Incidence of venous thromboembolism among patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer

Higher incidence of venous thromboembolism associated with increasing lines of treatment in heavily treated ovarian cancer patients

OBJECTIVE

Ovarian cancer is associated with a high rate of venous thromboembolism. Our objective is to report the incidence of venous thromboembolism in recurrent ovarian cancer, assess the impact on morbidity and mortality, and evaluate predictors of venous thromboembolism.

METHODS

A retrospective single institution cohort study was performed. Patients with a diagnosis of recurrent ovarian cancer between 2007 and 2020 and no previous history of venous thromboembolism were identified. Demographic and clinical variables were collected. Univariate and multivariable analyses were performed to identify predictors of venous thromboembolism.

RESULTS

Of the 345 patients included in this study, 77 (22.3%) developed a venous thromboembolism. Most (n=56, 72.7%) were actively receiving treatment at the time of diagnosis of venous thromboembolism, of whom 44 (78.6%) had received three or more lines of treatment. In total, 42 (54.5%) were admitted to hospital on diagnosis and one mortality (1.3%) occurred secondary to venous thromboembolism. An intermediate/high risk Khorana score was not predictive of venous thromboembolism (p=0.24). The risk of venous thromboembolism was significantly higher with increasing lines of chemotherapy (odds ratio 1.14, 95% confidence interval 1.02 to 1.28 per line, p=0.026). There was no significant difference in overall survival (62.9 vs 49.1 median months, p=0.29) between patients with and without venous thromboembolism.

CONCLUSIONS

More than 20% of patients with recurrent ovarian cancer developed a venous thromboembolism, and most occurred after three or more lines of treatment. The risk of venous thromboembolism was higher with increasing lines of chemotherapy. While venous thromboembolism did not appear to impact survival in this population, nearly half required hospitalization, emphasizing the morbidity of venous thromboembolism and potential impact on healthcare costs. Further studies are needed to improve risk stratification for venous thromboembolism in this high risk population.

Haemostatic Gene Expression in Cancer-Related Immunothrombosis: Contribution for Venous Thromboembolism and Ovarian Tumour Behaviour

Ovarian cancer (OC) is the deadliest gynaecological malignancy. Identifying new prognostic biomarkers is an important research field. Haemostatic components together with leukocytes can drive cancer progression while increasing the susceptibility to venous thromboembolism (VTE) through immunothrombosis. Unravelling the underlying complex interactions offers the prospect of uncovering relevant OC prognostic biomarkers, predictors of cancer-associated thrombosis (CAT), and even potential targets for cancer therapy. Thus, this study evaluated the expression of F3, F5, F8, F13A1, TFPI1, and THBD in peripheral blood cells (PBCs) of 52 OC patients. Those with VTE after tumour diagnosis had a worse overall survival (OS) compared to their counterparts (mean OS of 13.8 ± 4.1 months and 47.9 ± 5.7 months, respectively; log-rank test, p = 0.001). Low pre-chemotherapy F3 and F8 expression levels were associated with a higher susceptibility for OC-related VTE after tumour diagnosis (χ2, p < 0.05). Regardless of thrombogenesis, patients with low baseline F8 expression had a shorter progression-free survival (PFS) than their counterparts (adjusted hazard ratio (aHR) = 2.54; p = 0.021). Among those who were not under platelet anti-aggregation therapy, low F8 levels were also associated with a shorter OS (aHR = 6.16; p = 0.006). Moving forward, efforts should focus on external validation in larger cohorts.

Incidence of venous thromboembolism in patients with ovarian cancer receiving neoadjuvant chemotherapy: systematic review and meta-analysis

OBJECTIVE

Venous thromboembolism is associated with significant patient morbidity, mortality, and can lead to delays in treatment for patients with cancer. The objectives of this study were to identify the incidence of venous thromboembolism in patients with advanced ovarian cancer receiving neoadjuvant chemotherapy, and identify risk factors for venous thromboembolism.

METHODS

A systematic literature search of biomedical databases, including Ovid Medline, Web of Science, Scopus, CINAHL, and Embase was performed on December 6, 2022 and updated on December 21, 2023 for peer reviewed articles. Studies were included if they were cohort studies or randomized controlled trials that evaluated the incidence of venous thromboembolism for patients with ovarian cancer receiving neoadjuvant chemotherapy. Risk of bias assessment was performed using the Newcastle Ottawa Scale for cohort studies and the Cochrane risk of bias tool for randomized controlled trials. Random effects meta-analysis was used to pool results across studies.

RESULTS

A total of 2636 studies were screened, and 11 were included in the review. Ten were retrospective cohort studies, and one was a randomized controlled trial. The incidence of venous thromboembolism in the included studies ranged from 0% to 18.9%. The pooled incidence rate of venous thromboembolism was 10% (95% confidence interval (CI) 7% to 13%). This remained significant when restricted to only studies with a low risk of bias (pooled incidence of 11%, 95% CI 9% to 14%). Body mass index of ≥30 kg/m2 was a significant risk factor for venous thromboembolism with a pooled odds ratio of 1.76 (95% CI 1.13 to 2.76) CONCLUSIONS: The results from this study demonstrated a 10% incidence of venous thromboembolism for patients with advanced ovarian cancer receiving neoadjuvant chemotherapy. This suggests that there may be a role for universal thromboprophylaxis in this population.

TRIAL REGISTRATION

PROSPERO CRD42022339602.

Long Non-Coding RNAs: Bridging Cancer-Associated Thrombosis and Clinical Outcome of Ovarian Cancer Patients

Ovarian cancer (OC) and venous thromboembolism (VTE) have a close relationship, in which tumour cells surpass the haemostatic system to drive cancer progression. Long non-coding RNAs (lncRNAs) have been implicated in VTE pathogenesis, yet their roles in cancer-associated thrombosis (CAT) and their prognostic value are unexplored. Understanding how these lncRNAs influence venous thrombogenesis and ovarian tumorigenesis may lead to the identification of valuable biomarkers for VTE and OC management. Thus, this study evaluated the impact of five lncRNAs, namely MALAT1, TUG1, NEAT1, XIST and MEG8, on a cohort of 40 OC patients. Patients who developed VTE after OC diagnosis had worse overall survival compared to their counterparts (log-rank test, p = 0.028). Elevated pre-chemotherapy MEG8 levels in peripheral blood cells (PBCs) predicted VTE after OC diagnosis (Mann-Whitney U test, p = 0.037; Χ2 test, p = 0.033). In opposition, its low levels were linked to a higher risk of OC progression (adjusted hazard ratio (aHR) = 3.00; p = 0.039). Furthermore, low pre-chemotherapy NEAT1 levels in PBCs were associated with a higher risk of death (aHR = 6.25; p = 0.008). As for the remaining lncRNAs, no significant association with VTE incidence, OC progression or related mortality was observed. Future investigation with external validation in larger cohorts is needed to dissect the implications of the evaluated lncRNAs in OC patients.

Implementation of routine venous thromboembolism prophylaxis during neoadjuvant chemotherapy for patients with ovarian cancer

OBJECTIVE

To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis.

METHODS

This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models.

RESULTS

Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07-0.52) and post-implementation period (OR 0.34; 95% CI 0.17-0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07-0.53).

CONCLUSION

Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.

Incidence of venous thromboembolism in patients with advanced stage ovarian cancer undergoing neoadjuvant chemotherapy: Is it time for thromboprophylaxis?

OBJECTIVES

Our objectives were to determine the incidence, timing, and risk factors for venous thromboembolisms (VTEs) in patients with advanced stage epithelial ovarian cancer (EOC) who received neoadjuvant chemotherapy (NACT). We explored the utilization of direct-acting oral anticoagulants (DOACs) for VTE treatment.

METHODS

This retrospective cohort study included patients with advanced stage EOC receiving NACT followed by interval cytoreductive surgery (ICS) at a single institution. Risk factors were compared between patients with versus without VTE between EOC diagnosis and 180 days after ICS. Bleeding complications were compared between patient who received a DOAC versus non-DOAC.

RESULTS

VTE cases occurred amongst 33 of the 154 (21.4%) patients with 4 (2.6%) concurrent with EOC diagnosis, 9 (5.8%) between EOC diagnosis and NACT start, 13 (8.4%) between NACT start and ICS, and 7 (4.5%) within 180 days after ICS. There were no statistically significant differences in risk factors assessed (age, body mass index, functional status, histology, Khorana score, and smoking history) between patients with versus without VTE. Eleven patients (33.3%) received a DOAC for VTE treatment. There were no significant differences in number of intraoperative blood transfusions (p = 0.38), blood loss (p = 0.95), or bleeding complications (p = 0.53) between patients treated with a DOAC versus a non-DOAC.

CONCLUSION

There is a high incidence of VTE events (21.4%) in patients with advanced stage EOC undergoing NACT. Two-thirds of the VTEs may have been prevented with thromboprophylaxis as they occurred between EOC diagnosis and ICS. These data support consideration of thromboprophylaxis in all patients with advanced stage EOC undergoing NACT.

Direct oral anticoagulant (DOACs) prescribing practices of members of the Society of Gynecologic Oncology and American Society of Clinical Oncology

BACKGROUND

Cancer associated venous thromboembolism (VTE) is associated with significant morbidity and mortality. Direct oral anticoagulants (DOACs) have emerged as alternatives to injectable medications for both thromboprophylaxis and treatment of VTE. Several recent clinical trials have demonstrated safety and efficacy of DOACs in high risk patients receiving systemic chemotherapy as well as postoperative prophylaxis after surgery for gynecologic cancer. Major consensus guidelines from multiple organizations support the use of DOACs for these indications but prescription practices are not well characterized.

METHODS

A survey study was sent concurrently to members of the Society of Gynecologic Oncology (SGO) and American Society of Clinical Oncology (ASCO) Research Survey Pool between May and June of 2021. The study was designed to assess DOAC prescription practices amongst members of these societies who routinely prescribe chemotherapy. Bivariate analyses comparing responses from ASCO participants and SGO participants were compared using chi-squared and Fisher exact tests.

RESULTS

A total of 103 physicians were included in the ASCO group and 139 in the SGO group. A majority of participants in both groups reported familiarity with prescribing DOACs (99% of ASCO and 96% of SGO respondents). ASCO respondents were more likely to consider DOACs as first line therapy for treatment of cancer-associated VTE than SGO members (82% vs 63%, p < 0.01) and SGO members were more likely to consider low molecular weight heparin (LMWH) the standard of care treatment (66% vs 25% p < 0.01). Most respondents in both groups (75%) felt DOACs were equally safe and effective compared to LMWH but more ASCO members felt DOACs were cost effective (70% vs 49%, p < 0.01). More SGO respondents reported having prescribed prophylactic anticoagulation during chemotherapy than ASCO members (53% vs 35%, p < 0.01).

CONCLUSION

ASCO respondents were more likely to prescribe DOACs for both treatment and prophylaxis of cancer-associated VTE than SGO members. However, SGO members were more likely to prescribe prophylactic anticoagulation to high risk patients initiating chemotherapy compared to ASCO members.

Assessing the need for venous thromboembolism prophylaxis at the time of neoadjuvant chemotherapy for ovarian cancer: A literature review

OBJECTIVE

Gynecologic cancers, especially ovarian cancer, are associated with a high incidence of venous thromboembolism (VTE). Recent data have shown the risk of VTE development is not only limited to the postoperative period; there also appears to be an increased risk during neoadjuvant chemotherapy (NACT) administration, prompting the need for better risk stratification in this setting. We sought to assess the risk of VTE development in patients with ovarian cancer undergoing NACT.

METHODS

We performed a PubMed literature review using the following medical terms: advanced ovarian cancer, advanced peritoneal cancer, advanced fallopian tube cancer, thrombosis, thromboembolic events, and neoadjuvant chemotherapy. Eligible studies included patients with advanced ovarian, fallopian tube, or peritoneal cancer who underwent NACT and had VTE. VTE was defined as either a deep venous thrombosis or a pulmonary embolism.

RESULTS

Seven relevant studies were identified; all 7 were published between 2017 and 2021. Across these studies, we identified 1427 patients who underwent NACT and either had VTE at presentation or developed VTE during their treatment course. Of these patients, 1171 underwent NACT and were at risk for VTE development and were included in our pooled analysis. Of these patients, 144 (12.3%) developed VTE.

CONCLUSIONS

VTE prophylaxis may be considered in patients with ovarian cancer undergoing NACT.

Venous Thromboembolism in Cancer Patients Undergoing Chemotherapy: A Systematic Review and Meta-Analysis

Objective: Venous thromboembolism (VTE) is a life-threatening complication that may exacerbate cancer prognosis. Whilst some studies indicate an increased risk of VTE in cancer patients undergoing chemotherapy, the prevalence estimates on the pooled prevalence of VTE in cancer patients undergoing chemotherapy are not known. This study aims to calculate the pooled prevalence of VTE in chemotherapy-treated cancer patients. Methods: Studies on VTE occurrence in cancer patients undergoing chemotherapy were retrieved after database search. The terms used included “cancer”, “chemotherapy”, and “venous thromboembolism”. A random-effects meta-analysis was conducted to obtain a pooled estimate of VTE prevalence in cancer patients undergoing chemotherapy. Results: A total of 102 eligible studies involving 30,671 patients (1773 with VTE, 28,898 without) were included in the meta-analysis. The pooled estimate of VTE prevalence was found to be 6%, ranging from 6% to 7% (ES 6%; 95% CI 6−7%; z = 18.53; p < 0.001). Conclusions: The estimated pooled prevalence rate of VTEs was 6% in cancer patients undergoing CRT, which was higher than the overall crude prevalence rate (5.78%). Comprehensive cancer care should consider stratified VTE risk assessment based on cancer phenotype, given that certain phenotypes of cancer such as bladder, gastric and ovarian posing particularly high risks of VTE.

Therapeutic Strategies Focused on Cancer-Associated Hypercoagulation for Ovarian Clear Cell Carcinoma

Ovarian clear cell carcinoma (OCCC) is associated with chemotherapy resistance and poor prognosis, especially in advanced cases. Although comprehensive genomic analyses have clarified the significance of genomic alterations such as ARID1A and PIK3CA mutations in OCCC, therapeutic strategies based on genomic alterations have not been confirmed. On the other hand, OCCC is clinically characterized by a high incidence of thromboembolism. Moreover, OCCC specifically shows high expression of tissue factor and interleukin-6, which play a critical role in cancer-associated hypercoagulation and may be induced by OCCC-specific genetic alterations or the endometriosis-related tumor microenvironment. In this review, we focused on the association between cancer-associated hypercoagulation and molecular biology in OCCC. Moreover, we reviewed the effectiveness of candidate drugs targeting hypercoagulation, such as tissue factor- or interleukin-6-targeting drugs, anti-inflammatory drugs, anti-hypoxia signaling drugs, anticoagulants, and combined immunotherapy with these drugs for OCCC. This review is expected to contribute to novel basic research and clinical trials for the prevention, early detection, and treatment of OCCC focused on hypercoagulation.

Incidence of postoperative thrombotic events in ovarian cancer patients with a de-escalated prophylactic strategy: A retrospective cohort study

OBJECTIVE

This study aimed to determine the incidence of thrombotic events in ovarian cancer patients following a de-escalated prophylactic strategy and to stratify risk groups.

METHODS

We reviewed the records of patients who underwent debulking surgery for ovarian cancer at a single institution between January 2007 and May 2019. We identified clinically diagnosed and radiologically confirmed cases of thrombotic events-classified as pulmonary thromboembolism (PE), deep vein thrombosis (DVT), and other thrombotic events-within 6 months of debulking surgery.

RESULTS

After excluding 13 patients diagnosed with thromboembolism at the baseline or during neoadjuvant chemotherapy, 799 were analyzed. Since the introduction of medical prophylaxis at our institution in 2009, 482 patients (60%) received medical prophylaxis with subcutaneous injection of low molecular weight heparin for 5 days with mechanical prophylaxis, whereas 317 (40%) received mechanical prophylaxis only. After debulking surgery, thrombotic events occurred in 28 patients (3.5%) including PE (n = 11), DVT (n = 10), and other thrombotic events (n = 7). Multivariable analysis identified age, body mass index (BMI), and operative duration as independent risk factors associated with thrombotic events. A thrombotic event was an independent prognostic factor for overall survival (HR 2.17, 95% CI 1.16-4.1). A cut-off analysis for pre-operative identifiable risk factors showed age < 57 years and BMI < 21 could help define low-risk groups. One patient from 172 low-risk patients (0.58%) experienced a thrombotic event.

CONCLUSIONS

The thrombotic event incidence was low in our cohort. A de-escalated prophylaxis strategy may be considered in young (age < 57 years) and lean (BMI < 21) patients.

Risk of venous thromboembolism in ovarian cancer patients receiving neoadjuvant chemotherapy

PURPOSE

To determine the incidence of venous thromboembolism (VTE) and define clinical risk factors associated with the development of new-onset VTE in patients receiving neoadjuvant chemotherapy (NACT) for ovarian cancer (OC).

METHODS

An institutional ovarian cancer database was used to identify all OC patients receiving NACT from 04/2015-09/2018. VTE events were recorded and included clinically diagnosed deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The incidence of VTE events was categorized according to treatment phases (P): P0) First visit/prior to induction of NACT; P1) during NACT before interval debulking surgery (IDS); P2) intraoperative through day 28 post-IDS; P3) during adjuvant chemotherapy.

RESULTS

A total of 290 patients were identified during the study period. Seventy-five (25.9%) developed a VTE at some point from time of presentation through the peri-operative period. Forty (13.8%) presented with VTE prior to initiation of NACT. An additional 27 (11.6%) developed a VTE during NACT (P1); 6 (3.9%) during the intraoperative and 28-day post-operative period (P2); and 2 (1.3%) during the adjuvant period (P3). The overall VTE rate was 25.9% (n = 75). FIGO stage IV disease was the only factor associated with increased risk for a new-onset VTE [Odds Ratio (OR): 3.9 (95% Confidence Interval [CI] = 1.2-13.6; p = 0.03].

CONCLUSIONS

Patients receiving NACT for advanced OC are at extremely high risk for developing thromboembolic events, either at initial presentation or during induction of NACT, a treatment phase that is traditionally without use of prophylactic anticoagulation. Since Khorana scoring is not predictive in this population, clinicians might need to consider increased screening or use of prophylactic anticoagulation in patients receiving NACT for OC, particularly in advanced metastatic disease.

Potential of combination of DCE-MRI and DWI with serum CA125 and CA199 in evaluating effectiveness of neoadjuvant chemotherapy in breast cancer

BACKGROUND

To determine the potential of the combination of DCE-MRI imaging method with DWI and serum CA125 and CA199 levels in the evaluation of the efficacy of neoadjuvant chemotherapy in breast cancer patients.

METHODS

Sixty-five breast cancer patients who received neoadjuvant chemotherapy in our hospital from April 2016 to April 2017 were selected as research subjects. The patients received 4 courses of neoadjuvant chemotherapy. Lesions were monitored using DCE-MRI and DWI, while ELISA was used to measure the serum expression levels of the tumour markers CA125 and CA199. The patients were divided into the remission group and ineffective group based on pathological diagnosis.

RESULTS

There were significant differences in K_ep, K_trans, ADC_min, ADC_mean, tumour volume, and serum levels of CA125 and CA199 in patients in the remission group, before and after neoadjuvant chemotherapy, and there were significant differences in post-chemotherapy values of these indexes between the remission group and the ineffective group (p < 0.01).

CONCLUSION

Combination of DCE-MRI diagnostic imaging with DWI can directly reflect the lesions in breast cancer patients after neoadjuvant chemotherapy. Serum levels of CA125 and CA199 levels are useful for evaluation of the impact of neoadjuvant chemotherapy on breast cancer patients, including risk of cancer cell metastasis and changes in some small lesions.

Incidence and patient characteristics of venous thromboembolism during neoadjuvant chemotherapy for ovarian cancer

There is paucity of data on venous thromboembolism (VTE) in patients receiving neoadjuvant chemotherapy (NACT) for advanced stage ovarian cancer. We explored the incidence and predictors of VTE in this patient population. We performed a retrospective review of women with primary ovarian, fallopian tube or peritoneal cancer who received NACT between January 2012 and October 2018 at Cooper University Hospital. Patients with history of VTE, heparin therapy or direct oral anticoagulant use prior to cancer diagnosis were excluded. The primary outcome was incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE) after cancer diagnosis. We explored demographic and clinical variables associated with VTE. Of 90 patients included, 25 (28%) were diagnosed with VTE and 16 (64%) had PE. Eight patients were diagnosed after cancer diagnosis prior to the start of chemotherapy and 17 patients during NACT. Most patients had stage III disease and serous adenocarcinoma. There was a trend towards increased risk of VTE for Black patients (OR 3.22; CI 0.997-10.42; P = 0.051). Significantly fewer patients with VTE had debulking surgery (60% vs. 88%, P = 0.005). The risk of DVT increased by 8.7% per year of age (OR 1.087; 95% CI 1.01-1.17). Obesity, smoking status, medical comorbidities, disease stage, histology, invasive diagnostic surgery, and length of NACT were not associated with VTE. The incidence of VTE during neoadjuvant chemotherapy is high. Older age and Black race may increase the risk of VTE, and this morbid complication may adversely impact cancer treatment.

Venous Thromboembolism in Patients Receiving Neoadjuvant Chemotherapy for Advanced Ovarian Cancer and Impact on Survival

OBJECTIVE

To determine the incidence of venous thromboembolism (VTE) in patients with ovarian cancer receiving neoadjuvant chemotherapy (NACT), identify risk factors for VTE, and assess the effect of VTE on treatment trajectory and overall survival.

METHODS

This is a retrospective cohort study of patients diagnosed with ovarian, fallopian tube, or primary peritoneal cancer treated with NACT between 2013 to 2016 in Alberta, Canada. The primary outcome was incidence of VTE during NACT. Secondary outcomes were risk factors for VTE and overall survival. Data related to patient demographics, cancer treatment, and incidence of VTE were collected. Statistical analyses included Kaplan-Meier estimates and univariate and multivariate Cox regression analysis.

RESULTS

A total of 284 patients were included in this study. Average age at diagnosis was 63.8 years. The incidence of VTE during NACT was 13.3%. Patients with VTE were less likely to undergo interval debulking surgery (58.3%) than patients without VTE (78.6%). Kaplan-Meier estimates demonstrated a decrease in overall survival in patients who had VTE during NACT (15.0 mo; 95% CI 14.5-16.5) compared with patients who did not (26.8 mo; 95% CI 22.8-30.9) (P < 0.0001). Multivariate analysis identified albumin <35 g/L, BMI >30 kg/m², and non-serous histology as risk factors for VTE.

CONCLUSION

The risk of VTE in this cohort was 13.3%, which was associated with decreased overall survival. These findings suggest that thromboprophylaxis may have a role in this patient population.

Cost-Effectiveness of Venous Thromboembolism Prophylaxis During Neoadjuvant Chemotherapy for Ovarian Cancer

PURPOSE

Two recent clinical trials have demonstrated that direct oral anticoagulants (DOACs) are effective as venous thromboembolism (VTE) prophylaxis in patients with moderate-to-high risk ambulatory cancer initiating chemotherapy. Patients with advanced ovarian cancer receiving neoadjuvant chemotherapy are at particularly increased risk of VTE. We performed a cost-effectiveness analysis from a health system perspective to determine if DOACs are a feasible prophylactic strategy in this population.

METHODS

A simple decision tree was created from a health system perspective, comparing two strategies: prophylactic DOAC taken for 18 weeks during chemotherapy versus no VTE prophylaxis. Rates of VTE (7.3% DOAC v 13.6% no treatment), major bleeding (2.6% v 1.3%), and clinically relevant nonmajor bleeding (4.6% v 3.3%) were modeled. Cost estimates were obtained from wholesale drug costs, published studies, and Medicare reimbursement data. Probabilistic, one-way, and two-way sensitivity analyses were performed.

RESULTS

In the base case model, DOAC prophylaxis is more costly and more effective than no therapy (incremental cost-effectiveness ratio = $256,218 in US dollars/quality-adjusted life year). In one-way sensitivity analyses, reducing the DOAC cost by 32% or raising the baseline VTE rate above 18% renders this strategy potentially cost-effective with an incremental cost-effectiveness ratio below $150,000 in US dollars/quality-adjusted life year.

CONCLUSION

Further confirmation of the true baseline VTE rate among women initiating neoadjuvant chemotherapy for ovarian cancer will determine whether prophylactic dose DOAC is a value-based strategy. Less costly VTE prophylaxis options such as generic DOACs (once available) and aspirin also warrant investigation.

Procoagulant activity in high grade serous ovarian cancer patients following neoadjuvant chemotherapy-The role of the activated protein C pathway

INTRODUCTION

Ovarian cancer patients are at high risk of thrombosis particularly during chemotherapy treatment however the mechanism is not understood. The aim of this study is to investigate the role of the activated protein C (aPC) pathway in the procoagulant activity observed in ovarian cancer patients undergoing neoadjuvant chemotherapy.

PATIENTS AND METHODS

Thrombin generation was determined before and after addition of thrombomodulin (TM) in high grade serous ovarian cancer (HGSOC) patients treated with neoadjuvant chemotherapy (n = 29) compared with HGSOC patients who were chemo naïve (n = 23) and patients with benign tumours (n = 29). Plasma expression of proteins from the aPC pathway was analysed. mRNA expression was determined in endothelial (EA.hy926) and ovarian (OAW42) cell lines following addition of carboplatin and paclitaxel.

RESULTS

Lower levels of ETP (p < 0.007; p < 0.003) and peak thrombin (p < 0.0008; p < 0.0018) were found in the neoadjuvant group compared with both chemo naïve and benign groups. Following addition of TM, ETP (p < 0.0005) and peak thrombin (p < 0.0049) were higher in the neoadjuvant group compared with the benign controls indicating an increase in aPC resistance. Increased TM and lower levels of protein S were found in the neoadjuvant group compared with benign controls (p < 0.05; p < 0.003). Factor V levels were increased in the neoadjuvant group compared with the chemo naïve group (p < 0.05). Carboplatin and paclitaxel altered the expression of EPCR and thrombomodulin in OAW42 cells with a modest effect on EA.hy926 cells.

CONCLUSION

Chemotherapy induced procoagulant activity in HGSOC is associated with an alteration in expression of key members of the aPC pathway. This acquired aPC resistance may explain the procoagulant phenotype associated with ovarian cancer patients undergoing chemotherapy.

The prevalence, risk factors, and prognostic value of venous thromboembolism in ovarian cancer patients receiving chemotherapy: a systematic review and meta-analysis

BACKGROUND

Venous thromboembolism (VTE) in ovarian cancer (OC) patients has been widely investigated, but our knowledge on the role of VTE in OC patients receiving chemotherapy is limited. The aim of our study was to investigate the prevalence, risk factors, and prognostic value of chemotherapy-associated VTE in OC.

METHODS

Three databases (PubMed, Embase, and the Cochrane Library) were systematically searched from inception to October 14, 2020. The primary outcome was the prevalence of VTE in OC patients receiving chemotherapy. The risk factors and prognostic value of VTE were the secondary outcomes. The pooled prevalence of VTE was estimated using the generic inverse-variance method. The statistical heterogeneity was evaluated with Cochran's Q test and I² statistic. Funnel plot, Begg's test, and Egger's test were used to assess the potential publication bias in the meta-analysis.

RESULTS

A total of eleven observational studies with 4759 OC patients were included. The pooled prevalence of VTE was 9% (95% CI, 0.06-0.12) in OC patients receiving chemotherapy. The results of subgroup analysis and sensitivity analysis were basically consistent with the overall pooled estimate. Multiple significant risk factors associated with VTE were also identified including advanced age, D-dimer > 0.5 mg/mL, and tumor diameter > 10 cm. Only two included studies reported the prognostic value of VTE in OC patients receiving chemotherapy, but with inconsistent results. Funnel plot showed that there existed potential publication bias, which was further verified by statistical test, but the results of the trim-and-fill method showed the pooled estimate kept stable after adding two "missing" studies.

CONCLUSIONS

This current study revealed that the pooled prevalence of chemotherapy-related VTE in OC was approximately 9% in OC patients. Risk factors for chemotherapy-related VTE were also identified which may contribute to targeting potentially preventative measures for VTE in OC.

Direct oral anticoagulant use in gynecologic oncology: A Society of Gynecologic Oncology Clinical Practice Statement

Venous thromboembolism (VTE) is a common cause of morbidity and mortality in women with gynecologic malignancies. This practice statement provides clinical data and overall quality of evidence regarding the use of direct oral anticoagulants (DOACs) in this patient population. Specifically, it reviews patient selection, safety measures, and nuances of perioperative use of these medications. The scope of this document is limited to DOAC use in gynecologic oncology rather than a broad discussion of VTE prophylaxis and management in general. The following recommendations and examination of extant data are based on DOAC trials conducted primarily in mixed populations with different cancer subtypes. Many of these trials include few, or no, women with gynecologic cancer. However, because there is very limited data in gynecologic cancer-specific populations, the results of these studies represent the best available evidence to support treatment recommendations in our patients. The members of the Society of Gynecologic Oncology (SGO) Clinical Practice Committee believe that the results of these studies may be extrapolated, with caution, to VTE treatment and prophylaxis for patients with gynecologic cancer.

Incidence and risk factors for postoperative venous thromboembolism in patients with ovarian cancer: Systematic review and meta-analysis

BACKGROUND

Venous Thromboembolism (VTE) is a leading cause of morbidity and mortality in patients with ovarian malignancy. There is no meta-analysis available on this topic so far. The aim of our study was to quantitatively synthesize the data from studies with respect to the incidence and risk factors for postoperative VTE among cases with epithelial ovarian cancer (EOC).

METHODS

PubMed, Web of Science, and Embase were searched for papers containing the key words "venous thromboembolism", "postoperative", "postoperation", "ovarian neoplasm", "ovary neoplasm", "ovarian cancer", "ovary cancer", and "cancer of ovary". Studies selection, data extraction, quality assessment of eligible studies were performed independently by our different reviewers. Meta-analyses were conducted to determine postoperative VTE incidence and risk factors in women with EOC. Sensitivity analysis were used to verify the robustness of the results of meta-analyses if necessary.

RESULTS

In total, 19 studies were included in this meta-analysis. The pooled incidence for postoperative symptomatic VTE was 3% (95% CI, 0.03-0.04) and for postoperative symptomatic as well as asymptomatic VTE was 8% (95% CI, 0.07-0.09). The presence of history of VTE (OR, 2.37), advanced-stages (OR, 2.35), high complexity of surgery (OR, 2.20), clear cell carcinoma of ovary (OR, 2.53) and residual disease>1 cm (OR, 2.57) significantly increase the likelihood of having postoperative VTE. Other risk factors for postoperative VTE in EOC patients were BMI>30 (OR, 1.58), per 10-years increase in age (OR, 1.22), ASA score>2 (OR, 1.45), ascites (OR, 2.07), the diameter of residual disease is between 0 cm to 1 cm (OR, 2.06) and smoking history (OR, 1.54).

CONCLUSIONS

This study revealed that VTE, especially subclinical VTE, is a prevalent complication in postoperative patients with EOC. History of VTE, advanced FIGO stages, high complexity of surgery, obesity, older age, ascites, higher ASA score, smoking history and suboptimal debulking are associated with this increased incidence of postoperative VTE among patients with EOC. PROSPERO registration number: CRD42020209662.

Nurses' knowledge, attitudes, and behaviors toward venous thromboembolism prophylaxis: How to do better

OBJECTIVES

To investigate the cognition of nurses on the control and treatment of venous thromboembolism in China, thereby providing suitable countermeasures for clinical venous thromboembolism prophylaxis and treatment.

METHODS

In December 2019, a total of 1121 registered nurses from a university-affiliated hospital were selected to answer the self-designed and electronic questionnaire (Wenquanxing: www.wjx.cn/), which was designed to evaluate the nurses' knowledge (21 items), attitudes (6 items), and behaviors (9 items) toward venous thromboembolism prophylaxis. Descriptive, correlation, and regression analyses were conducted for data analysis.

RESULTS

Of the included 1121 nurses, only 55.43% nurses selected 100% correct answer. The influencing factors of knowledge included the department, education, professional ranks, and venous thromboembolism nursing experience. The nurses from ICU department gained the highest score, but the nurses from pediatrics department obtained the lowest score. The nurses with higher education level and professional ranks, and nursing experiences achieved higher scores. The total positive response rate for the attitude-related items was 68.54%. Nurses were primarily concerned about the financial penalty due to the inability to complete the work (49.0%). An increasing workload is the second primary concern of nurses (40.8%). The increasing medical cost, extension of hospital stay, and exacerbation of doctor-patient conflicts were the most serious difficulties involved in venous thromboembolism prophylaxis. The total correct score rate for the behaviors was 56.19%. Nearly half of the nurses could not offer advice for venous thromboembolism patients. The nursing experience, department, and years of work were related to the scores of knowledge-related items (all P < 0.05).

CONCLUSIONS

The overall knowledge level of the nurses was not optimistic. Although their general attitude toward venous thromboembolism prophylaxis was positive, their behaviors were influenced by many factors. Administrators should, therefore, make countermeasures to deal with these problems.