UK
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Howard LSGE, Barden S, Condliffe R, Connolly V, Davies CWH, Donaldson J, Everett B, Free C, Horner D, Hunter L, Kaler J, Nelson-Piercy C, O-Dowd E, Patel R, Preston W, Sheares K, Campbell T. British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE). Thorax 2018; 73:ii1-ii29. [PMID: 29898978 DOI: 10.1136/thoraxjnl-2018-211539] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Luke S G E Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | | | | | | | | | | | - Catherine Free
- Department of Respiratory Medicine, George Eliot Hospital, Nuneaton, UK
| | - Daniel Horner
- Emergency Department, Salford Royal NHS Foundation Trust, Salford, UK.,The Royal College of Emergency Medicine, London, UK
| | | | - Jasvinder Kaler
- Cardiovascular Department, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Emma O-Dowd
- Department of Respiratory Medicine, Nottingham City Hospital, Nottingham, UK
| | - Raj Patel
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Karen Sheares
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Dronkers CEA, Lijfering WM, Teichert M, van der Meer FJM, Klok FA, Cannegieter SC, Huisman MV. Persistence to direct oral anticoagulants for acute venous thromboembolism. Thromb Res 2018; 167:135-141. [PMID: 29843087 DOI: 10.1016/j.thromres.2018.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/29/2018] [Accepted: 05/13/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Currently, direct oral anticoagulants (DOACs) are the treatment of choice for venous thromboembolism (VTE) in the Netherlands. The main advantages of DOACs over vitamin K antagonists (VKAs) are that they are safer than VKA and that neither monitoring nor dose titrations are needed. A main drawback is a potential risk of lower drug persistence, as compared with VKA treatment, which is strictly controlled by anticoagulation clinics in the Netherlands. OBJECTIVES The primary aim of this study was to audit the persistence to DOAC treatment for acute VTE during the first 2 months in daily clinical practice. METHODS Dispensing data from the Dutch Foundation of Pharmaceutical Statistics were used to monitor persistence to DOAC for treatment of VTE from 1 January 2012-1 April 2016. Non-persistence was defined as the cumulative incidence of patients who completely stopped DOAC or VKA treatment. In addition, we estimated the persistence to VKA treatment for VTE in data from the Anticoagulation Clinic Leiden. RESULTS 1834 patients were selected as DOAC users for the indication VTE. The 2-month cumulative incidence of completely stopping DOAC was 20% (95% confidence interval [CI] 18-24). In the population of 4910 VKA users, 9.1% (95%CI 8.3-9.9) stopped prematurely with VKA. CONCLUSION The stopping rate of 20% we found is in line with other cardiovascular treatments. Further research into the reasons and consequences of prematurely stopping DOAC treatment for acute VTE is urgently needed.
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Affiliation(s)
- Charlotte E A Dronkers
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Real-world incidence of cancer following a first unprovoked venous thrombosis: Results from the EPIGETBO study. Thromb Res 2018. [DOI: 10.1016/j.thromres.2018.02.151] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Jara-Palomares L, Otero R, Jimenez D, Praena-Fernandez JM, Font C, Falga C, Soler S, Riesco D, Verhamme P, Monreal M. Validation of a prognostic score for hidden cancer in unprovoked venous thromboembolism. PLoS One 2018; 13:e0194673. [PMID: 29558509 PMCID: PMC5860754 DOI: 10.1371/journal.pone.0194673] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 03/07/2018] [Indexed: 01/07/2023] Open
Abstract
The usefulness of a diagnostic workup for occult cancer in patients with venous thromboembolism (VTE) is controversial. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to perform a nested case-control study to validate a prognostic score that identifies patients with unprovoked VTE at increased risk for cancer. We dichotomized patients as having low- (≤2 points) or high (≥3 points) risk for cancer, and tried to validate the score at 12 and 24 months. From January 2014 to October 2016, 11,695 VTE patients were recruited. Of these, 1,360 with unprovoked VTE (11.6%) were eligible for the study. At 12 months, 52 patients (3.8%; 95%CI: 2.9–5%) were diagnosed with cancer. Among 905 patients (67%) scoring ≤2 points, 22 (2.4%) had cancer. Among 455 scoring ≥3 points, 30 (6.6%) had cancer (hazard ratio 2.8; 95%CI 1.6–5; p<0.01). C-statistic was 0.63 (95%CI 0.55–0.71). At 24 months, 58 patients (4.3%; 95%CI: 3.3–5.5%) were diagnosed with cancer. Among 905 patients scoring ≤2 points, 26 (2.9%) had cancer. Among 455 patients scoring ≥3 points, 32 (7%) had cancer (hazard ratio 2.6; 95%CI 1.5–4.3; p<0.01). C-statistic was 0.61 (95%CI, 0.54–0.69). We validated our prognostic score at 12 and 24 months, although prospective cohort validation is needed. This may help to identify patients for whom more extensive screening workup may be required.
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Affiliation(s)
- Luis Jara-Palomares
- Department of Pneumonology, Medical Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla (IBiS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Hospital Universitario Virgen del Rocío, Seville, Spain
- * E-mail:
| | - Remedios Otero
- Department of Pneumonology, Medical Surgical Unit of Respiratory Diseases, Instituto de Biomedicina de Sevilla (IBiS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Hospital Universitario Virgen del Rocío, Seville, Spain
| | - David Jimenez
- Respiratory Department, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | | | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Conxita Falga
- Department of Internal Medicine, Consorci Hospitalari de Mataró, Barcelona, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - David Riesco
- Department of Internal Medicine, Hospital Sant Pau i Santa Tecla, Tarragona, Spain
| | - Peter Verhamme
- Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitario Germans Trias i Pujol de Badalona, Barcelona, Universidad Católica de Murcia, Spain
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Šarinayová S. [Not Available]. PRAXIS 2018; 107:271-275. [PMID: 29486646 DOI: 10.1024/1661-8157/a002897] [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: 06/08/2023]
Abstract
Zusammenfassung. Eine unprovozierte venöse Thromboembolie (VTE) kann das erste Zeichen einer Neoplasie sein. Bei 5–10 % der Patienten wird in den nachfolgenden zwölf Monaten eine Krebserkrankung diagnostiziert. Bei allen Patienten nach einer unprovozierten VTE sollte deshalb eine gründliche Anamnese, eine sorgfältige klinische Untersuchung, eine Blutanalyse (Blutbild mit Blutausstrich, Leberenzyme, Kalzium), der Urinstatus und ein Thorax-Röntgen durchgeführt werden. Zusätzlich sollten ergänzend, je nach Alter und Geschlecht, die spezifischen Vorsorgeuntersuchungen (Darm, Zervix, Mamma und Prostata) vorgenommen werden. Alle auffälligen Befunde sollten weiter abgeklärt werden. Für eine noch aggressivere Tumorsuche konnte bislang kein Vorteil in Hinsicht auf die Tumordetektionsrate oder auf die Senkung der krebsbedingten Mortalität gezeigt werden.
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Affiliation(s)
- Svetlana Šarinayová
- 1 Medizinische Universitätsklinik, Zentrum für Onkologie, Hämatologie und Transfusionsmedizin, Kantonsspital Aarau
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Pedersen AB, Vandenbroucke J, Horváth-Puhó E, Sørensen HT. Venous thromboembolism and risk of cancer in patients with rheumatoid arthritis. J Thromb Haemost 2017; 15:2325-2332. [PMID: 28913891 DOI: 10.1111/jth.13846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Indexed: 08/31/2023]
Abstract
Essentials Can venous thromboembolism (VTE) in rheumatoid arthritis (RA) patients be marker of cancer? RA patients with VTE and comparison cohorts from population-based registries were compared. Increased risk of cancer in RA patients with VTE during the first year of VTE was observed. Risk of cancer in RA patients was increased also during the longer period following VTE. SUMMARY Background It is unknown whether venous thromboembolism (VTE) in rheumatoid arthritis (RA) patients can be a marker of occult cancer. Objectives To examine risk of cancer subsequent to VTE among RA patients compared with risk of cancer in an RA cohort without VTE and in a general population without RA and without VTE. Patients/Methods All RA patients with a first-time diagnosis of VTE (index date) during 1978-2013 and comparison cohorts were identified from population-based registries in Denmark. Results We identified three cohorts: 2497 RA patients with VTE, 11 672 RA patients without VTE and 12 730 persons from the general population. The cumulative incidence of cancer within the first year of the index date was 3.2% among RA with VTE, 2.2% among RA without VTE, and 2.0% in the general population cohort. Incidence rate ratios (IRRs) were 1.79 (95% confidence interval [CI], 1.37-2.33) for RA patients with VTE vs. RA patients without VTE and 2.12 (95% CI, 1.63-2.76) for RA patients with VTE vs. the general population. The IRR of cancer at > 1 to 36 years from the index date among RA patients with VTE was 1.16 (95% CI, 1.00-1.34) compared with the RA patients without VTE and 1.33 (95% CI, 1.15-1.53) compared with the general population. Conclusions We found an increased risk of cancer in RA patients with VTE during the first year following VTE and also during the longer follow-up period. Thus, VTE may not only be a result of inflammation and immunological dysfunctions associated with RA, but may also be a marker for occult cancer.
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Affiliation(s)
- A B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - J Vandenbroucke
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
- Leiden University Medical Center, Albinusdreef 2, Leiden, the Netherlands
| | - E Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
| | - H T Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark
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Robin P, Le Roux PY, Tromeur C, Planquette B, Prévot-Bitot N, Lavigne C, Pastre J, Merah A, Couturaud F, Le Gal G, Salaun PY. Risk factors of occult malignancy in patients with unprovoked venous thromboembolism. Thromb Res 2017; 159:48-51. [DOI: 10.1016/j.thromres.2017.08.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 08/06/2017] [Accepted: 08/31/2017] [Indexed: 10/18/2022]
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Delluc A, Antic D, Lecumberri R, Ay C, Meyer G, Carrier M. Occult cancer screening in patients with venous thromboembolism: guidance from the SSC of the ISTH. J Thromb Haemost 2017; 15:2076-2079. [PMID: 28851126 DOI: 10.1111/jth.13791] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Indexed: 08/31/2023]
Affiliation(s)
- A Delluc
- EA 3878, Department of Internal Medicine and Chest Diseases, Centre hospitalier universitaire de Brest, Hôpital de la Cavale Blanche, Brest, France
| | - D Antic
- Clinic for Hematology, Lymphoma Center, Clinical Center Serbia, Medical Faculty, Department for Internal Medicine, University of Belgrade, Belgrade, Serbia
| | - R Lecumberri
- Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
| | - C Ay
- Department of Medicine I, Clinical Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - G Meyer
- Department of Respiratory Disease, Hôpital Européen Georges Pompidou, Université Paris Descartes, Sorbonne Paris Cité, INSERM UMRS 970 and CIC 1418, Paris, France
| | - M Carrier
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Extensive screening for occult malignancy in unprovoked venous thromboembolism: A meta-analysis. Thromb Res 2017; 157:147-153. [DOI: 10.1016/j.thromres.2017.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/03/2017] [Accepted: 07/14/2017] [Indexed: 11/22/2022]
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Dunn T, Rudrapatna VA, Hesse S, Sargsyan Z. Arterial Thromboses Heralding Cholangiocarcinoma. Am J Med 2017; 130:e341-e342. [PMID: 28344146 DOI: 10.1016/j.amjmed.2017.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Shayla Hesse
- National Institutes of Health Infectious Disease Fellowship Program, Bethesda, Md
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Yokoi K, Hara M, Ueda Y, Yamamoto K, Ota K, Kabata D, Kitamura T, Sakata Y, Shintani A. Epidemiological and outcome data in Japanese patients with deep vein thrombosis with and without malignancy. Heart Vessels 2017; 32:1469-1477. [PMID: 28741216 DOI: 10.1007/s00380-017-1025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 07/21/2017] [Indexed: 10/19/2022]
Abstract
There are very few epidemiological studies on Japanese patients with deep vein thrombosis (DVT). In particular, mortality rate differences in Japanese DVT patients with and without malignancy have rarely been evaluated. To elucidate these differences, we enrolled 211 patients who had been diagnosed with de-novo acute DVT of the pelvis or lower extremities between January 2012 and December 2015. The clinical characteristics, treatment information, and follow-up data were retrospectively assessed. We compared these variables in patients with (n = 120) and without (n = 91) concomitant malignancies. The median age of patients was 67 years, 33.7% were male, and 82.9% patients were treated with oral anticoagulants including direct oral anticoagulants. The clinical characteristics and treatment provided were almost identical in the two groups with some exceptions. Three-year survival rates of the total population, patients with malignancy, and patients without malignancy were 80.6, 67.6, and 97.6%, respectively (log-rank p < 0.001). Multivariable Cox regression analysis demonstrated that malignancy was independently associated with high risk of 3-year all-cause mortality with an adjusted hazard ratio of 9.1 (95% confidence interval; 2.1-39.0, p = 0.003). Bootstrap validation demonstrated an acceptable index corrected slope of 0.766 without significant overfitting in a multivariable model. In conclusion, we analyzed epidemiological data on Japanese patients with DVT. Malignancy was independently associated with increased 3-year all-cause mortality.
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Affiliation(s)
- Kensuke Yokoi
- Cardiovascular Division, Osaka National Hospital, Osaka, Japan
| | - Masahiko Hara
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Center of Medical Innovation and Translational Research 603A, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Yasunori Ueda
- Cardiovascular Division, Osaka National Hospital, Osaka, Japan
| | - Keiichi Yamamoto
- REDCap Group, Department of Medical Innovation, Osaka University Hospital, Suita, Japan
| | - Keiko Ota
- REDCap Group, Department of Medical Innovation, Osaka University Hospital, Suita, Japan
| | - Daijiro Kabata
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Center of Medical Innovation and Translational Research 603A, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ayumi Shintani
- Department of Clinical Epidemiology and Biostatistics, Osaka University Graduate School of Medicine, Center of Medical Innovation and Translational Research 603A, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
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Jara-Palomares L, Otero R, Jiménez D, Praena-Fernández JM, Rivas A, Font C, Wells PS, López-Reyes R, González-Martínez J, Monreal M. Sex Differences in Patients With Occult Cancer After Venous Thromboembolism. Clin Appl Thromb Hemost 2017; 24:489-495. [PMID: 28681634 DOI: 10.1177/1076029617711805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In patients with venous thromboembolism (VTE), male sex has been associated with an increased risk of occult cancer. The influence of sex on clinical characteristics, treatment, cancer sites, and outcome has not been thoroughly investigated yet. We used the Registro Informatizado Enfermedad TromboEmbólica registry to compare the clinical characteristics, treatment strategies, cancer sites, and clinical outcomes in patients with VTE having occult cancer, according to sex. As of June 2014, 5864 patients were recruited, of whom 444 (7.6%; 95% confidence interval: 6.8-8.2) had occult cancer. Of these, 246 (55%) were men. Median time elapsed from VTE to occult cancer was 4 months (interquartile range: 2-8.4), with no sex differences. Women were older, weighed less, and were less likely to have chronic lung disease than men. The most common cancer sites were the lung (n = 63), prostate (n = 42), and colorectal (n = 29) in men and colorectal (n = 38), breast (n = 23), uterine (n = 18), hematologic (n = 17), or pancreas (n = 15) in women. Men were more likely to have lung cancer than women (2.18% vs 0.30%; P < .01) and less likely to have pancreatic cancer (0.17% vs 0.5%; P = .03). Interestingly, breast cancer was more likely found in women aged ≥50 years than in those aged <50 years (0.97% vs 0.14%; P = .03). This study highlights the existence of sex differences in patients with VTE having occult cancer. One in every 2 men had lung, prostate, or colorectal cancer. In women, there is a heterogeneity of cancer sites, increasing risk of breast cancer in those aged >50 years.
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Affiliation(s)
- Luis Jara-Palomares
- 1 Medical Surgical Unit of Respiratory Diseases, CIBERES, Hospital Virgen del Rocío, Seville, Spain
| | - Remedios Otero
- 1 Medical Surgical Unit of Respiratory Diseases, CIBERES, Hospital Virgen del Rocío, Seville, Spain
| | - David Jiménez
- 2 Respiratory Department, Ramón y Cajal Hospital and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Juan Manuel Praena-Fernández
- 3 Statistics, Methodology and Research Evaluation Unit, Andalusian Public Foundation for Health Research Management, Hospital Virgen del Rocío, Seville, Spain
| | - Agustina Rivas
- 4 Department of Pneumonology, Hospital Universitario Araba, Álava, Spain
| | - Carme Font
- 5 Department of Medical Oncology, IDIBAPS/Translational Genomics and Targeted Therapeutics in Solid Tumors, Hospital Clinic, Barcelona, Spain
| | - Philip S Wells
- 6 Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Raquel López-Reyes
- 7 Department of Pneumonology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - José González-Martínez
- 8 Department of Internal Medicine, ALTHAIA, Xarxa Assistencial de Manresa, Barcelona, Spain
| | - Manuel Monreal
- 9 Department of Internal Medicine, Hospital Universitario Germans Trias i Pujol de Badalona, Universidad Católica de Murcia, Barcelona, Spain
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Robin P, Le Roux PY, Le Moigne E, Planquette B, Prévot-Bitot N, Roy PM, Pastre J, Merah A, Couturaud F, Le Gal G, Salaun PY. Additional testing following screening strategies for occult malignancy diagnosis in patients with unprovoked venous thromboembolism. Thromb Res 2017; 155:6-9. [DOI: 10.1016/j.thromres.2017.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 04/07/2017] [Accepted: 04/22/2017] [Indexed: 11/26/2022]
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Klein A, Shepshelovich D, Spectre G, Goldvaser H, Raanani P, Gafter-Gvili A. Screening for occult cancer in idiopathic venous thromboembolism - Systemic review and meta-analysis. Eur J Intern Med 2017; 42:74-80. [PMID: 28502867 DOI: 10.1016/j.ejim.2017.05.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/21/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Idiopathic venous thromboembolism (VTE) may be associated with an occult malignancy. Early detection of cancer might be translated to a better prognosis for these patients. However, the efficacy of extensive screening for cancer in patients with idiopathic VTE is controversial. MATERIALS AND METHODS Systemic review and meta-analysis of all available prospective trials comparing extensive to limited screening for occult malignancies in patients with idiopathic VTE. PRIMARY OUTCOME all-cause mortality. SECONDARY OUTCOMES cancer related mortality, early cancer diagnosis, cancer diagnosis at the end of follow up and cancer diagnosis at an early stage. Risk ratios (RR) with 95% confidence intervals (CIs) were estimated and pooled. RESULTS The study included five trials and 2287 patients. Extensive screening did not affect all-cause mortality at the end of follow up [RR 0.86 (95% CI 0.58-1.27)] or cancer-related mortality [RR 0.93 (95% CI 0.54-1.58)]. Yet, it yielded more diagnoses of cancer [RR 2.17 (95% CI 1.42-3.32)]. Rates of cancer diagnosis at an early stage did not differ statistically between the two groups [RR 1.49 (95% CI 0.86-2.56)]. However, analysis of the randomized controlled trials alone showed a tendency towards early stage cancer at diagnosis in extensive screening group in, with results almost statistically significant [RR 2.14 (95% CI 0.98-4.67), p=0.06]. CONCLUSIONS Extensive screening for malignancy after idiopathic VTE does not affect mortality rates. Yet, it yields more cancer diagnoses shortly after the VTE event. Further research is needed to determine whether extensive screening might be proper for specific high risk populations.
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Affiliation(s)
- Alina Klein
- Medicine A, Rabin Medical Center, Petah-Tikva, Israel
| | - Daniel Shepshelovich
- Medicine A, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv, Israel
| | - Hadar Goldvaser
- Institute of Oncology, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv, Israel
| | - Anat Gafter-Gvili
- Medicine A, Rabin Medical Center, Petah-Tikva, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Sackler School of Medicine, Tel-Aviv, Israel.
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Eischer L, Kammer M, Traby L, Kyrle PA, Eichinger S. Risk of cancer after anticoagulation in patients with unprovoked venous thromboembolism: an observational cohort study. J Thromb Haemost 2017; 15:1368-1374. [PMID: 28407356 DOI: 10.1111/jth.13702] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Indexed: 11/29/2022]
Abstract
Essentials Data on long-term cancer risk are controversial in patients with venous thromboembolism (VTE). We assessed long-term rates and risk factors of cancer in patients with VTE. Cancer risk after anticoagulation is not higher in VTE patients than in the general population. VTE recurrence is not predictive of a future cancer diagnosis. SUMMARY Background Patients with venous thromboembolism (VTE) are at risk of having a subsequent cancer diagnosis. The risk is highest during the first 6 months. Reports on cancer rates thereafter are controversial. We aimed to assess long-term rates and risk factors of cancer in patients with VTE. Methods and Results We followed patients with a first unprovoked VTE after discontinuation of anticoagulation, and excluded those receiving long-term antithrombotic therapy or with major thrombophilia. The study endpoint was the occurrence of cancer. Sixty-two (5.2%) of 1188 patients developed cancer during a median follow-up of 98 months. The cumulative incidence rates of cancer were 0.7% (95% confidence interval [CI] 0.2-1.2%), 3.1% (95% CI 2.0-4.1%) and 9% (95% CI 6.5-11.5) after 1, 5 and 15 years; these were not significantly different from those in the matched general population (0.6%, 3.4%, and 12.2%, respectively). The corresponding standardized incidence ratios (ratio of the observed cancer cases and the number of cases based on national cancer incidence rates) of 1.1 (95% CI 0.5-2.5), 1.0 (95% CI 0.6-1.4) and 0.9 (95% CI 0.7-1.2) did not indicate a difference in cancer incidence between our cohort and the general population. Advancing age (hazard ratio [HR] per decade 1.5, 95% CI 1.2-2.0) and shorter duration of anticoagulation (HR per 1-month decrease 1.3, 95% CI 1.1-1.6) were associated with an increased cancer risk, whereas VTE recurrence was not (HR 1.17, 95% CI 0.66-2.07). Conclusions Asymptomatic patients with unprovoked VTE who have completed anticoagulation therapy do not have a higher cancer risk. The inverse association between the duration of anticoagulation and the incidence of cancer warrants further investigation.
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Affiliation(s)
- L Eischer
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - M Kammer
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - L Traby
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - P A Kyrle
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Clinical Thrombosis Research, Vienna, Austria
| | - S Eichinger
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
- Karl Landsteiner Institute of Clinical Thrombosis Research, Vienna, Austria
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Khan F, Rahman A, Carrier M. Occult cancer detection in venous thromboembolism: the past, the present, and the future. Res Pract Thromb Haemost 2017; 1:9-13. [PMID: 30046669 PMCID: PMC6058204 DOI: 10.1002/rth2.12007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Unprovoked venous thromboembolism (VTE) can be the first manifestation of an undiagnosed cancer. Recently published studies have suggested that approximately 4-5% of patients with new unprovoked VTE will be diagnosed with cancer within 12 months of follow-up. Therefore, it is important for clinicians to keep a low threshold of suspicion for occult cancer in this patient population. After an unprovoked VTE diagnosis, patients should undergo a thorough medical history, physical examination, basic laboratory investigations (ie, complete blood count and liver function tests), chest X-ray, as well as age- and gender-specific cancer screening (breast, cervical, colon, and prostate). More intensive cancer screening including additional investigations (eg, computed tomography of the abdomen/pelvis) does not seem to increase the rate of occult cancer detection, decrease cancer-related morbidity, or increase survival or cost-effectiveness.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology, Public Health & Preventive MedicineUniversity of OttawaOttawaONCanada
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaONCanada
| | - Alvi Rahman
- School of Epidemiology, Public Health & Preventive MedicineUniversity of OttawaOttawaONCanada
| | - Marc Carrier
- Clinical Epidemiology ProgramOttawa Hospital Research InstituteOttawaONCanada
- Department of MedicineOttawa Blood Disease CentreUniversity of Ottawa and The Ottawa HospitalOttawaONCanada
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van Es N, Gal GL, Otten HM, Robin P, Piccioli A, Lécumberri R, Palomares LJ, Religa P, Rieu V, Rondina MT, Beckers MM, Prandoni P, Salaun PY, Nisio MD, Bossuyt PM, Büller HR, Carrier M. Screening for cancer in patients with unprovoked venous thromboembolism: protocol for a systematic review and individual patient data meta-analysis. BMJ Open 2017; 7:e015562. [PMID: 28601834 PMCID: PMC5663010 DOI: 10.1136/bmjopen-2016-015562] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Occult cancer is present in 4%-9% of patients with unprovoked venous thromboembolism (VTE). Screening for cancer may be considered in these patients, with the aim to diagnose cancers in an early, potentially curable stage. Information is needed about the risk of occult cancer, overall and in specific subgroups, additional risk factors and on the performance of different screening strategies. METHODS AND ANALYSIS MEDLINE, Embase and CENTRAL databases were searched from November 2007 to January 2016 for prospective studies that had evaluated protocol-mandated screening for cancer in patients with unprovoked VTE and with at least 12 months' follow-up. Two reviewers independently assessed articles for eligibility. Ten eligible studies were identified and individual patient data were obtained from each of them. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool . Generalised linear mixed-effects models was used to calculate estimates in a one-stage meta-analytic approach, overall and in a number of subgroups, including patients undergoing limited screening only, elderly patients, patients with previous VTE, smokers and patients using oestrogens. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review and individual patient data meta-analysis. Findings have been submitted for publication in peer-reviewed journals and presentations at national and international conferences to provide clinicians and other decision-makers with valid and precise risk estimates of occult cancer, overall and in specific clinical subgroups, with risk factors for occult cancer, with estimates of the diagnostic performance of limited screening and with an exploration of the benefit of extensive screening strategies.
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Affiliation(s)
- Nick van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Hans-Martin Otten
- Department of Internal Medicine, Slotervaartziekenhuis, Amsterdam, The Netherlands
| | - Philippe Robin
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Andrea Piccioli
- Departments of Cardiovascular Sciences and Medicine, University Hospital of Padua, Padua, Italy
| | - Ramon Lécumberri
- Hematology Service, Clinica Universidad de Navarra, Pamplona, Spain
| | - Luis Jara Palomares
- Medical Surgical Unit of Respiratory Diseases. Instituto de Biomedicina de Sevilla (IBiS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Sevilla, Spain
| | - Piotr Religa
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Warsaw Medical University, Warsaw, Poland
| | - Viriginie Rieu
- Department of Internal Medicine, CHU Estaing, Clermont-Ferrand, France
| | - Matthew T. Rondina
- Division of General Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Paolo Prandoni
- Departments of Cardiovascular Sciences and Medicine, University Hospital of Padua, Padua, Italy
| | - Pierre-Yves Salaun
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Marcello Di Nisio
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
- Dipartimento di Medicina e Scienze dell Invecchiamento, Università ‘Gabriele d'Annunzio’, Chieti-Pescara, Italy
| | - Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Harry R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
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Husseinzadeh H, Carrier M. Occult cancer detection in patients with hemostatic disorder and venous thromboembolism. Thromb Res 2017; 163:242-245. [PMID: 28587726 DOI: 10.1016/j.thromres.2017.05.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/21/2017] [Accepted: 05/31/2017] [Indexed: 11/28/2022]
Abstract
There are physiologic ties between Von Willebrand Factor (VWF) and circulating tumor cells. VWF appears to play a role in tumor biology, but it is unclear whether cancer behavior differs in Von Willebrand Disease. In patients presenting with venous thromboembolism (VTE), occult cancer is frequently considered as an underlying cause. The prevalence of occult cancer after provoked VTE is low (3%); therefore, cancer screening in these patients is not routinely recommended. In those with unprovoked VTE, occult cancer is more prevalent, estimated between 4 and 10%. Due to this elevated risk, occult cancer screening is recommended in this population. Multiple studies have investigated whether a "limited" approach (including history and physical exam, basic labs, and chest X-ray) versus "extensive" approach (addition of advanced imaging, such as computer tomography) is more effective. Current data fails to demonstrate extensive screening strategies diagnose more occult cancer, miss fewer cancers during follow up, or improve cancer-related mortality. Furthermore, many patients may be needlessly exposed to unnecessary diagnostic procedures with their associated complications and costs, as well as significant anxiety. Therefore, the decision to perform additional testing should be made on a case-by-case basis. Additional studies are needed to identify subgroups of patients with unprovoked VTE at highest risk for occult cancer.
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Affiliation(s)
- Holleh Husseinzadeh
- Department of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada.
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