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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [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: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Tao YN, Han Q, Jiao W, Yang LK, Wang F, Xue S, Shen M, Wang YH. Effects of ulinastatin therapy in deep vein thrombosis prevention after brain tumor surgery: A single-center randomized controlled trial. World J Clin Cases 2023; 11:7583-7592. [DOI: 10.12998/wjcc.v11.i31.7583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 10/11/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common neurosurgical complication after brain tumor resection, and its prophylaxis has been widely studied. There are no effective drugs in the clinical management of venous thromboembolism, and there is an absence of evidence-based medicine concerning the treatment of severe multiple traumas.
AIM To explore whether ulinastatin (UTI) can prevent VTE after brain tumor resection.
METHODS The present research included patients who underwent brain tumor resection. Patients received UTIs (400,000 IU) or placebos utilizing computer-based random sequencing (in a 1:1 ratio). The primary outcome measures were the incidence of VTE, coagulation function, pulmonary emboli, liver function, renal function, and drug-related adverse effects.
RESULTS A total of 405 patients were evaluated between January 2019 and December 2021, and 361 of these were initially enrolled in the study to form intention-to-treat, which was given UTI (n = 180) or placebo (n = 181) treatment in a random manner. There were no statistically significant differences in baseline clinical data between the two groups. The incidence of VTE in the UTI group was remarkably improved compared with that in the placebo group. UTI can improve coagulation dysfunction, pulmonary emboli, liver function, and renal function. No significant difference was identified between the two groups in the side effects of UTI-induced diarrhea, vomiting, hospital stays, or hospitalization costs. The incidence of allergies was higher in the UTI group than in the placebo group.
CONCLUSION The findings from the present research indicated that UTI can decrease the incidence of VTE and clinical outcomes of patients after brain tumor resection and has fewer adverse reactions.
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Affiliation(s)
- Yun-Na Tao
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Qian Han
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Wei Jiao
- Nursing, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Li-Kun Yang
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Fang Wang
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Shan Xue
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Meng Shen
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
| | - Yu-Hai Wang
- Department of Neurosurgery, The 904th Hospital of Joint Logistic Support Force, Wuxi 214044, Jiangsu Province, China
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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Ha H, Ko YH, Kim K, Hong J, Lee GW, Jeong SH, Bang SM, Yoon SS. Application of the Khorana score for cancer-associated thrombosis prediction in patients of East Asian ethnicity undergoing ambulatory chemotherapy. Thromb J 2023; 21:63. [PMID: 37271814 DOI: 10.1186/s12959-023-00505-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND The Khorana score (KS) has not been well studied in East Asian cancer patients, who have different genetic backgrounds for inherited thrombophilia, body metabolism, and cancer epidemiology. METHODS By using the Common Data Model, we retrospectively collected deidentified data from 11,714 consecutive newly diagnosed cancer patients who underwent first-line chemotherapy from December 2015 to December 2021 at a single institution in Korea, and we applied the KS for cancer-associated thrombosis (CAT) prediction. Age at diagnosis, sex, and use of highly thrombogenic chemotherapeutics were additionally investigated as potential risk factors for CAT development. RESULTS By 6 months after chemotherapy initiation, 207 patients (1.77%) experienced CAT. Only 0.4% had a body mass index (BMI) ≥ 35 kg/m2 and changing the cutoff to 25 kg/m2 improved the prediction of CAT. Age ≥ 65 years and the use of highly thrombogenic chemotherapeutics were independently associated with CAT development. KS values of 1 ~ 2 and ≥ 3 accounted for 52.3% and 7.6% of all patients, respectively, and the incidence of CAT in these groups was 2.16% and 4.16%, respectively, suggesting a lower incidence of CAT in the study population than in Westerners. The KS component regarding the site of cancer showed a good association with CAT development but needed some improvement. CONCLUSION The KS was partially validated to predict CAT in Korean cancer patients undergoing modern chemotherapy. Modifying the BMI cutoff, adding other risk variables, and refining the use of cancer-site data for CAT risk prediction may improve the performance of the KS for CAT prediction in East Asian patients.
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Affiliation(s)
- Hyerim Ha
- Department of Internal Medicine, Inha University College of Medicine, Inha University Hospital, Incheon, Republic of Korea
| | - Yeh-Hee Ko
- Department of Applied Statistics, Yonsei University, Seoul, Republic of Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Department of Medicine, College of Medicine, Seoul National University Hospital, Seoul National University, 101 Daehak-ro, Jongno-gu, Adjunct, Seoul, Republic of Korea.
- Department of Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Junshik Hong
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea.
| | - Gyeong-Won Lee
- Division of Hematology-Oncology, Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Republic of Korea
| | - Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National Bundang Hospital, Seongnam, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Republic of Korea
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5
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Overvad TF, Skjøth F, Piazza G, Noble S, Ording AG, Larsen TB, Nielsen PB. The Khorana score and venous and arterial thrombosis in patients with cancer treated with immune checkpoint inhibitors: A Danish cohort study. J Thromb Haemost 2022; 20:2921-2929. [PMID: 36112135 PMCID: PMC9828438 DOI: 10.1111/jth.15883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Thrombosis is common among patients with cancer. Primary thromboprophylaxis guided by the Khorana score is endorsed by guidelines but recommendations rely mainly on data from patients treated with chemotherapy. OBJECTIVES To explore if the Khorana score could risk stratify patients with cancer treated with immune checkpoint inhibitors according to risk of venous and arterial thrombosis. PATIENTS/METHODS The study population and Khorana score were defined using administrative Danish health registries. The primary outcome was 6-month risk of venous thromboembolism after initiation of checkpoint inhibitor treatment. Secondary outcomes were arterial thrombosis and any thromboembolic event. Death was considered a competing risk event. RESULTS Among 3946 patients with cancer initiating checkpoint inhibitor treatment without other indications for anticoagulation, the overall 6-month incidence of venous thromboembolism was 2.6% (95% confidence interval [CI]: 2.1-3.1). Risks were 2.1% (95% CI: 1.5-3.0), 2.6% (95% CI: 2.0-3.4), and 3.7% (95% CI: 2.1-5.9) in low (score 0), intermediate (score 1-2), and high risk (score ≥3) Khorana categories, respectively. Among patients eligible for primary thromboprophylaxis according to guidelines (Khorana score ≥2), risk of venous thromboembolism was 4.1% (95% CI: 3.1-5.4). Higher Khorana risk category was also associated with higher 6-month risk of both arterial thrombosis and any thromboembolic events. CONCLUSIONS The Khorana score was able to risk stratify patients with cancer treated with immune checkpoint inhibitors according to 6-month risk of thromboembolic events. Risks of venous thromboembolism were lower than in randomized thromboprophylaxis trials, thus questioning the absolute benefit of routine primary thromboprophylaxis in an unselected population of patients treated with immune checkpoint inhibitors.
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Affiliation(s)
- Thure F. Overvad
- Department of Clinical PharmacologyAalborg University HospitalAalborgDenmark
- Aalborg Thrombosis Research Unit, Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Flemming Skjøth
- Aalborg Thrombosis Research Unit, Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of MedicineBrigham and Women's Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Simon Noble
- Marie Curie Palliative Care Research CentreCardiff UniversityCardiffUK
| | - Anne G. Ording
- Aalborg Thrombosis Research Unit, Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of CardiologyAalborg University HospitalAalborgDenmark
| | - Torben B. Larsen
- Aalborg Thrombosis Research Unit, Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of CardiologyAalborg University HospitalAalborgDenmark
| | - Peter B. Nielsen
- Aalborg Thrombosis Research Unit, Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of CardiologyAalborg University HospitalAalborgDenmark
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Michailidou D, Zhang T, Kuderer NM, Lyman GH, Diamantopoulos AP, Stamatis P, Ng B. Predictive models for thromboembolic events in giant cell arteritis: A US veterans health administration population-based study. Front Immunol 2022; 13:997347. [DOI: 10.3389/fimmu.2022.997347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/17/2022] [Indexed: 11/13/2022] Open
Abstract
Giant cell arteritis (GCA) that affects older patients is an independent risk factor for thromboembolic events. The objective of this study was to identify predictive factors for thromboembolic events in patients with GCA and develop quantitative predictive tools (prognostic nomograms) for pulmonary embolism (PE) and deep venous thrombosis (DVT). A total of 13,029 patients with a GCA diagnosis were included in this retrospective study. We investigated potential predictors of PE and DVT using univariable and multivariable Cox regression models. Nomograms were then constructed based on the results of our Cox models. We also assessed the accuracy and predictive ability of our models by using calibration curves and cross-validation concordance index. Age, inpatient status at the time of initial diagnosis of GCA, number of admissions before diagnosis of GCA, and Charlson comorbidity index were each found to be independent predictive factors of thromboembolic events. Prognostic nomograms were then prepared based on these predictors with promising prognostic ability. The probability of developing thromboembolic events over an observation period of 5 years was estimated by with time-to-event analysis using the method of Kaplan and Meier, after stratifying patients based on predicted risk. The concordance index of the time-to-event analysis for both PE and DVT was > 0.61, indicating a good predictive performance. The proposed nomograms, based on specific predictive factors, can accurately estimate the probability of developing PE or DVT among patients with GCA.
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Li J, Chen H, Liu M, Lin Z, Ren X, Wang Y, Zou X, Gu Z. A risk prediction model for evaluating thrombosis extension of muscle calf venous thrombosis after craniotomy. Front Surg 2022; 9:992576. [PMID: 36311954 PMCID: PMC9614109 DOI: 10.3389/fsurg.2022.992576] [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: 07/12/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
Objective To explore the risk factors of muscle calf venous thrombosis (MCVT) after craniotomy and construct a risk prediction model, so as to provide tool for evaluating the prognosis of MCVT after craniotomy. Methods Retrospective analysis was performed on the data of patients undergoing craniotomy complicated with MCVT from January 1, 2018 to December 31, 2020. A prediction model was established by Logistic regression, and the predictive efficacy of the model was tested by ROC curve. The accuracy of the risk model was evaluated by Hosmer-Lemeshow (H-L) test, and the model was verified internally by cross validation. Results Among the 446 patients who underwent craniotomy complicated with MCVT, 112 cases (25.11%) had thrombosis extension. D-dimer, Capirini scores, length of hospital stay, malignant tumor, fracture, use of dehydrating agents and hemostatic agents were independently related to thrombosis extension after craniotomy. The area under ROC curve (AUROC) of the prediction model was 0.918 (0.888, 0.942), and the sensitivity and specificity of the maximum Youden index were 85.3% and 78.2%, respectively. H-L test showed that the prediction model was accurate (χ2 = 12.426, P = 0.133). The internal verification results of the prediction model showed that the AUROC value of the prediction model is 0.892. Conclusion The prediction model has a good prediction efficacy on the prognosis of post-craniotomy patients complicated with MCVT, and can be used as a tool to evaluate the risk of thrombosis extension.
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Affiliation(s)
- Juhua Li
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Correspondence: Zejuan Gu Juhua Li
| | - Huayu Chen
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mei Liu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Lin
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xingzhen Ren
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ying Wang
- Department of Neurosurgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Xingchen Zou
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zejuan Gu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Correspondence: Zejuan Gu Juhua Li
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8
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Anijs RJS, Laghmani EH, Ünlü B, Kiełbasa SM, Mei H, Cannegieter SC, Klok FA, Kuppen PJK, Versteeg HH, Buijs J. Tumor‐expressed
microRNAs
associated with venous thromboembolism in colorectal cancer. Res Pract Thromb Haemost 2022; 6:e12749. [PMID: 35794963 PMCID: PMC9248312 DOI: 10.1002/rth2.12749] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 11/23/2022] Open
Abstract
Background Colorectal cancer patients have an increased risk of developing venous thromboembolism (VTE), resulting in increased morbidity and mortality. Because the exact mechanism is yet unknown, risk prediction is still challenging; therefore, new biomarkers are needed. MicroRNAs (miRNAs) are small, relatively stable RNAs, that regulate a variety of cellular processes, and are easily measured in body fluids. Objective The aim of this study was to identify novel tumor‐expressed miRNAs associated with VTE. Methods In a cohort of 418 colorectal cancer patients diagnosed between 2001 and 2015 at the Leiden University Medical Center, 23 patients (5.5%) developed VTE 1 year before or after cancer diagnosis. Based on availability of frozen tumor material, tumor cells of 17 patients with VTE and 18 patients without VTE were isolated using laser capture microdissection and subsequently analyzed on the Illumina sequencing platform NovaSeq600 using 150‐bp paired‐end sequencing. Cases and controls were matched on age, sex, tumor stage, and grade. Differential miRNA expression was analyzed using edgeR. Results A total of 547 miRNAs were detected. Applying a 1.5‐fold difference and false discovery rate of <0.1, 19 tumor‐miRNAs were differentially regulated in VTE cases versus controls, with hsa‐miR‐3652, hsa‐miR‐92b‐5p, and hsa‐miR‐10,394‐5p as most significantly downregulated. Seven of the 19 identified miRNAs were predicted to regulate the gonadotropin‐releasing hormone receptor pathway. Conclusion We identified 19 differentially regulated tumor‐expressed miRNAs in colorectal cancer‐associated VTE, which may provide insights into the biological mechanism and in the future might have potential to serve as novel, predictive biomarkers.
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Affiliation(s)
- Rayna J. S. Anijs
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | - El Houari Laghmani
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
| | - Betül Ünlü
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
| | - Szymon M. Kiełbasa
- Department of Biomedical Data Sciences Leiden University Medical Center Leiden The Netherlands
| | - Hailiang Mei
- Department of Biomedical Data Sciences Leiden University Medical Center Leiden The Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical Epidemiology Leiden University Medical Center Leiden The Netherlands
| | - Frederikus A. Klok
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
| | - Peter J. K. Kuppen
- Department of Surgery Leiden University Medical Center Leiden The Netherlands
| | - Henri H. Versteeg
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
| | - Jeroen T. Buijs
- Einthoven Laboratory for Vascular and Regenerative Medicine, Division of Thrombosis and Hemostasis, Department of Medicine Leiden University Medical Center Leiden The Netherlands
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9
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Ciuffini L, Wang T, Lodigiani C, Carrier M. Thromboprophylaxis of cancer patients undergoing systemic therapy in the ambulatory setting. Best Pract Res Clin Haematol 2022; 35:101351. [DOI: 10.1016/j.beha.2022.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/02/2022]
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10
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Khorana AA, Barnard J, Wun T, Vijapurkar U, Damaraju CV, Moore KT, Wildgoose P, McCrae KR. Biomarker signatures in cancer patients with and without venous thromboembolism events: a substudy of CASSINI. Blood Adv 2022; 6:1212-1221. [PMID: 34807979 PMCID: PMC8864658 DOI: 10.1182/bloodadvances.2021005710] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 11/01/2021] [Indexed: 11/20/2022] Open
Abstract
Cancer is associated with an increased risk of venous thromboembolism (VTE). In the CASSINI study, ambulatory cancer patients with a Khorana risk score ≥2 had a reduced risk of VTE while receiving rivaroxaban. This analysis used blood samples from CASSINI to compare biomarker levels between patients with and without VTE. VTE occurred in 62 patients during the 6 months of CASSINI (cases), and they were matched by age, sex, cancer type, tumor stage, and Khorana score to 62 controls. Baseline blood samples were analyzed for 280 biomarkers, and biomarker distribution was compared using the Wilcoxon rank-sum test between groups defined by VTE occurrence and vital status. Sparse Bayesian regression modeling was used to select a joint panel of potential VTE biomarkers. Biomarkers with the largest differences in baseline distribution among cancer patients with and without VTE included decreases in stromal cell-derived factor-1 (SDF-1), thyroid-stimulating hormone (TSH), and monocyte chemotactic protein 4 and increases in growth hormone (GH) and interleukin-1 receptor type 1 (IL-1R1). Between survivors and those who died, significantly different biomarkers included ST2, IL-8, and C-reactive protein. Regression analyses also identified decreases in SDF-1 and TSH. Pathway analysis indicated enrichment of cytokine and chemokine activity with IL-1R1, SDF-1, and GH, which are the strongest predictors of VTE or death. Our analyses highlight the interactions between hemostatic and inflammatory processes and identify candidate biomarkers of cancer-associated VTE. Prospective studies will determine clinical relevance of these biomarkers. This trial was registered at www.ClinicalTrials.gov as #NCT02555878.
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Affiliation(s)
- Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, and
| | - John Barnard
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Ted Wun
- Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA; and
| | | | - CV Damaraju
- Janssen Scientific Affairs, LLC, Titusville, NJ
| | | | | | - Keith R. McCrae
- Taussig Cancer Institute and Case Comprehensive Cancer Center, and
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11
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Meißler S, Braun-Dullaeus R, Hansen M, Meyer F. [What the (general and abdominal) surgeon should know about thrombosis prophylaxis]. Chirurg 2022; 93:676-686. [PMID: 35147727 PMCID: PMC9246816 DOI: 10.1007/s00104-021-01568-6] [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] [Accepted: 12/18/2021] [Indexed: 01/19/2023]
Abstract
A persisting problem in the clinical operative routine is surgery-associated venous thromboembolisms with the possible complications. The competent and reliably realized prophylaxis of thromboembolism is part of the original and elementary tasks of the surgeon, both the operator as well as the clinically active physician. Many preventive approaches were developed and established in the daily management but a residual risk for development of thrombosis still remains. Under this aspect a search was carried out particularly with respect to scientific literature with review and guideline character on the topic of risk stratification, prophylactic procedures in general and for specific indications.
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Affiliation(s)
- Saskia Meißler
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Rüdiger Braun-Dullaeus
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Michael Hansen
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Frank Meyer
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland.
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12
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Mosaad M, Elnaem MH, Cheema E, Ibrahim I, Ab Rahman J, Kori AN, Hin HS. Cancer-Associated Thrombosis: A Clinical Scoping Review of the Risk Assessment Models Across Solid Tumours and Haematological Malignancies. Int J Gen Med 2021; 14:3881-3897. [PMID: 34335052 PMCID: PMC8318782 DOI: 10.2147/ijgm.s320492] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of death in cancer patients receiving outpatient chemotherapy. The latest guidelines emphasize stratifying the patients in terms of CAT risks periodically. Multiple risk assessment models (RAMs) were developed to classify patients and guide thromboprophylaxis to high-risk patients. This study aimed to discuss and highlight different RAMs across various malignancy types with their related advantages and disadvantages. A scoping review was conducted using predefined search terms in three scientific databases, including Google Scholar, Science Direct, and PubMed. The search for studies was restricted to original research articles that reported risk assessment models published in the last thirteen years (between 2008 and 2021) to cover the most recently published evidence following the development of the principal risk assessment score in 2008. Data charting of the relevant trials, scores, advantages, and disadvantages were done iteratively considering the malignancy type. Of the initially identified 1115 studies, 39 studies with over 67,680 patients were included in the review. In solid organ malignancy, nine risk assessment scores were generated. The first and most known Khorana risk score still offers the best available risk assessment model when used for high-risk populations with a threshold of 2 and above. However, KRS has a limitation of failure to stratify low-risk patients. The COMPASS-CAT score showed the best performance in the lung carcinoma patients who have a higher prevalence of thrombosis than other malignancy subtypes. In testicular germ cell tumours, Bezan et al RAM is a validated good discriminatory RAM for this malignancy subtype. CAT in haematological malignancy seems to be under-investigated and has multiple disease-related, and treatment-related confounding factors. AL-Ani et al score performed efficiently in acute leukemia. In multiple myeloma, both SAVED and IMPEDED VTE scores showed good performance. Despite the availability of different disease-specific scores in lymphoma-related thrombosis, the standard of care needs to be redefined.
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Affiliation(s)
- Manar Mosaad
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Ejaz Cheema
- School of Pharmacy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ismail Ibrahim
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Jamalludin Ab Rahman
- Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Ahlam Naila Kori
- Haematology Unit, Tengku Ampuan Afzan Hospital, Kuantan, Pahang, Malaysia
| | - How Soon Hin
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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13
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Nishimura A, Ikeda Y. [Predicting the Incidence of Venous Thromboembolism Using the Khorana Score: A Literature Review]. YAKUGAKU ZASSHI 2021; 141:611-622. [PMID: 33790126 DOI: 10.1248/yakushi.20-00228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Venous thromboembolism (VTE) is the second most common cause of cancer-related deaths globally. The Khorana score, a VTE prediction model, is calculated using the site of cancer, white blood cell count, hemoglobin level, platelet count, and body mass index. This study aimed to investigate the usefulness of the Khorana score, using data available in the literature. On July 28, 2020, we collected papers using the following keywords: "cancer", "venous thromboembolism", "deep vein thrombosis", "pulmonary embolism", and "Khorana score" on PubMed. Papers published after 2016 were eligible. The selection criteria were as follows: "English or Japanese", "original paper", "abstract and full text", and "comply with the clinical question". There were 131 papers that matched the keywords, and 15 of them complied with the selection criteria. In 15 papers, Khorana score was calculated in 8047 patients. In the low- and intermediate-risk groups, 532 of 6812 patients developed VTE [7.8%, 95%confidence intervals (CI) 7.2-8.5], whereas in the high-risk group, 127 of 1235 patients developed VTE (10.3%, 95% CI 8.7-12.1) [odds ratio (OR) 1.3, 95% CI 1.0-1.6] (I2=0%, τ2=0, p=0.50). Venous thromboembolism prediction using the Khorana score might be useful. However, most of the number of VTE patients are in the low- and intermediate-risk groups. Therefore, a comprehensive evaluation according to clinical conditions is required, regardless of the risk classification using the Khorana score.
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Affiliation(s)
| | - Yoshiaki Ikeda
- Faculty of Pharmaceutical Sciences, Kinjo Gakuin University
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14
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Mones JV, Streiff MB, Khorana AA, Bendheim GA, Damaraju CV, Wildgoose P, Burton P, Riess H, Soff GA. Rivaroxaban thromboprophylaxis for gastric/gastroesophageal junction tumors versus other tumors: A post hoc analysis of the randomized CASSINI trial. Res Pract Thromb Haemost 2021; 5:e12549. [PMID: 34308096 PMCID: PMC8292144 DOI: 10.1002/rth2.12549] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prophylactic anticoagulation with rivaroxaban significantly reduced the risk of cancer-associated thrombosis during the intervention period in the CASSINI trial. Direct oral anticoagulants may increase the risk of gastrointestinal (GI) tract bleeding in patients with an in situ GI tract cancer or lesion. OBJECTIVE This post hoc analysis characterized the efficacy and safety of rivaroxaban in patients with and without gastric/gastroesophageal junction (G/GEJ) tumors. METHODS Primary and secondary efficacy end points and adjudicated bleeding events, including bleeding sites, were analyzed for the intent-to-treat population by cancer type (G/GEJ vs non-G/GEJ) for the 180-day observation period. RESULTS In patients with G/GEJ tumors, the rates for the primary efficacy end point were 3.4% for rivaroxaban versus 6.9% for placebo (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.11-1.80). In patients with non-G/GEJ tumors, the rivaroxaban group had a lower risk of the primary end point (6.6% vs 9.3%; HR, 0.70; 95% CI, 0.40-1.21). Rates of major bleeding in patients with G/GEJ tumors were 4.6% (4/88) versus 1.2% (1/85) for rivaroxaban and placebo; rates in patients with non-G/GEJ tumors were 1.3% (4/317) versus 0.9% (3/319), respectively. CONCLUSIONS Excluding patients with G/GEJ tumors resulted in a definable population of cancer patients who achieved an improved benefit-risk balance from rivaroxaban prophylaxis.
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Affiliation(s)
- Jodi V. Mones
- Hematology ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | - Michael B. Streiff
- Division of HematologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer CenterCleveland ClinicClevelandOHUSA
| | - Gemma A. Bendheim
- Hematology ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
| | | | | | - Paul Burton
- Janssen Scientific Affairs, LLCTitusvilleNJUSA
| | - Hanno Riess
- Charité Universitätsmedizin BerlinBerlinGermany
| | - Gerald A. Soff
- Hematology ServiceMemorial Sloan Kettering Cancer CenterNew YorkNYUSA
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15
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Tamura Y, Sakata K, Terada K, Usui S, Kawashiri MA, Takamura M. Treatment with a Direct Oral Anticoagulant for Nonbacterial Thrombotic Endocarditis. Intern Med 2021; 60:1881-1885. [PMID: 33456040 PMCID: PMC8263173 DOI: 10.2169/internalmedicine.6368-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We herein report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with previously undiagnosed lung cancer. A 62-year-old woman presented to our hospital with multiple cerebral infarctions. There was no evidence of valvular heart disease or vegetations. Whole-leg ultrasonography revealed deep vein thrombosis of the left peroneal vein. We administered direct oral anticoagulants (DOACs) for a presumed diagnosis of paradoxical embolisms caused by patent foramen ovale. Unfortunately, she experienced further embolization and died. At a postmortem examination, she was diagnosed with NBTE and metastatic adenocarcinoma of the lung. Our experience with this patient suggests that DOACs may be an insufficient treatment for NBTE.
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Affiliation(s)
- Yudai Tamura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center, Japan
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Kazushi Terada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Masa-Aki Kawashiri
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
| | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Japan
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16
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Roberti R, Iannone LF, Palleria C, Curcio A, Rossi M, Sciacqua A, Armentaro G, Vero A, Manti A, Cassano V, Russo E, De Sarro G, Citraro R. Direct Oral Anticoagulants: From Randomized Clinical Trials to Real-World Clinical Practice. Front Pharmacol 2021; 12:684638. [PMID: 34122113 PMCID: PMC8188985 DOI: 10.3389/fphar.2021.684638] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 04/26/2021] [Indexed: 12/21/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are a more manageable alternative than vitamin K antagonists (VKAs) to prevent stroke in patients with nonvalvular atrial fibrillation and to prevent and treat venous thromboembolism. Despite their widespread use in clinical practice, there are still some unresolved issues on optimizing their use in particular clinical settings. Herein, we reviewed the current clinical evidence on uses of DOACs from pharmacology and clinical indications to safety and practical issues such as drugs and food interactions. Dabigatran is the DOAC most affected by interactions with drugs and food, although all DOACs demonstrate a favorable pharmacokinetic profile. Management issues associated with perioperative procedures, bleeding treatment, and special populations (pregnancy, renal and hepatic impairment, elderly, and oncologic patients) have been discussed. Literature evidence shows that DOACs are at least as effective as VKAs, with a favorable safety profile; data are particularly encouraging in using low doses of edoxaban in elderly patients, and edoxaban and rivaroxaban in the treatment of venous thromboembolism in oncologic patients. In the next year, DOAC clinical indications are likely to be further extended.
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Affiliation(s)
- Roberta Roberti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Luigi Francesco Iannone
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Caterina Palleria
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonio Curcio
- Department of Medical and Surgical Sciences, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Marco Rossi
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Angela Sciacqua
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giuseppe Armentaro
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Ada Vero
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Antonia Manti
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Velia Cassano
- Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Giovambattista De Sarro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Rita Citraro
- Science of Health Department, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
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17
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Abstract
Cardiac oncology is a subspecialty of cardiology engaging cardiologists and oncologists alike, in order to provide the best possible oncologic treatment for patients at high cardiovascular risk or developing cardio-toxicity during the course of their treatment, thus avoiding discontinuing it, and aiming at improving survival and quality of life. Early diagnosis and the effectiveness of the newer cancer treatments delivered an increasing number of long-term survivors (presently almost 30 million worldwide), at high risk of developing cardiovascular diseases. This predisposition has been correlated not only to the toxic side effects of the oncologic treatment but also to a real vulnerability to the risk factors in this patients population. For decades, the concept of cardio-toxicity in cardiac oncology has been restricted to ventricular dysfunction, but during the last few years the Food and Drug Administration has approved hundreds of new molecules and cardiac oncology has escalated its complexity. The introduction of new target therapy, proteasome inhibitors, immuno-modulators, and inhibitors of the immunitary checkpoint, magnified the concept of cardio-toxicity to a wider definition of ‘cardiovascular toxicity’ incorporating arterial hypertension, ischaemia, cardiomyopathy, myocarditis, arrhythmic complications, long QT, and arterial and venous thrombosis. We are still lacking guidelines on the new and varied forms of toxicity, as well as monitoring strategies in the short- and long-term follow-up.
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Affiliation(s)
- Irma Bisceglia
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
| | - Domenico Cartoni
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
| | - Sandro Petrolati
- Servizi Cardiologici Integrati, Azienda Ospedaliera San Camillo - Forlanini di Roma, Roma, Italy
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18
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Roopkumar J, Poudel SK, Gervaso L, Reddy CA, Velcheti V, Pennell NA, McCrae KR, Khorana AA. Risk of thromboembolism in patients with ALK- and EGFR-mutant lung cancer: A cohort study. J Thromb Haemost 2021; 19:822-829. [PMID: 33314597 DOI: 10.1111/jth.15215] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Thromboembolism (TE) is common in patients with non-small cell lung cancer (NSCLC) and is associated with worse outcomes. Recent advances in the understanding of NSCLC have led to the identification of molecular subtypes such as anaplastic lymphocyte kinase (ALK) and epidermal growth factor receptor (EGFR) mutations. The association of these subtypes with risk of TE has not been fully explored. METHODS We conducted a retrospective cohort study of consecutive NSCLC patients seen at the Cleveland Clinic from July 2002 through July 2017 for whom molecular classification and follow-up were available. TE events included deep vein thrombosis (DVT), pulmonary embolism (PE), visceral vein thrombosis (VVT), and arterial events. TE-free survival and overall survival rates for each of the molecular subtypes (wild-type, ALK-mutant, and EGFR-mutant) were estimated by the Kaplan-Meier method. Cox proportional hazard regression analysis was used to identify factors associated with the endpoints TE and overall survival. TE was analyzed as a conditional, time-dependent covariate to assess its impact with respect to overall survival. RESULTS The study population consisted of 461 patients. Approximately half were females (n = 263, 57%) and 58% (n = 270) were older than 65 years. TE occurred in 98 of 461 patients (21.3%) during a median follow-up of 33.1 months. The highest cumulative rates of TE were observed in patients with ALK-mutant NSCLC (N = 20/46, 43.5%) followed by patients with EGFR-mutant cancers (N = 35/165, 21.2%) and wild-type cancers (N = 43/250, 17.2%) P < .05. Cumulative incidence of TE at 6 months of follow-up was 15.7% (95% confidence interval [CI]: 5.0%-26.4%) for ALK-mutant cancers, 8.8% (95% CI: 4.4%-13.2%) for EGFR-mutant cancers, and 9.2% (95% CI: 5.4%-12.9%) for wild-type cancers. Patients who experienced TE had worse overall survival (all patients: hazard ratio = 2.8 95% CI 2.1-3.6, P < .001). CONCLUSIONS Patients with ALK-mutant advanced lung adenocarcinoma have the highest rate of TE. TE is associated with worse survival across molecular subtypes. These findings should be taken into consideration in decision-making regarding thromboprophylaxis.
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Affiliation(s)
- Joanna Roopkumar
- Department of Cancer Research, Mayo Clinic, Jacksonville, FL, USA
| | - Shyam K Poudel
- Department of Internal Medicine, Western Reserve Health Education, Warren, OH, USA
| | - Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, Milan, Italy
| | - Chandana A Reddy
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Vamsidhar Velcheti
- Department of Thoracic Medical Oncology, New York University, New York, NY, USA
| | - Nathan A Pennell
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Keith R McCrae
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alok A Khorana
- Department of Hematology & Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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19
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Khorana AA, Kuderer NM, McCrae K, Milentijevic D, Germain G, Laliberté F, MacKnight SD, Lefebvre P, Lyman GH, Streiff MB. Healthcare costs of patients with cancer stratified by Khorana score risk levels. J Med Econ 2021; 24:866-873. [PMID: 34181497 DOI: 10.1080/13696998.2021.1948681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS Patients with cancer are at high risk of venous thromboembolism (VTE), which entails a high economic burden. The risk of cancer-associated VTE can be assessed using the Khorana score (KS), a validated VTE risk prediction algorithm. This study compared healthcare costs associated with different KS in a population of patients newly diagnosed with cancer. METHODS The Optum Clinformatics DataMart database (01/01/2012-09/30/2017) was used to select adult patients with ≥1 hospitalization or ≥2 outpatient claims with a cancer diagnosis (index date) initiated on systemic therapy or radiation therapy. Patients were classified in mutually exclusive cohorts based on KS (i.e. KS = 0, 1, 2 or ≥3). The observation period spanned from index to the earliest among the end of data availability, death, end of insurance coverage, or 12 months. RESULTS In total 6,194 patients (KS = 0: 2,488; KS = 1: 2,125; KS = 2: 1,074; KS ≥ 3: 507) were included. On average, patients were aged 68 years, 48-52% were female, and the Quan-Charlson comorbidity index ranged between 1.1 and 1.4. Over the observation period, all-cause total healthcare costs per patient per month (PPPM) were $8,826 (KS = 0), $11,598 (KS = 1), $14,028 (KS = 2), and $16,211 (KS ≥ 3). Using the KS = 0 cohort as a reference, adjusted PPPM costs were $2,506, $4,775, and $6,452 higher in the KS = 1, KS = 2, and KS ≥ 3 cohorts, respectively. Hospitalization and outpatient costs were the main drivers of these differences. Similar results were found for VTE-related costs, which represented 4-11% of the total all-cause cost difference between KS cohorts. LIMITATIONS Residual confounders; results may not be generalized to patients with other insurance plans or those who received treatments other than systemic therapy or radiation therapy. CONCLUSIONS This real-world analysis found that cancer patients at higher risk of VTE (based on KS) incurred significantly greater all-cause and VTE-related healthcare costs compared with cancer patients at lower risk of VTE.
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Affiliation(s)
- Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | - Keith McCrae
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | | | | | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, WA, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, USA
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20
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Rutjes AW, Porreca E, Candeloro M, Valeriani E, Di Nisio M. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev 2020; 12:CD008500. [PMID: 33337539 PMCID: PMC8829903 DOI: 10.1002/14651858.cd008500.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) often complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is the third update of a review first published in February 2012. OBJECTIVES To assess the efficacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or no thromboprophylaxis, or an active control intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 3 August 2020. We also searched the reference lists of identified studies and contacted content experts and trialists for relevant references. SELECTION CRITERIA Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on risk of bias, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. We applied GRADE to assess the certainty of evidence. MAIN RESULTS We identified six additional randomised controlled trials (3326 participants) for this update, bringing the included study total to 32 (15,678 participants), all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic cancer. The certainty of the evidence ranged from high to very low across the different outcomes and comparisons. The main limiting factors were imprecision and risk of bias. Thromboprophylaxis with direct oral anticoagulants (direct factor Xa inhibitors apixaban and rivaroxaban) may decrease the incidence of symptomatic VTE (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.18 to 1.06; 3 studies, 1526 participants; low-certainty evidence); and probably increases the risk of major bleeding compared with placebo (RR 1.74, 95% CI 0.82 to 3.68; 3 studies, 1494 participants; moderate-certainty evidence). When compared with no thromboprophylaxis, low-molecular-weight heparin (LMWH) reduced the incidence of symptomatic VTE (RR 0.62, 95% CI 0.46 to 0.83; 11 studies, 3931 participants; high-certainty evidence); and probably increased the risk of major bleeding events (RR 1.63, 95% CI 1.12 to 2.35; 15 studies, 7282 participants; moderate-certainty evidence). In participants with multiple myeloma, LMWH resulted in lower symptomatic VTE compared with the vitamin K antagonist warfarin (RR 0.33, 95% CI 0.14 to 0.83; 1 study, 439 participants; high-certainty evidence), while LMWH probably lowers symptomatic VTE more than aspirin (RR 0.51, 95% CI 0.22 to 1.17; 2 studies, 781 participants; moderate-certainty evidence). Major bleeding was observed in none of the participants with multiple myeloma treated with LMWH or warfarin and in less than 1% of those treated with aspirin. Only one study evaluated unfractionated heparin against no thromboprophylaxis, but did not report on VTE or major bleeding. When compared with placebo or no thromboprophylaxis, warfarin may importantly reduce symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20; 1 study, 311 participants; low-certainty evidence) and may result in a large increase in major bleeding (RR 3.82, 95% CI 0.97 to 15.04; 4 studies, 994 participants; low-certainty evidence). One study evaluated antithrombin versus no antithrombin in children. This study did not report on symptomatic VTE but did report any VTE (symptomatic and incidental VTE). The effect of antithrombin on any VTE and major bleeding is uncertain (any VTE: RR 0.84, 95% CI 0.41 to 1.73; major bleeding: RR 0.78, 95% CI 0.03 to 18.57; 1 study, 85 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS In ambulatory cancer patients, primary thromboprophylaxis with direct factor Xa inhibitors may reduce the incidence of symptomatic VTE (low-certainty evidence) and probably increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo. LMWH decreases the incidence of symptomatic VTE (high-certainty evidence), but increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo or no thromboprophylaxis. Evidence for the use of thromboprophylaxis with anticoagulants other than direct factor Xa inhibitors and LMWH is limited. More studies are warranted to evaluate the efficacy and safety of primary prophylaxis in specific types of chemotherapeutic agents and types of cancer, such as gastrointestinal or genitourinary cancer.
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Affiliation(s)
- Anne Ws Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Emanuele Valeriani
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti Scalo, Italy
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
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Khorana AA, Kuderer NM, McCrae K, Milentijevic D, Germain G, Laliberté F, MacKnight SD, Lefebvre P, Lyman GH, Streiff MB. Cancer associated thrombosis and mortality in patients with cancer stratified by khorana score risk levels. Cancer Med 2020; 9:8062-8073. [PMID: 32954653 PMCID: PMC7643641 DOI: 10.1002/cam4.3437] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Khorana score (KS) clinical algorithm is used to predict VTE risk in cancer patients. The study objective was to evaluate VTE and survival rates among patients newly diagnosed with cancer and stratified by KS in a real-world population. METHODS Data from the Optum® Clinformatics® DataMart database between 01/01/2012-09/30/2017 was used to identify adults with ≥ 1 hospitalization or ≥ 2 outpatient claims with a cancer diagnosis (index date). Only patients who were initiated on chemotherapy or radiation therapy were included. Patients were classified based on KS (KS = 0, 1, 2 or ≥ 3). Time-to-first VTE and survival were evaluated from the index date to the earliest among end of data availability or insurance coverage, death, or 12 months post-index using Kaplan-Meier (KM) analyses. RESULTS A total of 2,488 (KS = 0); 2,125 (KS = 1), 1,074 (KS = 2), and 507 (KS ≥ 3) cancer patients were included. The 12-month KM rates of VTE were 3.1%, 5.4%, 7.9%, and 14.9% (associated median time to VTE of 2.7, 3.0, 1.4, and 1.7 months) among KS = 0, 1, 2, and ≥ 3 cohorts, respectively. Corresponding adjusted hazard ratios (95% CIs) relative to the KS = 0 cohort were 1.72 (1.25-2.38), 2.46 (1.73-3.50), and 4.99 (3.40-7.31) for the KS = 1, 2, and ≥ 3 cohorts, respectively (all P < .001). Regardless of KS, patients with VTE had significantly lower survival rates than those without. CONCLUSIONS This real-world claims-based cohort study of newly diagnosed cancer patients showed significantly higher rates of VTE with increased KS, confirming its predictive ability. Moreover, VTE was associated with lower survival rates within each KS cohort.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gary H. Lyman
- Fred Hutchinson Cancer Research Centerand University of WashingtonSeattleWAUSA
| | - Michael B. Streiff
- Division of HematologyDepartment of MedicineJohn Hopkins University School of MedicineBaltimoreMDUSA
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22
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Vadhan-Raj S, McNamara MG, Venerito M, Riess H, O'Reilly EM, Overman MJ, Zhou X, Vijapurkar U, Kaul S, Wildgoose P, Khorana AA. Rivaroxaban thromboprophylaxis in ambulatory patients with pancreatic cancer: Results from a pre-specified subgroup analysis of the randomized CASSINI study. Cancer Med 2020; 9:6196-6204. [PMID: 32663379 PMCID: PMC7476843 DOI: 10.1002/cam4.3269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic cancer patients are at risk for venous thromboembolism (VTE); the value of thromboprophylaxis has not been definitively established. METHODS This trial randomized cancer patients initiating a new regimen and at high risk for VTE (Khorana score ≥2) to rivaroxaban 10 mg or placebo up to day 180. This analysis examined the subset of pancreatic cancer patients. The primary efficacy endpoint was the composite of symptomatic deep-vein thrombosis (DVT), asymptomatic proximal DVT, any pulmonary embolism, and VTE-related death. The primary safety endpoint was International Society on Thrombosis and Haemostasis-defined major bleeding. RESULTS In total, 49/1080 (4.5%) patients enrolled had baseline VTE on screening, with higher rates (24/362 [6.6%]) in pancreatic cancer and they were not randomized. Of 841 randomized patients, 273 (32.5%) had pancreatic cancer; 155/273 (57% in each arm) completed the double-blind period. The primary endpoint occurred in 13/135 (9.6%) patients in the rivaroxaban group and in 18/138 (13.0%) in the placebo group (hazard ratio [HR] = 0.70; 95% CI, 0.34-1.43; P = .328) in up-to-day-180 period and 5/135 (3.7%) patients receiving rivaroxaban and 14/138 (10.1%) receiving placebo in the intervention period (HR = 0.35; 95% CI, 0.13-0.97; P = .034). Major bleeding was similar (2 [1.5%] receiving rivaroxaban and 3 [2.3%] receiving placebo). Correlative biomarker studies demonstrated significant decline in D-dimer (weeks 8 and 16) in patients randomized to rivaroxaban compared to placebo (P < .01). CONCLUSIONS In ambulatory pancreatic cancer patients, rivaroxaban did not result in significantly lower incidence of VTE or VTE-related death in the 180-day period. During the intervention period, however, rivaroxaban substantially reduced VTE without increasing major bleeding, suggesting benefit of rivaroxaban prophylaxis in this setting. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02555878.
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Affiliation(s)
- Saroj Vadhan-Raj
- The UT MD Anderson Cancer Center, Department of Sarcoma Medical Oncology, Section of Cytokines and Supportive Oncology, Houston, TX, USA
| | - Mairéad G McNamara
- Department of Medical Oncology, The Christie NHS Foundation Trust & Division of Cancer Sciences, University of Manchester, Manchester, United Kingdom
| | - Marino Venerito
- Klinik für Gastroenterologie, Hepatologie und Infektiologie Universitätsklinikum, Magdeburg, Germany
| | - Hanno Riess
- Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | | | - Xiao Zhou
- The UT MD Anderson Cancer Center, Department of Sarcoma Medical Oncology, Section of Cytokines and Supportive Oncology, Houston, TX, USA
| | | | - Simrati Kaul
- Janssen Scientific Affairs, LLC, Titusville, NJ, USA
| | | | - Alok A Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH, USA
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23
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Zhou X, Lin X, Shen R, Qu Y, Mo C, Li Y, Chen Q, Wu G, Chen Z, Huang K. A retrospective analysis of risk factors associated with catheter-related thrombosis: a single-center study. Perfusion 2020; 35:806-813. [PMID: 32419612 DOI: 10.1177/0267659120915142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Catheter-related thrombosis may lead to catheter infections and failure, further deep venous thrombosis, and pulmonary embolism. Recognizing the risk factors for catheter-related thrombosis is extremely important to inform the development of catheter care guidelines. METHODS Data were collected from a total of 1,532 patients who had undergone venous catheterization, including indwelling catheterization from 19 March 2019 to 30 March 2019 in the Sun Yat-sen Memorial Hospital. The factors for which data were to be collected included the patients' physical characteristics, catheter-related factors, and catheter care-related factors. Logistic regression analysis, the chi-squared test, Fisher's exact test, and the t-test were used to analyze the data. RESULTS Of the 1,532 patients studied, 28 developed intraductal thrombi, and of the factors analyzed, malignancy, a catheterization history, a history of thrombophilia, surgery during the week before catheterization, the catheterization duration, and anticoagulant therapy were significant risk factors associated with catheter-related thrombosis (all p < 0.05). There were no significant associations between the catheter brand, the number of lumens, the insertion direction, or the factors associated with catheter care and catheter-related thrombosis (all p > 0.05). CONCLUSION Our study incorporated clear and systematic risk factors associated with catheter-related thrombosis. Malignancy, history of thrombophilia, history of catheterization, surgery during the week before catheterization, and catheterization duration were associated with increased risks of catheter-related thrombosis. Prophylactic anticoagulation was effective for preventing and treating catheter-related thrombosis.
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Affiliation(s)
- Xuezhen Zhou
- Department of Nursing, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xi Lin
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Runnan Shen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Yingying Qu
- Venous Catheter Nursing Clinic, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chunling Mo
- Venous Catheter Nursing Clinic, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan Li
- Venous Catheter Nursing Clinic, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Qinchang Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China.,The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guitao Wu
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Zhenhong Chen
- Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, China
| | - Kai Huang
- Department of Cardiovascular Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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24
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Cois A, Kea B. In reply: Is it time to initiate venothromobolism prophylaxis for acute and ambulatory outpatients with lower limb immobilisation? Emerg Med J 2020; 37:390. [PMID: 32398232 DOI: 10.1136/emermed-2020-209741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Adrian Cois
- Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Bory Kea
- Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA.,Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
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25
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Bauersachs R, Khorana AA, Lee AYY, Soff G. Cancer-associated venous thromboembolism: Treatment and prevention with rivaroxaban. Res Pract Thromb Haemost 2020; 4:532-549. [PMID: 32548552 PMCID: PMC7292665 DOI: 10.1002/rth2.12327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 12/17/2022] Open
Abstract
Cancer-associated venous thromboembolism (VTE) is a frequent, potentially life-threatening event that complicates cancer management. Anticoagulants are the cornerstone of therapy for the treatment and prevention of cancer-associated thrombosis (CAT); factor Xa-inhibiting direct oral anticoagulants (DOACs; apixaban, edoxaban, and rivaroxaban), which have long been recommended for the treatment of VTE in patients without cancer, have been investigated in this setting. The first randomized comparisons of DOACs against low-molecular-weight heparin for the treatment of CAT indicated that DOACs are efficacious in this setting, with findings reflected in recent updates to published guidance on CAT treatment. However, the higher risk of bleeding events (particularly in the gastrointestinal tract) with DOACs highlights the need for appropriate patient selection. Further insights will be gained from additional studies that are ongoing or awaiting publication. The efficacy and safety of DOAC thromboprophylaxis in ambulatory patients with cancer at a high risk of VTE have also been assessed in placebo-controlled randomized controlled trials of apixaban and rivaroxaban. Both studies showed efficacy benefits with DOACs, but both studies also showed a nonsignificant increase in major bleeding events while on treatment. This review summarizes the evidence base for rivaroxaban use in CAT, the patient profile potentially most suited to DOAC use, and ongoing controversies under investigation. We also describe ongoing studies from the CALLISTO (Cancer Associated thrombosis-expLoring soLutions for patients through Treatment and Prevention with RivarOxaban) program, which comprises several randomized clinical trials and real-world evidence studies, including investigator-initiated research.
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Affiliation(s)
- Rupert Bauersachs
- Department of Vascular MedicineKlinikum Darmstadt GmbHDarmstadtGermany
- Center of Thrombosis and HemostasisUniversity of MainzMainzGermany
| | - Alok A. Khorana
- Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOHUSA
| | - Agnes Y. Y. Lee
- British Columbia Cancer AgencyUniversity of British ColumbiaVancouverBCCanada
| | - Gerald Soff
- Memorial Sloan Kettering Cancer CenterNew YorkNYUSA
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26
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Khorana AA, McNamara MG, Kakkar AK, Streiff MB, Riess H, Vijapurkar U, Kaul S, Wildgoose P, Soff GA. Assessing Full Benefit of Rivaroxaban Prophylaxis in High-Risk Ambulatory Patients with Cancer: Thromboembolic Events in the Randomized CASSINI Trial. TH OPEN 2020; 4:e107-e112. [PMID: 32462111 PMCID: PMC7245534 DOI: 10.1055/s-0040-1712143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/09/2020] [Indexed: 11/19/2022] Open
Abstract
Introduction In the CASSINI study, rivaroxaban thromboprophylaxis significantly reduced primary venous thromboembolism (VTE) endpoints during the intervention period, but several thromboembolic events designated as secondary efficacy endpoints were not included in the primary analysis. This study was aimed to evaluate the full impact of rivaroxaban thromboprophylaxis on all prespecified thromboembolic endpoints occurring on study. Methods CASSINI was a double-blind, randomized, placebo-controlled study in adult ambulatory patients with cancer at risk for VTE (Khorana score ≥2). Patients were screened at baseline for deep-vein thrombosis (DVT) and randomized if none was found. The primary efficacy endpoint was a composite of lower extremity proximal DVT, symptomatic upper extremity, or lower extremity distal DVT, any pulmonary embolism, and VTE-related death. This analysis evaluated all prespecified thromboembolic endpoints occurring on study to determine the full benefit of rivaroxaban prophylaxis. All endpoints were independently adjudicated. Results Total thromboembolic events occurred in fewer patients randomized to rivaroxaban during the full study period (29/420 [6.9%] and 49/421 [11.6%] patients in rivaroxaban and placebo groups, respectively [hazard ratio (HR) = 0.57; 95% confidence interval (CI): 0.36-0.90; p = 0.01]; number needed to treat [NNT] = 21). Similarly, fewer patients randomized to rivaroxaban experienced thromboembolism during the intervention period (13/420 [3.1%] patients) versus placebo (38/421 [9.0%] patients; HR = 0.33; 95% CI: 0.18-0.62; p < 0.001; NNT = 17). Conclusion Our findings confirm the substantial benefit of rivaroxaban thromboprophylaxis when considering all prespecified thromboembolic events, even after excluding baseline screen-detected DVT. The low NNT, coupled with prior data demonstrating a high number needed to harm, should assist clinicians in determining the risk/benefit of thromboprophylaxis in high-risk patients with cancer.
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Affiliation(s)
- Alok A. Khorana
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio, United States
| | - Mairéad G. McNamara
- Division of Cancer Sciences, Department of Medical Oncology, University of Manchester, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Ajay K. Kakkar
- Thrombosis Research Institute and University College London, London, United Kingdom
| | - Michael B. Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Hanno Riess
- Department of Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ujjwala Vijapurkar
- Clinical Biostatistics, Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Simrati Kaul
- Medical Affairs Internal Medicine, Janssen Scientific Affairs, LLC, Titusville, New Jersey, United States
| | - Peter Wildgoose
- Medical Affairs Internal Medicine, Janssen Scientific Affairs, LLC, Titusville, New Jersey, United States
| | - Gerald A. Soff
- Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States
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27
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Kakkos SK, Arnaoutoglou E, Tsolakis IA, Giannoukas A, Papadimitriou CA, Kentepozidis N, Boukovinas I, Kalofonos HP, Labropoulos N, Matsagkas M. Frequency and predictors of chemotherapy-associated venous thromboembolism: the prospective PREVENT study. INT ANGIOL 2020; 39:112-117. [PMID: 32057213 DOI: 10.23736/s0392-9590.20.04272-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Our knowledge on the burden of symptomatic and asymptomatic venous thromboembolism (VTE) in patients with cancer undergoing chemotherapy is limited. The aim of our study was to prospectively investigate the frequency of symptomatic VTE and asymptomatic deep vein thrombosis of the lower limbs among cancer patients undergoing chemotherapy. METHODS We studied 231 patients (164 men) with pancreatic (N.=36), lung (N.=136), ovarian (N.=32) or prostate (N.=27) cancer receiving first line (N.=192, 83.1%) or adjuvant chemotherapy, followed-up for 3-6 months. RESULTS Some 17 patients were diagnosed with VTE, either asymptomatic detected on leg ultrasound (N.=7) or symptomatic (N.=10). The total frequency of VTE was 10.3% (17/165 with follow-up). Pancreatic cancer had the highest frequency of VTE (4/25, 16%) followed by ovarian (3/26, 11.5%) and lung cancer (10/94, 10.6%). There was no statistically significant difference in VTE rates among cancer types (P=0.36). VTE occurred more frequently in the presence of metastases (13/85, 15.3% vs. 4/80, 5.0%, for the remainder, P=0.03, OR 3.4). In the subgroup of patients receiving first line treatment, VTE occurred more frequently in patients with metastases (13/84, 15.5% vs. 2/53, 3.8%, for the remainder, P=0.033). In patients with pancreatic, lung or ovarian cancer receiving first line treatment, VTE occurred more frequently in patients with metastatic disease (19.1% vs. 4.0%, for the remainder, P=0.015). CONCLUSIONS VTE occurrence in this real-world patient cohort was high, reaching almost 20% in certain groups, like those with disseminated pancreatic, lung or ovarian cancer receiving first-line chemotherapy. Furthermore, VTE occurs mostly as a symptomatic event, being likely a result of the prothrombotic state of malignancy.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, University of Thessaly, Larissa, Greece.,Department of Anesthesiology, University of Ioannina, Ioannina, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Christos A Papadimitriou
- Unit of Oncology, Second Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Nicos Labropoulos
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
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28
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Peippo MH, Kurki S, Seppänen H, Lassila R, Carpén O. CA 19-9 doubling time in pancreatic cancer as a predictor of venous thromboembolism: a hospital database study. Acta Oncol 2020; 59:237-241. [PMID: 31650877 DOI: 10.1080/0284186x.2019.1679881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Maija H. Peippo
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
- Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Samu Kurki
- Auria Biobank, University of Turku and Turku University Hospital, Turku, Finland
| | - Hanna Seppänen
- Department of Surgery, Translational Cancer Medicine Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riitta Lassila
- Department of Hematology and Comprehensive Cancer Center, Unit of Coagulation Disorders, and Research Program in Systems Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Olli Carpén
- Institute of Biomedicine, Research Center for Cancer, Infections and Immunity, University of Turku, Turku, Finland
- Department of Pathology, Medicum and Research Program in Systems Oncology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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29
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Li A, Kuderer NM, Garcia DA, Khorana AA, Wells PS, Carrier M, Lyman GH. Direct oral anticoagulant for the prevention of thrombosis in ambulatory patients with cancer: A systematic review and meta-analysis. J Thromb Haemost 2019; 17:2141-2151. [PMID: 31420937 DOI: 10.1111/jth.14613] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND It is unclear if direct oral anticoagulant (DOAC) is efficacious and safe for prophylaxis of venous thromboembolism (VTE) in ambulatory patients with cancer. METHODS We performed a systematic review using EMBASE, MEDLINE, and CENTRAL. Inclusion criteria included adult ambulatory patients with cancer, prophylactic use of DOAC, and randomized controlled trials. Exclusion criteria included pediatric patients, inpatient or postoperative setting, therapeutic indication of DOAC, or non-phase III randomized controlled trial. Two authors screened/reviewed articles and abstracted the data. Meta-analysis was performed using random-effects model. Efficacy outcome included overall and symptomatic VTE incidence during the first 6 months. Safety outcomes included major bleeding and clinically relevant non-major bleeding (CRNMB) incidence during the on-treatment period. Subgroup analysis was performed for intermediate- and high-risk Khorana score. RESULTS A total of 202 records were identified and 28 full-text articles were assessed. Two studies with 1415 participants were included for meta-analysis. For DOAC vs placebo, the relative risks for overall and symptomatic VTE incidence by 6 months were 0.56 (0.35-0.89) and 0.58 (0.29-1.13), respectively. The relative risks for major bleeding and CRNMB while on-treatment were 1.96 (0.80-4.82) and 1.28 (0.74-2.20), respectively. Patients with high-risk Khorana score (3+) derived the largest absolute risk reduction of VTE. CONCLUSIONS Low-dose DOAC reduces the rate of overall VTE in higher risk cancer patients starting systemic chemotherapy. It may reduce the rate of symptomatic VTE but increase the likelihood of bleeding.
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Affiliation(s)
- Ang Li
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Nicole M Kuderer
- Advanced Cancer Research Group and Department of Medicine, University of Washington, Seattle, WA, USA
| | - David A Garcia
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Philip S Wells
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Gary H Lyman
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Divisions of Public Health Sciences and Clinical Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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30
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Anwar A, Jafri F, Ashraf S, Jafri MAS, Fanucchi M. Paraneoplastic syndromes in lung cancer and their management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:359. [PMID: 31516905 DOI: 10.21037/atm.2019.04.86] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Paraneoplastic syndromes are most frequently associated with lung cancer. This review considers a variety of paraneoplastic syndromes associated with lung cancer and discusses their pathophysiology, clinical features and management options.
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Affiliation(s)
- Asad Anwar
- Department of Internal Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Firas Jafri
- Department of Internal Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Sara Ashraf
- Department of Hematology/Oncology, Marshall University, Huntington, WV, USA
| | - Mohammad Ali S Jafri
- Department of Hematology/Oncology, Westchester Medical Center, Valhalla, NY, USA
| | - Michael Fanucchi
- Department of Hematology/Oncology, Westchester Medical Center, Valhalla, NY, USA
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31
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Bossaer JB, Covert KL. Direct oral anticoagulants in patients with cancer. Am J Health Syst Pharm 2019; 76:1019-1027. [DOI: 10.1093/ajhp/zxz095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AbstractPurposeThis review summarizes the available evidence concerning direct oral anticoagulant (DOAC) use to treat venous thromboembolism (VTE) in patients with cancer as well as pertinent safety data on the use of DOACs in patients with both cancer and atrial fibrillation.SummaryThe introduction of DOACs into clinical practice changed the way thrombotic complications are managed and prevented in diverse patient populations, including VTE and atrial fibrillation. Low-molecular-weight heparins have been the standard of care for treating VTE in cancer patients due to superiority over vitamin K antagonists in preventing recurrent VTE. Therefore, widespread DOAC use for VTE in patients with active cancer has not been adopted.ConclusionRecent randomized clinical trials (SELECT-D, Hokusai VTE Cancer) have provided evidence that DOACs may have a role in treating VTE in cancer patients.
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Affiliation(s)
- John B Bossaer
- Bill Gatton College of Pharmacy, East Tennessee State University, Mountain Home, TN
| | - Kelly L Covert
- Bill Gatton College of Pharmacy, East Tennessee State University, Mountain Home, TN
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Shioyama W, Oka T, Yasui T, Fujita M. Single-drug approach with rivaroxaban: A case of successful anticoagulation against cancer-associated thrombosis. J Cardiol Cases 2019; 20:39-41. [PMID: 31440308 PMCID: PMC6698256 DOI: 10.1016/j.jccase.2019.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/14/2019] [Accepted: 03/13/2019] [Indexed: 11/16/2022] Open
Abstract
We report a patient with pulmonary embolism and deep vein thrombosis induced by cancer chemotherapy who received successful anticoagulation using a single-drug approach with rivaroxaban. Cancer-associated thrombosis (CAT) is a leading cause of non-cancer death in patients with cancer, which is induced by cancer itself and/or chemotherapy agents including cisplatin and gemcitabine. By contrast, hemorrhagic state is another feature of advanced cancer. In these opposite conditions of cancer patients, CAT have to be controlled by appropriate anticoagulation. This case shows potential for single-drug approach with rivaroxaban and direct oral anticoagulants being effective and safety strategy against CAT. <Learning objective: Single-drug approach of direct oral anticoagulants (DOACs) against CAT induced by cisplatin and gemcitabine showed satisfactory anticoagulation without heparin and warfarin. CAT has been important issue in oncology field, and single-drug approach of DOACs could be an effective and safety strategy for anticoagulation against CAT.>
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Affiliation(s)
- Wataru Shioyama
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Toru Oka
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Taku Yasui
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
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Majmudar K, Quintero LD, Fuentes HE, Stocker S, Tafur AJ, Lee CJ, Talamonti M. Postoperative venous thromboembolism and mortality in patients with pancreatic surgery. J Surg Oncol 2019; 120:494-500. [PMID: 31222842 DOI: 10.1002/jso.25589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/01/2019] [Accepted: 05/31/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Pancreatic cancer is strongly associated with thrombosis. We investigated early postoperative venous thromboembolism (PVTE) mortality among patients with pancreatic surgery and compared outcomes in adenocarcinoma pancreatic cancer (ACPC) to non-adenocarcinoma pancreatic neoplasm (NACPN). METHODS We analyzed a prospectively collected database of patients who underwent pancreatic cancer or neoplasm-related surgery. As NACPN is underrepresented in other studies, we selected NACPN patients and a random sample of ACPC patients. PVTE was defined as VTE occurring within 3 months of surgical intervention. Statistical analysis was performed using Cox proportional hazards regression. RESULTS A total of 441 pancreatic surgery patients were included, with 331 ACPC and 110 NACPN. Median follow-up was 449 days during which 90 (20.4%) patients developed VTE. PVTE occurred in 53 (12.0%) patients, including 41 (12.4%) ACPC patients and 12 (10.9%) NACPN patients. Those with PVTE had 60% higher mortality rate. A multivariable analysis found that PVTE is an independent predictor of increased mortality (HR Adj, 1.6; 95% CI, 1.1-2.2; P < .01). The mortality impact was not consistent between ACPC (HR, 3.2; 95% CI, 1.3-7.9) and NACPN groups (HR, 1.3; 95% CI, 0.9-1.8). CONCLUSIONS Postoperative venous thromboembolism is an independent predictor of increased mortality in pancreatic surgery, specifically in adenocarcinoma pancreatic cancer surgery.
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Affiliation(s)
- Kaushal Majmudar
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Luis D Quintero
- Department of Medicine, Division of Internal Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Harry E Fuentes
- Department of Medicine, Division of Hematology-Oncology, Mayo Clinic, Rochester, Minnesota
| | - Susan Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Alfonso J Tafur
- Department of Medicine, Division of Vascular Medicine, NorthShore University HealthSystem, Evanston, Illinois.,Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Cheong J Lee
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.,Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
| | - Mark Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois.,Department of Surgery, University of Chicago Medical Center, Chicago, Illinois
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Cohen AT, Bauersachs R. Rivaroxaban and the EINSTEIN clinical trial programme. Blood Coagul Fibrinolysis 2019; 30:85-95. [PMID: 30920394 PMCID: PMC6504120 DOI: 10.1097/mbc.0000000000000800] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 02/08/2019] [Accepted: 02/11/2017] [Indexed: 12/19/2022]
Abstract
: Rivaroxaban, a direct oral anticoagulant, is widely used for the treatment of venous thromboembolism (VTE) in adult patients. The approval of rivaroxaban for the treatment of deep vein thrombosis and pulmonary embolism and the extended secondary prevention of recurrent VTE is based on the results of the EINSTEIN DVT and EINSTEIN PE trials, and the EINSTEIN EXT and EINSTEIN CHOICE trials, respectively. This review provides an updated overview of these completed EINSTEIN studies in adult patients, including results of subanalyses in patients at high risk of recurrent VTE, and discusses the emerging data from the EINSTEIN Junior programme, which is evaluating the use of rivaroxaban for the treatment of paediatric VTE. In the EINSTEIN DVT and EINSTEIN PE trials, rivaroxaban (15 mg twice daily for 21 days, followed by 20 mg once daily thereafter) was shown to be an effective and safe alternative to standard anticoagulation for the treatment of deep vein thrombosis and pulmonary embolism in a broad range of adult patients. These results are supported by increasing amounts of real-world data from patients treated with rivaroxaban in routine clinical practice worldwide. In the EINSTEIN EXT and EINSTEIN CHOICE trials, rivaroxaban was superior to placebo and acetylsalicylic acid, respectively, for the extended treatment of VTE - physicians can now choose between two doses of rivaroxaban (20 mg once daily or 10 mg once daily) for the extended prevention of recurrent VTE, based on a patient's risk of recurrence, bleeding and personal preferences.
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Affiliation(s)
- Alexander T. Cohen
- Department of Haematological Medicine, Guy's and St Thomas’ NHS Foundation Trust, King's College London, London, UK
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
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Debourdeau P, Simonin C, Carbasse C, Debourdeau T, Zammit C, Scotté F. [Primary prophylaxis of venous thromboembolism in ambulatory cancer patients treated with antineoplastic agents]. Rev Med Interne 2019; 40:523-532. [PMID: 30928244 DOI: 10.1016/j.revmed.2019.03.003] [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: 10/31/2018] [Revised: 02/27/2019] [Accepted: 03/12/2019] [Indexed: 11/29/2022]
Abstract
Apart from myeloma, primary prophylaxis of venous thromboembolism (VTE) in ambulatory cancer patients treated with chemotherapy is underused, despite its proven benefit for pancreatic cancer and to a lesser extent for lung cancer. This prophylaxis has been showed to be effective for myeloma, pancreas but in absolute numbers these cancers lead to a few venous thromboembolic events. Up to date, VTE risk scores cannot be used as a discriminatory criterion to select a high-risk population that could really benefit from this prevention. VTE depends in part on oncogenic mutations of tumor cells that result in an imbalance between activation and inhibition pathways that are involved in venous thrombus formation. So, stratification of risk of VTE in cancer patients could be considered from a clinical and molecular point of view and result in a tailored prophylaxis. This "personalized medicine" that is currently used for the anti-tumor treatment of many cancers and hematological malignancies, could lead to a more effective prophylaxis of VTE in cancer patients.
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Affiliation(s)
- P Debourdeau
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France.
| | - C Simonin
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France
| | - C Carbasse
- Institut Sainte Catherine, 250, chemin de Baigne-Pieds, CS 80005, 84918 Avignon cedex 09, France
| | - T Debourdeau
- Faculté de médecine Lyon est, université Claude Bernard Lyon 1, 8, boulevard Rockefeller, 69008 Lyon, France
| | - C Zammit
- Hôpitaux des Portes de Camargue, route d'Arles, 13150 Tarascon, France
| | - F Scotté
- Hôpital Foch, 40, rue Worth, BP 36, 92151 Suresnes cedex, France
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Khorana AA, Soff GA, Kakkar AK, Vadhan-Raj S, Riess H, Wun T, Streiff MB, Garcia DA, Liebman HA, Belani CP, O'Reilly EM, Patel JN, Yimer HA, Wildgoose P, Burton P, Vijapurkar U, Kaul S, Eikelboom J, McBane R, Bauer KA, Kuderer NM, Lyman GH. Rivaroxaban for Thromboprophylaxis in High-Risk Ambulatory Patients with Cancer. N Engl J Med 2019; 380:720-728. [PMID: 30786186 DOI: 10.1056/nejmoa1814630] [Citation(s) in RCA: 451] [Impact Index Per Article: 90.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Ambulatory patients receiving systemic cancer therapy are at varying risk for venous thromboembolism. However, the benefit of thromboprophylaxis in these patients is uncertain. METHODS In this double-blind, randomized trial involving high-risk ambulatory patients with cancer (Khorana score of ≥2, on a scale from 0 to 6, with higher scores indicating a higher risk of venous thromboembolism), we randomly assigned patients without deep-vein thrombosis at screening to receive rivaroxaban (at a dose of 10 mg) or placebo daily for up to 180 days, with screening every 8 weeks. The primary efficacy end point was a composite of objectively confirmed proximal deep-vein thrombosis in a lower limb, pulmonary embolism, symptomatic deep-vein thrombosis in an upper limb or distal deep-vein thrombosis in a lower limb, and death from venous thromboembolism and was assessed up to day 180. In a prespecified supportive analysis involving the same population, the same end point was assessed during the intervention period (first receipt of trial agent to last dose plus 2 days). The primary safety end point was major bleeding. RESULTS Of 1080 enrolled patients, 49 (4.5%) had thrombosis at screening and did not undergo randomization. Of the 841 patients who underwent randomization, the primary end point occurred in 25 of 420 patients (6.0%) in the rivaroxaban group and in 37 of 421 (8.8%) in the placebo group (hazard ratio, 0.66; 95% confidence interval [CI], 0.40 to 1.09; P = 0.10) in the period up to day 180. In the prespecified intervention-period analysis, the primary end point occurred in 11 patients (2.6%) in the rivaroxaban group and in 27 (6.4%) in the placebo group (hazard ratio, 0.40; 95% CI, 0.20 to 0.80). Major bleeding occurred in 8 of 405 patients (2.0%) in the rivaroxaban group and in 4 of 404 (1.0%) in the placebo group (hazard ratio, 1.96; 95% CI, 0.59 to 6.49). CONCLUSIONS In high-risk ambulatory patients with cancer, treatment with rivaroxaban did not result in a significantly lower incidence of venous thromboembolism or death due to venous thromboembolism in the 180-day trial period. During the intervention period, rivaroxaban led to a substantially lower incidence of such events, with a low incidence of major bleeding. (Funded by Janssen and others; CASSINI ClinicalTrials.gov number, NCT02555878.).
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Affiliation(s)
- Alok A Khorana
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Gerald A Soff
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Ajay K Kakkar
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Saroj Vadhan-Raj
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Hanno Riess
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Ted Wun
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Michael B Streiff
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - David A Garcia
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Howard A Liebman
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Chandra P Belani
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Eileen M O'Reilly
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Jai N Patel
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Habte A Yimer
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Peter Wildgoose
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Paul Burton
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Ujjwala Vijapurkar
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Simrati Kaul
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - John Eikelboom
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Robert McBane
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Kenneth A Bauer
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Nicole M Kuderer
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
| | - Gary H Lyman
- From the Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland (A.A.K.); the Department of Medicine, Memorial Sloan Kettering Cancer Center (G.A.S., E.M.O.), and Weill Cornell Medical College (G.A.S., E.M.O.), New York; the Thrombosis Research Institute and University College London, London (A.K.K.); University of Texas M.D. Anderson Cancer Center, Houston (S.V.-R.), and U.S. Oncology Research-Texas Oncology, Tyler (H.A.Y.) - both in Texas; the Department of Medicine, Charité Universitätsmedizin Berlin, Berlin (H.R.); the Division of Hematology-Oncology, University of California Davis School of Medicine, Sacramento (T.W.), and the Keck School of Medicine, University of Southern California, Los Angeles (H.A.L.); the Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore (M.B.S.); the University of Washington School of Medicine (D.A.G., N.M.K., G.H.L.), Advanced Cancer Research Group (N.M.K.), and Fred Hutchinson Cancer Research Center (G.H.L.), Seattle; Penn State Cancer Institute, Milton S. Hershey Medical Center, Hershey, PA (C.P.B.); the Department of Cancer Pharmacology, Levine Cancer Institute, Atrium Health, Charlotte, NC (J.N.P.); Janssen Scientific Affairs, Titusville (P.W., P.B., S.K.), and Janssen Research and Development, Raritan (U.V.) - both in New Jersey; the Department of Medicine, McMaster University, Hamilton, ON, Canada (J.E.); the Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (R.M.); and the Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston (K.A.B.)
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Chan NC, Weitz JI. Rivaroxaban for prevention and treatment of venous thromboembolism. Future Cardiol 2019; 15:63-77. [PMID: 30779598 DOI: 10.2217/fca-2018-0076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Until recently, heparins and vitamin K antagonists (VKAs) were the cornerstones for prevention and treatment of venous thromboembolism (VTE). This situation changed with the introduction of the direct oral anticoagulants, which are now replacing low-molecular-weight heparin for thromboprophylaxis after elective hip or knee arthroplasty and VKAs for VTE treatment. Rivaroxaban, an oral factor Xa inhibitor, was the first direct oral anticoagulant licensed for VTE prevention and treatment. This paper provides the rationale for factor Xa as a target for anticoagulants, describes the development of rivaroxaban, reviews its pharmacological profile, discusses the clinical trials with rivaroxaban for VTE prevention and treatment and highlights areas of uncertainty.
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Affiliation(s)
- Noel C Chan
- Thrombosis & Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis & Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Beyer-Westendorf J, Klamroth R, Kreher S, Langer F, Matzdorff A, Riess H. Non-vitamin K Antagonist Oral Anticoagulants (NOAC) as an Alternative Treatment Option in Tumor-Related Venous Thromboembolism. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019; 116:31-38. [PMID: 30832760 PMCID: PMC6401514 DOI: 10.3238/arztebl.2019.0031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 04/17/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) is 4 to 7 times higher in cancer patients than in the normal population. Moreover, cancer patients who take anticoagulants suffer more frequently from hemorrhagic complications and VTE recurrences. Patients often find low-molecular-weight heparin (LMWH) treatment unpleasant; approximately 20% stop taking LMWH during the first six months of treatment. METHODS Based on a non-systematic literature search, an interdisciplinary group of specialists (hematology, oncology, hemostaseology, and angiology) developed a set of recommendations concerning the treatment of tumor-related thrombosis with non-vitamin K antagonist oral anticoagulants (NOAC). RESULTS Patient-, tumor-, and tumor-treatment-related factors and clinical situations were identified that should be considered in therapeutic decision-making in the indi- vidual case. NOAC may be an alternative that lessens the rate of VTE recurrence (though at the cost of more hemorrhagic complications), without lessening mortality. Moreover, many factors need to be considered that can limit the utility of NOAC treatment or even make it impossible. CONCLUSION It seems likely that, in future, the treatment of tumor-related VTE will often not involve a single decision to use either NOAC or LWMH, but rather a switching of treatment in either of two directions: from LWMH to NOAC in stable phases of the underlying malignant disease, conferring better quality of life to suitable patients; or from NOAC to LWMH, e.g., in patients suffering from emesis or thrombocytopenia, to whom the greater clinical experience with LWMH, parenteral application, or stepwise dose titration can confer benefits.
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Affiliation(s)
- Jan Beyer-Westendorf
- Department of Medicine I, Division of Hematology and Hemostaseology, University Hospital “Carl Gustav Carus” Dresden; King’s Thrombosis Service, Department of Hematology, King‘s College London
| | - Robert Klamroth
- Department of Internal Medicine, Angiology and Hemostaseology, Vivantes Klinikum im Friedrichshain Berlin
| | | | - Florian Langer
- II. Medical Clinic and Polyclinic, Hubertus Wald Tumorzentrum – University Cancer Center Hamburg (UCCH), University Medical Center Hamburg-Eppendorf
| | - Axel Matzdorff
- Medical Clinic II, Asklepios Klinikum Uckermark, Schwedt
| | - Hanno Riess
- Medical Department, Division of Hematology, Oncology and Tumor Immunology, Charité – Universitätsmedizin Berlin
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Alexander M, Ball D, Solomon B, MacManus M, Manser R, Riedel B, Westerman D, Evans SM, Wolfe R, Burbury K. Dynamic Thromboembolic Risk Modelling to Target Appropriate Preventative Strategies for Patients with Non-Small Cell Lung Cancer. Cancers (Basel) 2019; 11:cancers11010050. [PMID: 30625975 PMCID: PMC6356389 DOI: 10.3390/cancers11010050] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/29/2018] [Indexed: 12/24/2022] Open
Abstract
Prevention of cancer-associated thromboembolism (TE) remains a significant clinical challenge and priority world-wide safety initiative. In this prospective non-small cell lung cancer (NSCLC) cohort, longitudinal TE risk profiling (clinical and biomarker) was undertaken to develop risk stratification models for targeted TE prevention. These were compared with published models from Khorana, CATS, PROTECHT, CONKO, and CATS/MICA. The NSCLC cohort of 129 patients, median follow-up 22.0 months (range 5.6—31.3), demonstrated a hypercoagulable profile in >75% patients and TE incidence of 19%. High TE risk patients were those receiving chemotherapy with baseline fibrinogen ≥ 4 g/L and d-dimer ≥ 0.5 mg/L; or baseline d-dimer ≥ 1.5 mg/L; or month 1 d-dimer ≥ 1.5 mg/L. The model predicted TE with 100% sensitivity and 34% specificity (c-index 0.67), with TE incidence 27% vs. 0% for high vs. low-risk. A comparison using the Khorana, PROTECHT, and CONKO methods were not discriminatory; TE incidence 17–25% vs. 14–19% for high vs. low-risk (c-index 0.51–0.59). Continuous d-dimer (CATS/MICA model) was also not predictive of TE. Independent of tumour stage, high TE risk was associated with cancer progression (HR 1.9, p = 0.01) and mortality (HR 2.2, p = 0.02). The model was tested for scalability in a prospective gastrointestinal cancer cohort with equipotency demonstrated; 80% sensitivity and 39% specificity. This proposed TE risk prediction model is simple, practical, potent and can be used in the clinic for real-time, decision-making for targeted thromboprophylaxis. Validation in a multicentre randomised interventional study is underway (ACTRN12618000811202).
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Affiliation(s)
- Marliese Alexander
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
- Pharmacy Department, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
| | - David Ball
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Radiation Oncology Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Benjamin Solomon
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Medical Oncology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Michael MacManus
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Radiation Oncology Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Renee Manser
- Department of Respiratory and Sleep Disorders Medicine, Royal Melbourne Hospital, Grattan Street, Parkville, VIC 3050, Australia.
| | - Bernhard Riedel
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - David Westerman
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Pathology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Department of Haematology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
| | - Sue M Evans
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Rory Wolfe
- Department of Epidemiology and Preventive Medicine Monash University, 99 Commercial Road, Melbourne, VIC 3004, Australia.
| | - Kate Burbury
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, VIC 3010, Australia.
- Department of Pathology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
- Department of Haematology, Peter MacCallum Cancer Centre, 305 Grattan St, Melbourne, VIC 3000, Australia.
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Prisco D, Tufano A, Cenci C, Pignatelli P, Santilli F, Di Minno G, Perticone F. Position paper of the Italian Society of Internal Medicine (SIMI) on prophylaxis and treatment of venous thromboembolism in patients with cancer. Intern Emerg Med 2019; 14:21-38. [PMID: 30276659 DOI: 10.1007/s11739-018-1956-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/18/2018] [Indexed: 02/01/2023]
Abstract
Cancer patients are at high risk of developing thrombotic events, including venous thromboembolism (VTE) [deep venous thrombosis (DVT) and pulmonary embolism (PE)], and arterial thrombosis. DVT and PE represent the second leading cause of death in cancer patients; moreover, the development of thromboembolic events in cancer patients is linked to a greater need of hospitalization and frequency of side effects during treatment, in particular bleeding, and to an increased risk of recurrence during and following antithrombotic therapy. The thromboembolic risk may be different in different subgroups of cancer population, being highest in patients with metastatic disease, patients with pancreas, stomach, kidney or primary brain cancer, or during therapeutic interventions or surgery. This document focuses on several relevant topics including the epidemiology and pathogenesis of cancer-associated VTE, the current and future strategies of primary prevention and anticoagulant treatment, and the management of bleeding complications. The main literature data are discussed in detail, including, when available, evidence from randomized clinical trials and meta-analyses, international guidelines statements, the results of recently published trials comparing direct oral anticoagulants to low molecular weight heparin, and the design and aims of ongoing trials on prevention/treatment of cancer-associated VTE.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University Hospital, Via S. Pansini, 5, 80131, Naples, Italy.
| | - Caterina Cenci
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, La Sapienza University of Rome, Rome, Italy
| | - Francesca Santilli
- Department of Medicine and Aging and Center of Aging Science and Translational Medicine (CESI-Met), "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, Regional Reference Centre for Coagulation Disorders, "Federico II" University Hospital, Via S. Pansini, 5, 80131, Naples, Italy
| | - Francesco Perticone
- Department of Medical and Surgical Sciences, "Magna-Græcia" University of Catanzaro, Catanzaro, Italy
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Chen YW, Wang MJ, Khorana AA. Prevalence of Venous Thromboembolism Diagnosed in Emergency Department Visits by Cancer Patients and Associated Healthcare Resource Utilization in the United States. Am J Hematol 2018; 93. [PMID: 29790587 DOI: 10.1002/ajh.25148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Yu-Wei Chen
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Min-Jung Wang
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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42
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Zareba P, Duivenvoorden WC, Pinthus JH. Thromboembolism in Patients with Bladder Cancer: Incidence, Risk Factors and Prevention. Bladder Cancer 2018; 4:139-147. [PMID: 29732385 PMCID: PMC5929309 DOI: 10.3233/blc-170146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patients with bladder cancer are at high risk of developing both venous and arterial thromboembolic events. Factors that contribute to this phenomenon include the hypercoagulable state induced by the malignancy itself, medical comorbidities that are common in this predominantly elderly patient population as well as treatments such as prolonged pelvic surgery and cisplatin-based chemotherapy. While formal guidelines address prevention of venous thromboembolism in patients undergoing radical cystectomy, consensus regarding the role of pharmacologic prophylaxis in patients with bladder cancer being treated with chemotherapy, either with neoadjuvant or adjuvant intent in conjunction with radical cystectomy, as part of bladder preservation protocols or for metastatic disease, has proved elusive. The present narrative review was undertaken to define the incidence of and identify risk factors for thromboembolism among patients with bladder cancer, as well as to assess the efficacy of pharmacologic prophylaxis in reducing the risk of thromboembolism in this patient population.
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Affiliation(s)
- Piotr Zareba
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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43
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Mukai M, Oka T. Mechanism and management of cancer-associated thrombosis. J Cardiol 2018; 72:89-93. [PMID: 29588087 DOI: 10.1016/j.jjcc.2018.02.011] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 02/27/2018] [Indexed: 01/14/2023]
Abstract
Thromboembolism is considered to have a substantial impact on outcomes in patients with cancer. Although progress in cancer therapy and the advent of new anticancer agents such as molecular targeted drugs have improved the outcomes of patients with cancer, the incidence of cancer-therapy-related thromboembolism is increasing, and the management of this adverse reaction has become a major problem. Cancer is intimately related to thrombosis. Thrombus formation results from the complex interaction of various factors, such as tissue factors, coagulation abnormalities, activated platelet activation, activated adhesion activation, and endothelial cell dysfunction. Thrombosis has an impact on cancer proliferation and extension. The condition known as "cancer-related thrombosis" must therefore be managed differently from thrombosis in patients without cancer.
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Affiliation(s)
- Mikio Mukai
- Osaka Prefectural Hospital Organization, Osaka International Cancer Institute, Department of Medical Check up, Onco-Cardiology Unit, Osaka, Japan.
| | - Toru Oka
- Osaka Prefectural Hospital Organization, Osaka International Cancer Institute, Department of Medical Check up, Onco-Cardiology Unit, Osaka, Japan
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44
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Lopes RD, Guimarães PO, Crowther M, Hylek E, Feitosa-Filho GS, Ritt LE, Filgueiras N, Garcia DA. Highlights from the Tenth International Symposium of Thrombosis and Anticoagulation (ISTA X), September 22 and 23, 2017, Salvador, Bahia, Brazil. J Thromb Thrombolysis 2018. [PMID: 29524111 DOI: 10.1007/s11239-018-1639-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
To discuss and share knowledge about advances in the care of patients with thrombotic disorders, the Tenth International Symposium of Thrombosis and Anticoagulation was held in Salvador, Bahia, Brazil, on September 22 and 23, 2017. This scientific program was developed by clinicians for clinicians and was promoted by two major clinical research institutes-the Brazilian Clinical Research Institute and the Duke Clinical Research Institute of the Duke University School of Medicine. Comprising academic presentations and open discussion, the symposium had as its primary goal to educate, motivate, and inspire internists, cardiologists, hematologists, and other physicians by convening national and international visionaries, thought-leaders, and dedicated clinician-scientists. This paper summarizes the symposium proceedings.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Box 3850, 2400 Pratt Street, Durham, NC, 27705, USA.
| | - Patricia O Guimarães
- Duke Clinical Research Institute, Duke University School of Medicine, Box 3850, 2400 Pratt Street, Durham, NC, 27705, USA
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Elaine Hylek
- Boston University Medical Center, Boston, MA, USA
| | - Gilson S Feitosa-Filho
- Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brazil.,Hospital Santa Izabel - Santa Casa da Bahia, Salvador, BA, Brazil.,Hospital Ana Nery, Salvador, BA, Brazil
| | - Luiz E Ritt
- Escola Bahiana de Medicina e Saúde Pública (EBMSP), Salvador, BA, Brazil.,Hospital Cárdio Pulmonar, Salvador, BA, Brazil
| | - Nivaldo Filgueiras
- Universidade Salvador (UNIFACS) - rede Laureate, Salvador, BA, Brazil.,Universidade do Estado da Bahia (UNEB), Salvador, BA, Brazil.,Fundação Bahiana de Cardiologia, Salvador, BA, Brazil.,Hospital da Cidade, Salvador, BA, Brazil
| | - David A Garcia
- Department of Medicine, University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA
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Graf C, Ruf W. Tissue factor as a mediator of coagulation and signaling in cancer and chronic inflammation. Thromb Res 2018; 164 Suppl 1:S143-S147. [PMID: 29703473 DOI: 10.1016/j.thromres.2018.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 01/11/2018] [Accepted: 01/12/2018] [Indexed: 12/23/2022]
Abstract
Thrombosis is frequently diagnosed as a first symptom in tumor patients and the clinical management of hypercoagulability in cancer patients remains challenging due to concomitant changes in risk factors for severe bleeding. It therefore remains a priority to better understand interactions of the hemostatic system with cancer biology. Specifically, further research is needed to elucidate the details and effects of new anticoagulants on extravascular coagulation and the interplay between cancer progression and chronic inflammation. In addition, it will be important to identify subgroups of cancer patients benefiting from specific modulations of the coagulation system without increasing the bleeding risk. Here, we review recent findings on tissue factor (TF) regulation, its procoagulant activity and TF signaling in the various cell types of the tumor microenvironment.
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Affiliation(s)
- Claudine Graf
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Medical Center, Mainz, Germany.
| | - Wolfram Ruf
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Medical Center, Mainz, Germany; Department of Immunology and Microbiology, The Scripps Research Institute, La Jolla, CA, USA
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