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Kaptein FH, Guman NA, Lohle SB, Klok FA, Mairuhu AT, Kamphuisen PW, Es NV, Huisman MV. Treatment Patterns of Cancer-associated Thrombosis in the Netherlands: The Four Cities Study. TH OPEN 2024; 8:e61-e71. [PMID: 38298199 PMCID: PMC10827569 DOI: 10.1055/a-2214-8101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/17/2023] [Indexed: 02/02/2024] Open
Abstract
Background Current guidelines recommend either low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) as first-line treatment in cancer-associated venous thromboembolism (VTE). Aim This study aimed to investigate treatment regimens for cancer-associated VTE over the past 5 years, explore predictors for initial treatment (LMWH vs. DOAC), and to assess the risks of recurrent VTE and bleeding. Methods This was a Dutch, multicenter, retrospective cohort study including consecutive patients with cancer-associated VTE between 2017 and 2021. Treatment predictors were assessed with multivariable logistic regression models. Six-month cumulative incidences for recurrent VTE and major bleeding (MB) were estimated with death as competing risk. Results In total, 1,215 patients were included. The majority (1,134/1,192; 95%) started VTE treatment with anticoagulation: 561 LMWH (47%), 510 DOACs (43%), 27 vitamin K antagonist (2.3%), and 36 other/unknown type (3.0%). The proportion of patients primarily treated with DOACs increased from 18% (95% confidence interval [CI] 12-25) in 2017 to 70% (95% CI 62-78) in 2021. Poor performance status (adjusted odds ratio [aOR] 0.72, 95% CI 0.53-0.99) and distant metastases (aOR 0.61, 95% CI 0.45-0.82) were associated with primary treatment with LMWH. Total 6-month cumulative incidences were 6.0% (95% CI 4.8-7.5) for recurrent VTE and 7.0% (95% CI 5.7-8.6) for MB. During follow-up, 182 patients (15%) switched from LMWH to a DOAC, and 54 patients (4.4%) vice versa, for various reasons, including patient preference, recurrent thrombosis, and/or bleeding. Conclusion DOAC use in cancer-associated VTE has increased rapidly over the past years. Changes in anticoagulation regimen were frequent over time, and were often related to recurrent thrombotic and bleeding complications, illustrating the complexity and challenges of managing cancer-associated VTE.
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Affiliation(s)
- Fleur H.J. Kaptein
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Noori A.M. Guman
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Susan B. Lohle
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Pieter W. Kamphuisen
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, the Netherlands
| | - Nick Van Es
- Department of Vascular Medicine, Amsterdam University Medical Center Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Pulmonary Hypertension and Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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Milani A, Tuninetti V, Pignata S, Lorusso D, Castaldo D, De Giorgi U, Savarese A, Biglia N, Scandurra G, Mangili G, Di Maio M, Turinetto M, Bellero M, Mammoliti S, Testa S, Scotto G, Purro A, Artioli G, Valabrega G. Prescribing pattern of anticoagulants in patients with cancer associated thrombosis: Results of a survey among MITO group and AIOM society. TUMORI JOURNAL 2023; 109:490-495. [PMID: 36609207 DOI: 10.1177/03008916221146820] [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] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Low molecular weight heparin (LMWH) has been the backbone of the treatment of cancer associated thrombosis (CAT). Direct-acting oral anticoagulants (DOACs) have shown efficacy and safety not inferior to LMWH and guidelines included DOACs as an option for CAT treatment. Nevertheless, DOACs are still poorly prescribed in patients with cancer. The aim of this survey was to better understand prescription patterns of anticoagulants, in particular of DOACs, especially in gynecological cancers (GCs). METHODS Our survey was made up of 21 questions, the last four questions addressed to medical doctors (MDs) involved in GCs. An invitation to complete the survey was sent by e-mail to 691 MITO (Multicentre Italian Trials in Ovarian cancer and gynaecologic malignancies) and 2093 AIOM (Associazione Italiana di Oncologia Medica) members. RESULTS Overall, 113 MDs completed the questionnaire, 69 involved in GCs. Most respondents (46, 41%) were aged 30-40 years old, worked in public hospitals (59, 52.2%), were medical oncologists (86, 76.1%). LMWH was the preferred choice for the treatment of CAT (104, 92%). However, 89 respondents (78.8%) prescribed or asked to prescribe a DOAC for CAT. The major concern about DOACs was the difficulty in verifying the therapeutic effect and the absence of antidotes in case of bleeding (37.9%). In patients with GCs, DOACs were used with niraparib, olaparib, rucaparib and immune checkpoint inhibitors (ICIs) in less than 10 patients by 23%, 20%, 9% and 10.2% of respondents, respectively. CONCLUSION The responders are aware of the Direct-acting oral anticoagulants option and would like to use them.
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Affiliation(s)
- Andrea Milani
- Pronto Soccorso, Ospedale San Lorenzo, ASL TO5, Turin, Italy
| | - Valentina Tuninetti
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Sandro Pignata
- Department of Urogynecology, National Cancer Institute, Pascale Foundation (Scientific Institute for Research and Healthcare), Naples, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Daniele Castaldo
- Segreteria Multicenter Italian Trials in Ovarian Cancer and Gynaecologic Malignancies (MITO) Group, Naples, Italy
| | - Ugo De Giorgi
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), IRCCS, Meldola, Italy
| | | | - Nicoletta Biglia
- Obstetrics and Gynaecology Unit, Umberto I Hospital, Department of Surgical Sciences, School of Medicine, University of Turin, Turin, Italy
| | | | - Giorgia Mangili
- Obstetrics and Gynecology Unit, IRCCS San Raffaele Scientific Institute, Via Olgettina, 60, 20132 Milano, Italy
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Margherita Turinetto
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Marco Bellero
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | | | - Silvia Testa
- Anestesia e Rianimazione, Struttura Complessa di Anestesia e Rianimazione, Ospedale San Lorenzo, ASL TO5, Turin, Italy
| | - Giulia Scotto
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
| | - Andrea Purro
- Pronto Soccorso, Ospedale San Lorenzo, ASL TO5, Turin, Italy
| | | | - Giorgio Valabrega
- Department of Oncology, University of Turin, Division of Medical Oncology, Ordine Mauriziano Hospital, Turin, Italy
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Napolitano M, Siragusa S. The Role of Injectables in the Treatment and Prevention of Cancer-Associated Thrombosis. Cancers (Basel) 2023; 15:4640. [PMID: 37760609 PMCID: PMC10526875 DOI: 10.3390/cancers15184640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of death among patients with cancer. CAT can manifest itself as venous thromboembolism (VTE), in the form of deep vein thrombosis or pulmonary embolism, or arterial thromboembolism. The pathophysiology of CAT is complex and depends on cancer-, patient-, treatment- and biomarkers-related factors. Treatment of VTE in patients with cancer is complex and includes three major classes of anticoagulant agents: heparin and its derivatives, e.g., low molecular weight heparins, direct oral anticoagulants (DOACs), and vitamin K inhibitors. Given the tremendous heterogeneity of clinical situations in patients with cancer and the challenges of CAT, there is no single universal treatment option for patients suffering from or at risk of CAT. Initial studies suggested that patients seemed to prefer an anticoagulant that would not interfere with their cancer treatment, suggesting the primacy of cancer over VTE, and favoring efficacy and safety over convenience of route of administration. Recent studies show that when the efficacy and safety aspects are similar, patients prefer the oral route of administration. Despite this, injectables are a valid option for many patients with cancer.
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Affiliation(s)
- Mariasanta Napolitano
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, 90121 Palermo, Italy;
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Mahé I, Chapelle C, Plaisance L, Bertoletti L, Mismetti P, Mayeur D, Mahé G, Couturaud F. Management of Cancer-Associated Thrombosis in France: A National Survey among Vascular Disease and Supportive Care Specialists. Cancers (Basel) 2022; 14:cancers14174143. [PMID: 36077680 PMCID: PMC9454850 DOI: 10.3390/cancers14174143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/15/2022] [Accepted: 08/22/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Patients with venous thromboembolism events in the context of cancer should receive anticoagulants for at least 6 months. Both low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) are considered in international guidelines, with a different approach. To investigate the determinants of decision, at thrombosis diagnosis and after 6 months, and the practices when facing special situations, such as venous thromboembolic recurrence or thrombocytopenia, we designed a survey among specialists of cancer-associated thromboembolism, including vignettes about patients with different cancer sites and questions. We considered points related to cancer disease, anticancer treatments and characteristics of patients. Abstract Low molecular weight heparins (LMWHs) are recommended by international guidelines for at least 6 months in patients with cancer-associated thromboembolism (CAT). Direct oral anticoagulants (DOACs) have been proposed as an alternative to LMWH. In clinical practice, the specialists in charge of CAT have to decide which anticoagulant to prescribe. An electronic survey tool, including vignettes and questions, was sent to members of the French Society of Vascular Medicine, the French-speaking association for supportive care in oncology and the Investigation Network On Venous Thrombo-Embolism. Among the 376 respondents, LMWHs were reported as the first choice by most specialists. The prescription of DOACs within the first 3 weeks of CAT diagnosis was highly dependent on the cancer site: 5.9%, 18.6% and 24.5% in patients with locally advanced colorectal, lung and breast cancer, respectively. The determinants were mostly related to cancer (site and stage or evolution) and to anticancer treatments. For 61% of physicians, some anticancer treatments were contraindications to DOACs. However, almost 90% of physicians considered switching to DOAC after a median 3-month period of LMWHs. In daily practice, LMWHs and DOACs are now considered by specialists of CAT; the decision is mostly driven by the site of cancer. The role of anticancer treatments in the decision remains to be investigated.
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Affiliation(s)
- Isabelle Mahé
- Université Paris Cité, 75006 Paris, France
- Service de Médecine Interne, Hôpital Louis Mourier, AP-HP, 92700 Colombes, France
- Innovative Therapies in Haemostasis, INSERM UMR_S1140, 75006 Paris, France
- INNOVTE-FCRIN (Investigation Network On Venous Thrombo-Embolism), 42055 Saint-Etienne, France
- Correspondence:
| | - Céline Chapelle
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, 42270 Saint-Etienne, France
- SAINBIOSE INSERM U1059, Université Jean Monnet, Université de Lyon, 42023 Saint-Etienne, France
| | - Ludovic Plaisance
- Université Paris Cité, 75006 Paris, France
- Service de Médecine Interne, Hôpital Louis Mourier, AP-HP, 92700 Colombes, France
| | - Laurent Bertoletti
- INNOVTE-FCRIN (Investigation Network On Venous Thrombo-Embolism), 42055 Saint-Etienne, France
- SAINBIOSE INSERM U1059, Université Jean Monnet, Université de Lyon, 42023 Saint-Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, 42055 Saint-Etienne, France
- INSERM CIC-1408, CHU de St-Etienne, 42055 Saint-Etienne, France
| | - Patrick Mismetti
- INNOVTE-FCRIN (Investigation Network On Venous Thrombo-Embolism), 42055 Saint-Etienne, France
- SAINBIOSE INSERM U1059, Université Jean Monnet, Université de Lyon, 42023 Saint-Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, 42055 Saint-Etienne, France
- INSERM CIC-1408, CHU de St-Etienne, 42055 Saint-Etienne, France
| | - Didier Mayeur
- Oncology Department, Centre Georges François Leclerc, 1, Rue Professeur Marion, BP77980, CEDEX, 21079 Dijon, France
| | - Guillaume Mahé
- Unité de Médecine Vasculaire, CHU Rennes, 35000 Rennes, France
- INSERM CIC 1414, 35200 Rennes, France
- University of Rennes 1, 35000 Rennes, France
- University of Rennes 2, M2S-EA 7470, 35000 Rennes, France
| | - Francis Couturaud
- INNOVTE-FCRIN (Investigation Network On Venous Thrombo-Embolism), 42055 Saint-Etienne, France
- Département de Médecine Interne et Pneumologie, INSERM U1304 (GETBO), CHU Brest, Université de Bretagne Occidentale, 29238 Brest, France
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