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Walker CA, Edwards C, McIntire D, Makepeace L, Holloway SB, Kakadiaris E, Spirtos AN, Miller DS, Lea JS. Predicting VTE and utility of thromboprophylaxis in metastatic and recurrent cervical cancer. Gynecol Oncol 2024; 188:22-26. [PMID: 38875744 DOI: 10.1016/j.ygyno.2024.05.028] [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: 04/28/2024] [Accepted: 05/25/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE Patients with cervical cancer who are diagnosed with venous thromboembolism (VTE) have worse outcomes compared to those not affected. There has yet to be a reliable method to predict or prevent VTE in cervical cancer patients. Our objective is to describe the incidence of VTE in patients with recurrent and metastatic (r/mCC) and determine risk factors that may predict VTE in this setting. METHODS We performed an observational cohort study of 386 patients with r/mCC who received at least one line of systemic chemotherapy. We collected demographic, clinical, histologic data and Khorana scores for all patients. Inclusion and exclusion criteria were applied before analysis. Statistical analysis was performed using Pearson chi-square, Student's t-test, and Wilcoxon rank-sum. RESULTS 232 patients were included for evaluation. Mean age was 49 years (range 20-83). The majority (167, 72%) of patients had squamous cell histology. 169 (72.8%) patients received treatment for recurrent disease and 63 (27.2%) for metastatic, stage IVB disease. 180 (78%) patients received prior radiation and 134 (58%) received bevacizumab. VTE was diagnosed in 89 (38%) patients. There were no statistically significant differences amongst clinical and pathologic characteristics between patients who developed VTE and those who did not. There was no significant association between BMI, Khorana score, radiation, bevacizumab, or immunotherapy and the development of VTE. CONCLUSION Approximately 40% of patients with r/mCC experienced a new VTE. There were no independent risk factors that could predict VTE in this population. Due to the overwhelmingly high incidence of VTE, prophylactic anticoagulation could be strongly considered in patients with r/mCC.
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Affiliation(s)
- Christopher A Walker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Carson Edwards
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Don McIntire
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Lydia Makepeace
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Steven Blaine Holloway
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Ev Kakadiaris
- Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Alexandra N Spirtos
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - David S Miller
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Jayanthi S Lea
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America.
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2
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Roy DC, Wang TF, Lun R, Zahrai A, Mallick R, Burger D, Zitikyte G, Hawken S, Wells P. Circulating Blood Biomarkers and Risk of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis. Thromb Haemost 2024. [PMID: 38768631 DOI: 10.1055/a-2330-1371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Cancer patients have an increased risk of venous thromboembolism (VTE). Currently, the availability of highly discriminatory prediction models for VTE in cancer patients is limited. The implementation of biomarkers in prediction models might lead to refined VTE risk prediction. In this systematic review and meta-analysis, we aimed to evaluate candidate biomarkers and their association with cancer-associated VTE. METHODS We searched Medline, EMBASE, and Cochrane Central for studies that evaluated biomarkers in adult cancer patients from inception to September 2022. We included studies reporting on VTE after a cancer diagnosis with biomarker measurements performed at a defined time point. Median/mean differences (for continuous measures) and odds ratios (for dichotomous measures) with 95% confidence intervals were estimated and pooled using random-effects models. RESULTS We included 113 studies in the systematic review. Of these, 50 studies were included in the meta-analysis. We identified two biomarkers at cancer diagnosis (factor VIII and time to peak thrombin), three biomarkers pre-chemotherapy (D-dimer, fibrinogen, and mean platelet volume), and one biomarker preoperatively (platelet count) that had significant median or mean differences. Additionally, we found that hemoglobin <100 g/L and white blood count >11 × 109/L were significantly associated with future VTE risk only when measured at cancer diagnosis. Pre-chemotherapy neutrophil-to-lymphocyte ratio ≥3 and preoperative platelet count ≥400 × 109/L were also found to be associated with future VTE risk. CONCLUSION In conclusion, this study identified nine candidate blood biomarkers that may help in optimizing VTE prediction in cancer patients that should be further explored in future studies.
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Affiliation(s)
- Danielle Carole Roy
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tzu-Fei Wang
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ronda Lun
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Vascular Neurology, Stanford Healthcare, Palo Alto, California, United States
| | - Amin Zahrai
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Dylan Burger
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Steven Hawken
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Philip Wells
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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3
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Falanga A, Lorusso D, Colombo N, Cormio G, Cosmi B, Scandurra G, Zanagnolo V, Marietta M. Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention. Cancers (Basel) 2024; 16:1769. [PMID: 38730721 PMCID: PMC11083004 DOI: 10.3390/cancers16091769] [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: 02/14/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University “A. Moro”, 70124 Bari, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppa Scandurra
- Unità Operativa Oncologia Medica, Ospedale Cannizzaro di Catania, 95126 Catania, Italy;
| | | | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy;
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4
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Smorodin E, Chuzmarov V, Veidebaum T. The Potential of Integrative Cancer Treatment Using Melatonin and the Challenge of Heterogeneity in Population-Based Studies: A Case Report of Colon Cancer and a Literature Review. Curr Oncol 2024; 31:1994-2023. [PMID: 38668052 PMCID: PMC11049198 DOI: 10.3390/curroncol31040149] [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: 01/28/2024] [Revised: 03/19/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024] Open
Abstract
Melatonin is a multifunctional hormone regulator that maintains homeostasis through circadian rhythms, and desynchronization of these rhythms can lead to gastrointestinal disorders and increase the risk of cancer. Preliminary clinical studies have shown that exogenous melatonin alleviates the harmful effects of anticancer therapy and improves quality of life, but the results are still inconclusive due to the heterogeneity of the studies. A personalized approach to testing clinical parameters and response to integrative treatment with nontoxic and bioavailable melatonin in patient-centered N-of-1 studies deserves greater attention. This clinical case of colon cancer analyzes and discusses the tumor pathology, the adverse effects of chemotherapy, and the dynamics of markers of inflammation (NLR, LMR, and PLR ratios), tumors (CEA, CA 19-9, and PSA), and hemostasis (D-dimer and activated partial thromboplastin time). The patient took melatonin during and after chemotherapy, nutrients (zinc, selenium, vitamin D, green tea, and taxifolin), and aspirin after chemotherapy. The patient's PSA levels decreased during CT combined with melatonin (19 mg/day), and melatonin normalized inflammatory markers and alleviated symptoms of polyneuropathy but did not help with thrombocytopenia. The results are analyzed and discussed in the context of the literature on oncostatic and systemic effects, alleviating therapy-mediated adverse effects, association with survival, and N-of-1 studies.
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Affiliation(s)
- Eugeniy Smorodin
- Department of Chronic Diseases, National Institute for Health Development, Paldiski mnt 80, 10617 Tallinn, Estonia;
| | - Valentin Chuzmarov
- 2nd Surgery Department, General Surgery and Oncology Surgery Centre, North Estonia Medical Centre, J. Sütiste Str. 19, 13419 Tallinn, Estonia
| | - Toomas Veidebaum
- Department of Chronic Diseases, National Institute for Health Development, Paldiski mnt 80, 10617 Tallinn, Estonia;
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5
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Charpidou A, Gerotziafas G, Popat S, Araujo A, Scherpereel A, Kopp HG, Bironzo P, Massard G, Jiménez D, Falanga A, Kollias A, Syrigos K. Lung Cancer Related Thrombosis (LCART): Focus on Immune Checkpoint Blockade. Cancers (Basel) 2024; 16:450. [PMID: 38275891 PMCID: PMC10814098 DOI: 10.3390/cancers16020450] [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: 11/07/2023] [Revised: 12/10/2023] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Cancer-associated thrombosis (CAT) is a common complication in lung cancer patients. Lung cancer confers an increased risk of thrombosis compared to other solid malignancies across all stages of the disease. Newer treatment agents, including checkpoint immunotherapy and targeted agents, may further increase the risk of CAT. Different risk-assessment models, such as the Khorana Risk Score, and newer approaches that incorporate genetic risk factors have been used in lung cancer patients to evaluate the risk of thrombosis. The management of CAT is based on the results of large prospective trials, which show similar benefits to low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs) in ambulatory patients. The anticoagulation agent and duration of therapy should be personalized according to lung cancer stage and histology, the presence of driver mutations and use of antineoplastic therapy, including recent curative lung surgery, chemotherapy or immunotherapy. Treatment options should be evaluated in the context of the COVID-19 pandemic, which has been shown to impact the thrombotic risk in cancer patients. This review focuses on the epidemiology, pathophysiology, risk factors, novel predictive scores and management of CAT in patients with active lung cancer, with a focus on immune checkpoint inhibitors.
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Affiliation(s)
- Andriani Charpidou
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
| | - Grigorios Gerotziafas
- Assistance Publique-Hôpitaux de Paris, Thrombosis Center, Service D’Hématologie Biologique Hôpital Tenon, Sorbonne Université, 75005 Paris, France
| | - Sanjay Popat
- Royal Marsden Hospital, Institute of Cancer Research, London SW3 6JJ, UK
| | - Antonio Araujo
- Department of Medical Oncology, Centro Hospitalar Universitário do Porto, 4099-001 Porto, Portugal;
| | - Arnaud Scherpereel
- Department of Pulmonary and Thoracic Oncology, University of Lille, University Hospital (CHU), 59000 Lille, France;
| | - Hans-Georg Kopp
- Departments of Molecular Oncology and Thoracic Oncology, Robert-Bosch-Hospital Stuttgart, 70376 Stuttgart, Germany
| | - Paolo Bironzo
- Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10124 Turin, Italy
| | - Gilbert Massard
- Department of Thoracic Surgery, Hôpitaux Robert Schuman, 2540 Luxembourg, Luxembourg
| | - David Jiménez
- Respiratory Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, 28034 Madrid, Spain;
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, University of Milan Bicocca, 24129 Bergamo, Italy
| | - Anastasios Kollias
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
| | - Konstantinos Syrigos
- Third Department of Internal Medicine and Laboratory, Athens Medical School, National and Kapodistrian University of Athens, Sotiria General Hospital, 157 72 Athens, Greece; (A.K.)
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Khorana AA. Primary Thromboprophylaxis in People With Cancer-Where Next? JAMA Oncol 2023; 9:1545-1546. [PMID: 37733351 DOI: 10.1001/jamaoncol.2023.3569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Affiliation(s)
- Alok A Khorana
- Department of Hematology Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
- Case Comprehensive Cancer Center, Cleveland, Ohio
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7
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Sørensen HT, Pedersen L, van Es N, Büller HR, Horváth-Puhó E. Impact of venous thromboembolism on the mortality in patients with cancer: a population-based cohort study. THE LANCET REGIONAL HEALTH. EUROPE 2023; 34:100739. [PMID: 37809052 PMCID: PMC10558815 DOI: 10.1016/j.lanepe.2023.100739] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/12/2023] [Accepted: 09/13/2023] [Indexed: 10/10/2023]
Abstract
Background Despite recent improvements in the treatment of cancer, little is known about the long-term survival in patients with cancer and venous thromboembolism. We aimed to examine the five-year mortality of venous thromboembolism in cancer patients in a large population-based cohort study. Methods Using Danish healthcare registries from 1995 to 2020, we obtained data on cancer patients with venous thromboembolism and comparison cohorts of cancer patients without venous thromboembolism, matched in terms of cancer type, age, sex, and year of cancer diagnosis, and adjusted for level of comorbidity and frailty using the Charlson Comorbidity Index Score and Hospital Frailty Risk Score, marital status, use of selected medications, and recent surgery (<90 days). Findings During the study period, 886,536 patients were diagnosed with cancer. Of 1882 cancer patients diagnosed at the time of their venous thromboembolism, 44.4% (835/1882) had distant metastases. In this cohort, the one- and five-year mortality cumulative incidences were 68% (1284/1882) and 84% (1578/1882), respectively, in contrast to 38% (2135/5549) and 67% (3653/5549) in the comparison cohort. The mortality rate ratio was 4.34 (95% confidence interval [CI], 3.95-4.78) for the first year of follow-up and 3.44 (95% CI 3.17-3.73) for the five-year follow-up period. Of the 23,366 patients diagnosed with venous thromboembolism after cancer diagnosis, 18% (4183/23,366) had distant metastases at the time of cancer diagnosis. The cumulative incidence of death at one year was 45% (10,465/23,366; mortality rate ratio 3.48, 95% CI 3.37-3.60) and at five years 69% (15,669/23,366; mortality rate ratio 2.57, 95% CI 2.50-2.63). Interpretation Despite improved cancer treatment, venous thromboembolism in cancer patients is strongly associated with a poor prognosis. Funding The study was supported by grants from the Independent Research Fund Denmark (record no. 3101-00102B) and the Karen Elise Jensen Foundation.
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Affiliation(s)
- Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
- Clinical Excellence Research Center, Stanford University, Stanford, CA, USA
| | - Lars Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Harry R. Büller
- Department of Vascular Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension & Thrombosis, Amsterdam, the Netherlands
| | - Erzsébet Horváth-Puhó
- Department of Clinical Epidemiology, Aarhus University Hospital and Aarhus University, Aarhus, Denmark
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8
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Elalamy I, Cohen-Solal A, Hanon O, Mirabel M, Mismetti P, Spano JP. Primary prevention of cancer-associated venous thrombosis: Rationale and challenges in clinical practice. Curr Res Transl Med 2023; 71:103405. [PMID: 37478777 DOI: 10.1016/j.retram.2023.103405] [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: 02/17/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
Cancer-associated venous thrombosis (CAT) is a common, multifactor event known to complicate the course of cancer and jeopardize a patient's prognosis. The current guidelines regarding the prevention of CAT are sometimes considered insufficiently precise about specific situations, or are poorly applied. The expected benefits of thromboprophylaxis are balanced by the risk of major bleeding induced by anticoagulation, which implies a need to accurately identify ambulatory patients at high risk of thrombosis or hemorrhage. The Khorana score is commonly used for this, but is limited by the non-reproducibility of predicted performance across cancer types, and by the fact that antitumor treatment and cardiovascular risks are not included. The COMPASS-CAT score, which includes those two aspects, was found to be a more accurate predictor of venous thromboembolism in patients with lung cancer, and to better distinguish between patients at low or high risk of thrombosis. The frailty of patients with cancer is also a major issue, and should be taken into account when thromboprophylaxis is considered. According to current guidelines, CAT prophylaxis should be considered for hospitalized patients, those for whom surgery is scheduled, or those with pancreatic cancers. In ambulatory patients, decisions should be made according to patient, cancer and antitumoral treatment characteristics. Low molecular weight heparin is the gold standard of CAT prophylaxis. Despite increased risks of bleeding or drug-drug interactions in cancer patients, direct oral anticoagulants could be alternate options for high-risk ambulatory patients that should be accompanied by a careful global analysis of benefits, harms, and patient preferences.
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Affiliation(s)
- Ismail Elalamy
- Thrombosis Center, Hematology Department (DMU BioGeM), Assistance Publique Hôpitaux de Paris, Sorbonne University of Medicine, Paris, France; Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Research Centre Saint-Antoine, University Institute of Cancerology, Sorbonne University of Medicine, Paris, France; The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM Unité 942 MASCOT, AP-HP, Département de cardiologie et maladies vasculaires, Hôpital Lariboisière, Paris, France
| | - Olivier Hanon
- Université Paris Cité, EA4468, AP-HP, hôpitaux Universitaires Paris Centre, Département de Gériatrie, Hôpital Broca, Paris, France
| | - Mariana Mirabel
- Département de Cardiologie, Institut mutualiste Montsouris, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire, Saint Etienne, France
| | - Jean-Philippe Spano
- Service d'Oncologie médicale, APHP-SU, IUC, Hôpital La Pitié-Salpêtrière, Paris, France
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Mantha S, Chatterjee S, Singh R, Cadley J, Poon C, Chatterjee A, Kelly D, Sterpi M, Soff G, Zwicker J, Soria J, Ruiz M, Muñoz A, Arcila M. Application of Machine Learning to the Prediction of Cancer-Associated Venous Thromboembolism. RESEARCH SQUARE 2023:rs.3.rs-2870367. [PMID: 37214902 PMCID: PMC10197737 DOI: 10.21203/rs.3.rs-2870367/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Venous thromboembolism (VTE) is a common and impactful complication of cancer. Several clinical prediction rules have been devised to estimate the risk of a thrombotic event in this patient population, however they are associated with limitations. We aimed to develop a predictive model of cancer-associated VTE using machine learning as a means to better integrate all available data, improve prediction accuracy and allow applicability regardless of timing for systemic therapy administration. A retrospective cohort was used to fit and validate the models, consisting of adult patients who had next generation sequencing performed on their solid tumor for the years 2014 to 2019. A deep learning survival model limited to demographic, cancer-specific, laboratory and pharmacological predictors was selected based on results from training data for 23,800 individuals and was evaluated on an internal validation set including 5,951 individuals, yielding a time-dependent concordance index of 0.72 (95% CI = 0.70-0.74) for the first 6 months of observation. Adapted models also performed well overall compared to the Khorana Score (KS) in two external cohorts of individuals starting systemic therapy; in an external validation set of 1,250 patients, the C-index was 0.71 (95% CI = 0.65-0.77) for the deep learning model vs 0.66 (95% CI = 0.59-0.72) for the KS and in a smaller external cohort of 358 patients the C-index was 0.59 (95% CI = 0.50-0.69) for the deep learning model vs 0.56 (95% CI = 0.48-0.64) for the KS. The proportions of patients accurately reclassified by the deep learning model were 25% and 26% respectively. In this large cohort of patients with a broad range of solid malignancies and at different phases of systemic therapy, the use of deep learning resulted in improved accuracy for VTE incidence predictions. Additional studies are needed to further assess the validity of this model.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gerald Soff
- University of Miami Health System/Sylvester Comprehensive Cancer Center
| | | | - José Soria
- Biomedical Research Institute Sant Pau (IIB-Sant Pau)
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10
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Affiliation(s)
- Isabelle Mahé
- Université Paris Cité, Paris, France
- Assistance Publique des Hôpitaux de Paris, Hôpital Louis Mourier, Médecine Interne, Colombes, France
- Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- INNOVTE, FCRIN, France
- Address for correspondence: Dr Isabelle Mahé, Université Paris Cité, APHP, Hôpital Louis Mourier, Service de Médecine Interne, Inserm UMR_S1140, Innovations thérapeutiques en hémostase, 178 rue des Renouillers, 92700 Colombes, France. @isabellemahe1
| | - Florian Scotté
- Gustave Roussy, Patient Pathway Department, Villejuif, France
| | - Ismail Elalamy
- INNOVTE, FCRIN, France
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l’Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group “Cancer, Vessel Biology and Therapeutics,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
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11
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Teichman AL, Cotton BA, Byrne J, Dhillon NK, Berndtson AE, Price MA, Johns TJ, Ley EJ, Costantini T, Haut ER. Approaches for optimizing venous thromboembolism prevention in injured patients: Findings from the consensus conference to implement optimal venous thromboembolism prophylaxis in trauma. J Trauma Acute Care Surg 2023; 94:469-478. [PMID: 36729884 PMCID: PMC9975027 DOI: 10.1097/ta.0000000000003854] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Venous thromboembolism (VTE) is a major issue in trauma patients. Without prophylaxis, the rate of deep venous thrombosis approaches 60% and even with chemoprophylaxis may be nearly 30%. Advances in VTE reduction are imperative to reduce the burden of this issue in the trauma population. Novel approaches in VTE prevention may include new medications, dosing regimens, and extending prophylaxis to the postdischarge phase of care. Standard dosing regimens of low-molecular-weight heparin are insufficient in trauma, shifting our focus toward alternative dosing strategies to improve prophylaxis. Mixed data suggest that anti-Xa-guided dosage, weight-based dosing, and thromboelastography are among these potential strategies. The concern for VTE in trauma does not end upon discharge, however. The risk for VTE in this population extends well beyond hospitalization. Variable extended thromboprophylaxis regimens using aspirin, low-molecular-weight heparin, and direct oral anticoagulants have been suggested to mitigate this prolonged VTE risk, but the ideal approach for outpatient VTE prevention is still unclear. As part of the 2022 Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma, a multidisciplinary array of participants, including physicians from multiple specialties, pharmacists, nurses, advanced practice providers, and patients met to attack these issues. This paper aims to review the current literature on novel approaches for optimizing VTE prevention in injured patients and identify research gaps that should be investigated to improve VTE rates in trauma.
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Affiliation(s)
- Amanda L. Teichman
- Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Bryan A. Cotton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Memorial Hermann Hospital, Houston, TX
| | - James Byrne
- Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Allison E. Berndtson
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California San Diego School of Medicine, San Diego, CA
| | | | - Tracy J. Johns
- Department of Trauma and Acute Care Surgery, Atrium Health Navicent, Macon, GA
| | - Eric J. Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Todd Costantini
- Division of Trauma, Surgical Critical Care, and Burns, Department of Surgery, University of California San Diego School of Medicine, San Diego, CA
| | - Elliott R. Haut
- Division of Acute Care Surgery, Department of Surgery, Department of Anesthesiology and Critical Care Medicine, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- The Armstrong Institute for Patient Safety and Quality Johns Hopkins Medicine, Baltimore, MD
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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12
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Kaptein FH, Guman NA, van Es N, Kamphuisen PW, Klok FA, Mairuhu AT, Huisman MV. Treatment and prevention of cancer-associated thrombosis in the Netherlands: A national survey. Res Pract Thromb Haemost 2023; 7:100057. [PMID: 36846646 PMCID: PMC9943872 DOI: 10.1016/j.rpth.2023.100057] [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: 09/20/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background In the recent years, numerous studies on the optimal treatment and prevention of cancer-associated venous thromboembolism (VTE) have been published, leading to updated (inter)national guidelines. These include direct oral anticoagulants (DOACs) as the first-line treatment agent in general and the recommendation of primary thromboprophylaxis in selected ambulatory patients. Objectives The objective of this study was to evaluate the clinical practice regarding treatment and prevention of VTE in patients with cancer in the Netherlands and practice variation among different specialties. Methods An online survey was conducted between December 2021, and June 2022, among Dutch physicians (oncologists, hematologists, vascular medicine specialists, acute internal medicine specialists, and pulmonologists) treating patients with cancer, in which we explored the treatment of choice for cancer-associated VTE, the use of VTE risk stratification tools, and primary thromboprophylaxis. Results A total of 222 physicians participated, of whom the majority (81%) used DOACs as a first-line agent for treating cancer-associated VTE. The treatment varied between the following specialties: hematologists and acute internal medicine specialists more often prescribed low-molecular-weight heparin than physicians of the other specialties (OR, 0.32; 95% CI, 0.13-0.80). The minimum duration of anticoagulant treatment was usually 3 to 6 months (87%), and treatment was extended when the malignancy was still active (98%). Regarding the prevention of cancer-associated VTE, no risk stratification tool was used. Three quarters of respondents never prescribed thromboprophylaxis to ambulatory patients, mostly because the thrombosis risk was not perceived high enough to justify prophylaxis. Conclusion Dutch physicians largely adhere to the updated guidelines regarding the treatment of cancer-associated VTE but less to the recommendations for its prevention.
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Affiliation(s)
- Fleur H.J. Kaptein
- Department of Medicine - 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
- Pulmonary Hypertension & 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
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Pieter W. Kamphuisen
- Department of Vascular Medicine, Amsterdam University Medical Center location University of Amsterdam, Amsterdam, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
- Department of Internal Medicine, Tergooi Medical Center, Hilversum, The Netherlands
| | - Frederikus A. Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Menno V. Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- Correspondence Menno V. Huisman, Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2300RC, Leiden, the Netherlands.
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13
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Garas SN, McAlpine K, Ross J, Carrier M, Bossé D, Yachnin D, Mallick R, Cagiannos I, Morash C, Breau RH, Lavallée LT. Venous thromboembolism risk in patients receiving neoadjuvant chemotherapy for bladder cancer. Urol Oncol 2022; 40:381.e1-381.e7. [PMID: 35581123 DOI: 10.1016/j.urolonc.2022.04.006] [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: 11/18/2021] [Revised: 03/26/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION There is limited evidence to inform thromboprophylaxis use for patients receiving neoadjuvant chemotherapy prior to surgery in bladder cancer. We sought to determine the incidence of venous thromboembolism (VTE) in patients receiving neoadjuvant chemotherapy and cystectomy. We also assessed if the Khorana score was associated with VTE risk. METHODS A retrospective cohort study was performed on consecutive patients who received a radical cystectomy for bladder cancer at The Ottawa Hospital between January 2016 and August 2020. Demographic information, chemotherapy data, operative characteristics, VTE and bleeding outcomes were collected from the start of treatment to 90 days postoperative. A Khorana score was calculated for each patient who received neoadjuvant chemotherapy. The primary outcome for this study was the incidence of VTE from the time the patient started treatment with neoadjuvant chemotherapy until 90 days post-cystectomy. Secondary outcomes included risk factors for VTE during neoadjuvant chemotherapy. RESULTS Among 181 radical cystectomy cases during the study period, 123 had muscle-invasive disease and 72 (39.8%) received neoadjuvant chemotherapy. Eighteen (25.0%) patients who received neoadjuvant chemotherapy and radical cystectomy developed a VTE from the start of chemotherapy to 90 days postoperative. Thirteen of the 18 VTEs (72%) occurred while the patient was receiving chemotherapy. In multivariable analysis, the only factor associated with a significantly increased risk of VTE was treatment with neoadjuvant chemotherapy (Relative risk (RR) 3.05, 95% confidence interval [CI] 1.16-8.02; P = 0.02). A higher Khorana score was not associated with an increased risk of VTE in patients who received neoadjuvant chemotherapy (RR = 0.33, 95% CI 0.08-1.28, P = 0.11). One (1.4%) patient had a major bleeding event during neoadjuvant chemotherapy. CONCLUSIONS Patients receiving neoadjuvant chemotherapy and radical cystectomy are at very high-risk of VTE. Prospective studies that assess the benefits and harms of pharmacologic thromboprophylaxis in this population are needed.
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Affiliation(s)
- Shady N Garas
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Kristen McAlpine
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - James Ross
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Marc Carrier
- Division of Hematology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dominic Bossé
- Division of Hematology, Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Yachnin
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Ranjeeta Mallick
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Ilias Cagiannos
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Chris Morash
- Division of Urology, University of Ottawa, Ottawa, ON, Canada
| | - Rodney H Breau
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Luke T Lavallée
- Division of Urology, University of Ottawa, Ottawa, ON, Canada; The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.
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14
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Farge D, Frere C, Connors JM, Khorana AA, Kakkar A, Ay C, Muñoz A, Brenner B, Prata PH, Brilhante D, Antic D, Casais P, Guillermo Esposito MC, Ikezoe T, Abutalib SA, Meillon-García LA, Bounameaux H, Pabinger I, Douketis J. 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19. Lancet Oncol 2022; 23:e334-e347. [PMID: 35772465 PMCID: PMC9236567 DOI: 10.1016/s1470-2045(22)00160-7] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/05/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
The International Initiative on Thrombosis and Cancer is an independent academic working group of experts aimed at establishing global consensus for the treatment and prophylaxis of cancer-associated thrombosis. The 2013, 2016, and 2019 International Initiative on Thrombosis and Cancer clinical practice guidelines have been made available through a free, web-based mobile phone application. The 2022 clinical practice guidelines, which are based on a literature review up to Jan 1, 2022, include guidance for patients with cancer and with COVID-19. Key recommendations (grade 1A or 1B) include: (1) low-molecular-weight heparins (LMWHs) for the initial (first 10 days) treatment and maintenance treatment of cancer-associated thrombosis; (2) direct oral anticoagulants for the initial treatment and maintenance treatment of cancer-associated thrombosis in patients who are not at high risk of gastrointestinal or genitourinary bleeding, in the absence of strong drug-drug interactions or of gastrointestinal absorption impairment; (3) LMWHs or direct oral anticoagulants for a minimum of 6 months to treat cancer-associated thrombosis; (4) extended prophylaxis (4 weeks) with LMWHs to prevent postoperative venous thromboembolism after major abdominopelvic surgery in patients not at high risk of bleeding; and (5) primary prophylaxis of venous thromboembolism with LMWHs or direct oral anticoagulants (rivaroxaban or apixaban) in ambulatory patients with locally advanced or metastatic pancreatic cancer who are treated with anticancer therapy and have a low risk of bleeding.
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Affiliation(s)
- Dominique Farge
- Unité de Médecine Interne (UF04): CRMR MATHEC, Maladies Auto-immunes et Thérapie Cellulaire, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Nord-Université de Paris, Paris, France; Faculté de Médecine, Institut de Recherche St-Louis, EA-3518, Université de Paris, Paris, France; Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada.
| | - Corinne Frere
- INSERM UMRS 1166, GRC 27 GRECO, DMU BioGeM, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alok A Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ajay Kakkar
- Thrombosis Research Institute, London, UK; Faculty of Medical Sciences, University College London, London, UK
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Andres Muñoz
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Pedro H Prata
- Hematology-Transplantation Department, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Nord-Université de Paris, Paris, France
| | - Dialina Brilhante
- Francisco Gentil Portuguese Institute of Oncology, Lisbon Center, Lisbon, Portugal
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Patricia Casais
- Instituto de Investigaciones en Salud Pública, Universidad de Buenos, Buenos Aires, Argentina
| | | | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | | | | | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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15
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Inpatient primary prophylaxis of cancer-associated thromboembolism (CAT). Support Care Cancer 2022; 30:8501-8509. [PMID: 35655046 DOI: 10.1007/s00520-022-07137-9] [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: 02/01/2022] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Cancer-associated thrombosis (CAT) increases morbidity and mortality in oncology patients. The risk of CAT is increased with hospitalization for acute medical illness. The goal of this review will be to examine the available evidence for (1) risk assessment and (2) primary thromboprophylaxis, (3) international published guideline recommendations, and (4) future directions to manage oncology patients admitted for an acute medical illness. METHODS A review was performed for each subject to gather information on the available evidence and recommendations available for oncology patients hospitalized for an acute medical illness. RESULTS Risk assessments for thrombosis are primarily developed and validated in the general population. There is not a risk assessment that has specifically been developed and validated in oncology patients hospitalized for an acute medical illness. Most evidence for thromboprophylaxis of oncology patients is from sub-group analysis of larger randomized-controlled trials in the general population. Evidence is conflicting and suggests an individualized approach evaluating the risk-benefit of thromboprophylaxis. The strength of recommendations of international guidelines is limited because of the available evidence. Guidelines usually recommend utilizing and/or offering thromboprophylaxis to oncology patients hospitalized for an acute medical illness barring contraindications. Future evidence needs to improve risk assessments and knowledge of the appropriate agent, dose, and duration of thromboprophylaxis if indicated. CONCLUSION Evidence for risk assessments and primary prophylaxis for oncology patients hospitalized for acute medical illness appears limited, with many research opportunities available to improve understanding on management of this patient population.
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16
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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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17
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Angelini DE, Khorana AA. Building a CAT clinic - real-world systems approaches to prevention and treatment. Thromb Res 2022; 213 Suppl 1:S84-S86. [DOI: 10.1016/j.thromres.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/18/2022]
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18
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Alma S, Eloi D, Léa V, Julie C, Valérie M, Pierre G, Hilgers W, Philippe G, Christine Z, Philippe D. Incidence of venous thromboembolism and discriminating capacity of Khorana score in lung cancer patients treated with immune checkpoint inhibitors. J Thromb Thrombolysis 2022; 54:287-294. [PMID: 35396660 DOI: 10.1007/s11239-022-02649-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2022] [Indexed: 11/26/2022]
Abstract
Venous-thromboembolism (VTE) is increased in lung cancer patients (LCP) treated with immune-checkpoint inhibitors (ICIs) but risk factors are not identified and the Khorana Score (KS) is not validated. To assess VTE incidence and its clinical impact, to investigate potential clinical risk factors and KS performance in LCP. Retrospective analysis of LCP initiating ICIs treatment between June 2015 and November 2020 in a for-profit cancer center. 481 patients were included: 62% adenocarcinoma, 70% PDL1 + , 86% stage-IV-disease. Over a median follow-up of 9.8 months, 47 VTE were observed: 28 pulmonary embolisms, 15 deep venous thromboses (distal n = 9, proximal n = 6), 3 inferior vena cava thromboses, 1 other VTE, no superficial or digestive vein thrombosis. Median time from ICIs' initiation to VTE was 180 (11-1277) days. Overall survival was significantly lower in patients who experienced VTE (42.5 vs. 86.8 months, p = 0.006). In univariate analysis patients VTE was more frequent in metastatic patients (11.1% vs. 1.5%, p = 0.015) and lower in those treated with durvalumab (1.9% vs. 9.6%, p = 0.046). Logistic regression analysis showed that non-metastatic status (OR 0.13; 0.02-0.95, p = 0.04) and BMI (OR 1.07; 1.01-1.14, p = 0.028) were associated with VTE. The rate of VTE was the same in patients with a KS < or ≥ 2 (10.2% vs. 9.3%, p = 0.87). ICIs-treated LCP are at high risk of thromboembolism. VTE has a negative impact on survival. KS does not perform well in LCP. It is important to identify which VTE prediction models are available to be used in adult ambulatory lung cancer patients.
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Affiliation(s)
- Stancu Alma
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Debourdeau Eloi
- Department of Ophthalmology, Gui de Chauliac Hospital, 34000, Montpellier, France
- Institute for Neurosciences of Montpellier INM, Univ. Montpellier, INSERM, 34091, Montpellier, France
| | - Vazquez Léa
- Supportive Care Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France.
| | - Coussirou Julie
- Pharmacy, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Matagne Valérie
- Pharmacy, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Grassi Pierre
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Werner Hilgers
- Thoracic Oncology Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
| | - Girard Philippe
- Thoracic Oncology Unit, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Zammit Christine
- Vascular Medicine Department, Hôpital Des Portes de Camargue, route d'Arles, 13150, Tarascon, France
| | - Debourdeau Philippe
- Supportive Care Unit, Institut Sainte Catherine, 250 chemin de baigne pieds, 84918, Avignon Cedex 09, France
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19
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Almudena FBL, Javier Jareño Esteban J, Miguel Díez JD, Zabaleta IMD, Hernández CG, Rivas MPO, Ortega CG. Evaluation of the Khorana predictive thrombotic risk and thromboprophylaxis score in cancer patients in a third level hospital. OPEN RESPIRATORY ARCHIVES 2022. [PMID: 37497323 PMCID: PMC10369566 DOI: 10.1016/j.opresp.2022.100170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Introduction Current clinical guidelines do not recommend the routine use of thromboprophylaxis in cancer primary unselected patients. Identifying cancer patients who could be beneficiaries of thrombotic prophylaxis is a real challenge. We aimed to analyse the application of Khorana score in cancer patients. We also tried to evaluate the prescription of primary thromboprophylaxis in cancer patients at risk of venous thromboembolic disease (VTED). Methods A retrospective observational study of survival of hospitalised patients diagnosed with pulmonary embolism (PE) at the Hospital Central de la Defensa from January 2009 to March 2018. They were stratified into tumour PE (TPE) and non-tumour PE (nTPE). A case-control study was also carried out by TPE patients and non PE cancer patients (nPEC). Results 108 patients were diagnosed with TPE, 260 nTPE and 324 nPEC. Gynaecological tumours were the most frequent (23.1%), followed by lung, digestive and urological cancer (20.4% each) in the TPE group. Death risk was 1.9 times higher in cancer patients (95% CI: 1.23-2.8) (p < 0.001). Khorana score was ≥3 points in 9.7% of TPE and 3.1% of nPEC compared to 26.2% of TPE and 9.9% of nPEC with Khorana score ≥2 points (p < 0.001). 7.4% of TPE patients received thromboprophylaxis. Khorana score in TPE patients without thromboprophylaxis was ≥3 points in the 9% and ≥2 points in the 24%. Conclusions There is an underutilisation of thromboprophylaxis in our cancer patients and mainly in those with high risk of VTED, as well as poor adherence to the Khorana score. More studies are needed to validate these findings and to optimise predictive strategies in the management of these patients.
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20
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Building a CAT Clinic - real-world systems approaches to prevention and treatment. Thromb Res 2022. [DOI: 10.1016/j.thromres.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Cancer-associated thrombosis (including venous thromboembolism (VTE) and arterial events) is highly consequential for patients with cancer and is associated with worsened survival. Despite substantial improvements in cancer treatment, the risk of VTE has increased in recent years; VTE rates additionally depend on the type of cancer (with pancreas, stomach and primary brain tumours having the highest risk) as well as on individual patient's and cancer treatment factors. Multiple cancer-specific mechanisms of VTE have been identified and can be classified as mechanisms in which the tumour expresses proteins that alter host systems, such as levels of platelets and leukocytes, and in which the tumour expresses procoagulant proteins released into the circulation that directly activate the coagulation cascade or platelets, such as tissue factor and podoplanin, respectively. As signs and symptoms of VTE may be non-specific, diagnosis requires clinical assessment, evaluation of pre-test probability, and objective diagnostic testing with ultrasonography or CT. Risk assessment tools have been validated to identify patients at risk of VTE. Primary prevention of VTE (thromboprophylaxis) has long been recommended in the inpatient and post-surgical settings, and is now an option in the outpatient setting for individuals with high-risk cancer. Anticoagulant therapy is the cornerstone of therapy, with low molecular weight heparin or newer options such as direct oral anticoagulants. Personalized treatment incorporating risk of bleeding and patient preferences is essential, especially as a diagnosis of VTE is often considered by patients even more distressing than their cancer diagnosis, and can severely affect the quality of life. Future research should focus on current knowledge gaps including optimizing risk assessment tools, biomarker discovery, next-generation anticoagulant development and implementation science.
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22
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Impacto del perfil mutacional sobre el riesgo trombótico en pacientes con cáncer. Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Validation of the Khorana score for predicting venous thromboembolism in 40 218 cancer patients initiating chemotherapy. Blood Adv 2022; 6:2967-2976. [PMID: 35045569 PMCID: PMC9131922 DOI: 10.1182/bloodadvances.2021006484] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/04/2022] [Indexed: 11/20/2022] Open
Abstract
The Khorana score is recommended for guiding primary venous thromboembolism prophylaxis in cancer patients, but its clinical utility overall and across cancer types remains debatable. Also, some previous validation studies have ignored competing risk of death, hereby potentially overestimating venous thromboembolism risk. We identified ambulatory cancer patients initiating chemotherapy without other indications for anticoagulation using Danish health registries and estimated six-month cumulative incidence of venous thromboembolism stratified by Khorana levels. Analyses were conducted with and without considering death as competing risk using the Kaplan-Meier method versus the cumulative incidence function. Analyses were performed overall and stratified by cancer types. Of 40,218 patients, 35.4% were categorized by Khorana as low risk (score 0), 53.6% as intermediate risk (score 1-2) and 10.9% as high risk (score ≥3). Considering competing risk of death, the corresponding six-month risks of venous thromboembolism were 1.5% (95% CI 1.3-1-7), 2.8% (95% CI 2.6-3.1), and 4.1% (95% CI 3.5-4.7), respectively. Among patients recommended anticoagulation by guidelines (Khorana score ≥2), six-month risk was 3.6% (95% CI 3.3-3.9). Kaplan-Meier analysis overestimated incidence up to 23% compared with competing risk analyses. Using the guideline-recommended threshold of ≥2, the Khorana score did not risk stratify patients with hepatobiliary or pancreatic cancer, lung cancer, and gynecologic cancer. In conclusion, the Khorana score was able to stratify ambulatory cancer patients according to risk of venous thromboembolism, but not for all cancer types. Absolute risks varied by methodology but were lower than in key randomized trials. Thus, although certain limitations with outcome identification using administrative registries apply, the absolute benefit of implementing routine primary thromboprophylaxis in an unselected cancer population may be smaller than seen in randomized trials.
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Angelini DE, Khorana AA. Building a CAT clinic - real-world systems approaches to prevention and treatment. Thromb Res 2021; 208:173-175. [PMID: 34801921 DOI: 10.1016/j.thromres.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
Cancer patients have an increased risk of developing venous thrombosis. The implementation of a cancer associated thrombosis clinic can be instrumental for the prevention, early recognition, and management of venous thromboembolism in this vulnerable population. Cancer thrombosis clinics rely on a multidisciplinary approach to care and require standardization along with a dedicated team of healthcare professionals. Cancer thrombosis clinics have the potential to improve patient outcomes and lower healthcare expenditure. Herein, we describe a successful model of a cancer thrombosis clinic and highlight the potential impact on clinical outcomes.
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Affiliation(s)
- Dana E Angelini
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America.
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America
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Abu Saadeh F, Marchocki Z, O'Toole SA, Ibrahim N, Gleeson N, Norris LA. Extended thromboprophylaxis post gynaecological cancer surgery; the effect of weight adjusted and fixed dose LMWH (Tinzaparin). Thromb Res 2021; 207:25-32. [PMID: 34530386 DOI: 10.1016/j.thromres.2021.08.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/16/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Gynaecological cancer surgery is associated with high rates of venous thromboembolism (VTE) despite recommended prophylaxis. We sought to investigate the impact of extended prophylaxis with fixed dose and weight based LMWH in patients undergoing gynaecological cancer surgery. METHODS VTE rates were recorded in patients who received LMWH prophylaxis (4500 IU Tinzaparin once daily) for the duration of hospital stay (2006-2012) (n = 610) and were compared with VTE rates in patients who underwent surgery after the introduction of extended prophylaxis (3500/4500 IU Tinzaparin for patients with BMI < 40kg/m2 and 75 IU/kg for BMI > 40 kg/m2) (2012-2017) (n = 651). Peak (4 h) anti-Xa levels in a subset of patients were also evaluated. RESULTS 73 (5.7%) cases of VTE were recorded during 1 year of follow-up. 20 cases occurred during hospital stay. There was no significant difference in the rate of VTE between the extended prophylaxis cohort and the standard prophylaxis cohort. 23/24 patients who developed VTE in the extended prophylaxis cohort received a fixed (4500 units) dose of Tinzaparin. 63% of patients who received a fixed LMWH dose had peak anti-Xa levels below the target range (0.2-0.4 IU/ml). Peak anti-Xa was lower in patients who subsequently developed VTE compared with those who received either fixed dose (P = 0.041) and weight adjusted Tinzaparin (P = 0.0006). CONCLUSIONS Extended prophylaxis with Tinzaparin does not significantly reduce VTE rates in gynaecological cancer patients post surgery. Peak anti-Xa levels may be suboptimal in many patients receiving a fixed LMWH dose. Further studies are required to determine whether weight adjusted doses of Tinzaparin may provide more effective prophylaxis following gynaecological cancer surgery.
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Affiliation(s)
- F Abu Saadeh
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Division of Gynaecology Oncology, St James's Hospital, Dublin 8, Ireland; Trinity St. James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland.
| | - Z Marchocki
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Division of Gynaecology Oncology, St James's Hospital, Dublin 8, Ireland; Trinity St. James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland.
| | - S A O'Toole
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Trinity St. James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland; Dept of Histopathology, Trinity College Dublin, Ireland.
| | - N Ibrahim
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Division of Gynaecology Oncology, St James's Hospital, Dublin 8, Ireland.
| | - N Gleeson
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Division of Gynaecology Oncology, St James's Hospital, Dublin 8, Ireland; Trinity St. James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland.
| | - L A Norris
- Department of Obstetrics and Gynaecology, Trinity Centre for Health Sciences, St. James's Hospital, Dublin 8, Ireland; Trinity St. James's Cancer Institute, St. James's Hospital, Dublin 8, Ireland.
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Lee S, Shenoy A, Shi D, Husien M, Serrano PE, Parpia S. Prognostic Factors for Venous Thromboembolism in Patients with Solid Tumours on Systemic Therapy: A Systematic Review. TH OPEN 2021; 5:e461-e469. [PMID: 34604695 PMCID: PMC8483896 DOI: 10.1055/a-1642-4572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/07/2021] [Indexed: 11/14/2022] Open
Abstract
Background
Patients undergoing systemic cancer therapy are susceptible to developing venous thromboembolism (VTE). The most pertinent prognostic factors for VTE remain unclear. This systematic review aims to summarize prognostic factors associated with VTE in this population.
Methods
MEDLINE, Embase, and CENTRAL databases were searched for observational or randomized studies that used multivariable analysis adjusted for tumor type and/or metastatic disease to model the risk of VTE. Adjusted effect estimates for each prognostic factor were collected for all of the included studies. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool.
Results
From 5,988 search results, 15 eligible studies and 42 prognostic factors were identified. A total of 8,554 patients of whom 456 (5.33%) developed VTE were included. Fourteen studies had a high risk of bias and one study had a moderate risk. The most commonly reported prognostic factors include age, gender, tumor site, metastasis, performance status, and systemic therapy type. Poor performance status and the use of platinum-based chemotherapy compounds were associated with an increased risk of VTE across the majority of studies. The evidence to suggest that the other prognostic factors identified were associated with VTE development was inconclusive. Several individual studies identified novel biomarkers for VTE. Heterogeneity in statistical methods and prognostic factor definitions across studies precluded meta-analysis.
Conclusion
Overall, many prognostic factors were identified; however, the evidence for association with development of VTE for most of the factors is inconclusive. Findings were limited by high heterogeneity and risk of bias in the included studies.
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Affiliation(s)
- Sandra Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anika Shenoy
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Daniel Shi
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Lee S, Shenoy A, Shi D, Husien M, Serrano PE, Parpia S. Prognostic Factors for Venous Thromboembolism in Patients with Solid Tumours on Systemic Therapy: A Systematic Review. TH OPEN 2021. [PMID: 34604695 DOI: 10.1055/s-0041-1736310] [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: 10/20/2022] Open
Abstract
Background Patients undergoing systemic cancer therapy are susceptible to developing venous thromboembolism (VTE). The most pertinent prognostic factors for VTE remain unclear. This systematic review aims to summarize prognostic factors associated with VTE in this population. Methods MEDLINE, Embase, and CENTRAL databases were searched for observational or randomized studies that used multivariable analysis adjusted for tumor type and/or metastatic disease to model the risk of VTE. Adjusted effect estimates for each prognostic factor were collected for all of the included studies. Risk of bias was assessed using the Quality in Prognostic Factor Studies (QUIPS) tool. Results From 5,988 search results, 15 eligible studies and 42 prognostic factors were identified. A total of 8,554 patients of whom 456 (5.33%) developed VTE were included. Fourteen studies had a high risk of bias and one study had a moderate risk. The most commonly reported prognostic factors include age, gender, tumor site, metastasis, performance status, and systemic therapy type. Poor performance status and the use of platinum-based chemotherapy compounds were associated with an increased risk of VTE across the majority of studies. The evidence to suggest that the other prognostic factors identified were associated with VTE development was inconclusive. Several individual studies identified novel biomarkers for VTE. Heterogeneity in statistical methods and prognostic factor definitions across studies precluded meta-analysis. Conclusion Overall, many prognostic factors were identified; however, the evidence for association with development of VTE for most of the factors is inconclusive. Findings were limited by high heterogeneity and risk of bias in the included studies.
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Affiliation(s)
- Sandra Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Anika Shenoy
- Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Daniel Shi
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Pablo E Serrano
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Sameer Parpia
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Páramo JA, Marcos-Jubilar M, Lecumberri R. Impact of the mutation profile on thrombotic risk in cancer patients. Rev Clin Esp 2021; 222:93-99. [PMID: 34548256 DOI: 10.1016/j.rceng.2021.04.008] [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: 01/05/2021] [Accepted: 04/16/2021] [Indexed: 10/20/2022]
Abstract
Patients with cancer present with an elevated risk of thrombosis, which entails high morbidity and mortality. Various predictive scales that incorporate clinical and biological data have been developed to identify those at high risk of thrombosis, but, in general, they do not allow for the optimal selection of subjects who are candidates for thromboprophylaxis. Recent studies have demonstrated that the mutation profile has a high impact on the risk of thrombosis; this will facilitate developing new predictive models of thrombosis in patients with cancer.
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Affiliation(s)
- J A Páramo
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona, Spain.
| | - M Marcos-Jubilar
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona, Spain
| | - R Lecumberri
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona, Spain
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Pfrepper C, Knödler M, Schorling RM, Seehofer D, Petros S, Lordick F. Predictors for thromboembolism in patients with cholangiocarcinoma. J Cancer Res Clin Oncol 2021; 148:2415-2426. [PMID: 34499224 PMCID: PMC9349130 DOI: 10.1007/s00432-021-03794-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with cancer are at increased risk of thromboembolic events contributing significantly to cancer-related morbidity and mortality. Because cholangiocarcinoma is a rare type of cancer, the incidence of thromboembolism in this patient population is not well defined. METHODS Patients with cholangiocarcinoma treated at the University Cancer Center Leipzig between January 2014 and December 2018 were analyzed retrospectively regarding the incidence of arterial and venous thromboembolism. RESULTS A total of 133 newly and consecutively diagnosed patients were included, of whom 22% had stage IV disease. Thromboembolism was diagnosed in 39 (29.3%), with 48% of the events occurring between 60 days prior and 30 days after the initial diagnosis. Arterial thrombosis accounted for 19% and portal venous thrombosis for 33% of the events, while the rest of events occurred in the non-portal venous system. In multivariable analysis, an ONKOTEV score ≥ 2 was the only independent predictor for thromboembolism. Serum CA 19-9 was available in 87 patients (65.4%). In this subgroup, CA 19-9 above the median of 97.7 U/ml and vascular or lymphatic compression were independent predictors for thromboembolism in the first year and CA 19-9 alone remained a significant predictor over the whole observation period. An ONKOTEV score ≥ 2 and increasing age were predictors of survival. CONCLUSIONS A very high thromboembolic risk was observed in cholangiocarcinoma, comparable to the risk situation in pancreatic and gastric cancer. The ONKOTEV score and serum CA 19-9 are independent predictors of thromboembolic events. Prospective validation of our observations in this patient population is warranted.
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Affiliation(s)
- Christian Pfrepper
- Department of Hematology, Cellular Therapy and Hemostaseology, Division of Hemostaseology, University of Leipzig Medical Center, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Maren Knödler
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
| | - Ruth Maria Schorling
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University of Leipzig Medical Center, Leipzig, Germany
| | - Sirak Petros
- Department of Hematology, Cellular Therapy and Hemostaseology, Division of Hemostaseology, University of Leipzig Medical Center, Liebigstr. 20, 04103, Leipzig, Germany.,Medical ICU, University of Leipzig Medical Center, Leipzig, Germany
| | - Florian Lordick
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
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Validation of the Khorana Venous Thromboembolism Risk Score in Japanese Cancer Patients. JACC: ASIA 2021; 1:259-270. [PMID: 36338156 PMCID: PMC9627826 DOI: 10.1016/j.jacasi.2021.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022]
Abstract
Background Although the Khorana venous thromboembolism (VTE) risk score (KRS) is well recognized as a simple VTE risk assessment method in patients with cancer, whether it is suitable for Asian populations is unclear. Objectives This study validated KRS for the prediction of VTE and investigated the value of the KRS in predicting mortality in Japanese patients with cancer. Methods A body mass index value of 25 kg/m2 or more was defined as obesity according to World Health Organization consensus. A total of 27,687 patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups by the KRS. The primary and secondary endpoints were VTE and all-cause mortality, respectively. Results The prevalence of VTE was 1.7%, 7.3%, and 11.0% for low-, intermediate-, and high-score patients, respectively. Receiver operating characteristic (ROC) analysis showed that the KRS significantly predicted VTE (area under the curve, 0.679; 95% confidence interval [CI] 0.666-0.692; P < 0.001). The cutoff value for the KRS was 1.0. Logistic regression analysis demonstrated that the KRS was an independent predictor of VTE (odds ratio 1.766; 95% CI 1.673-1.865; P < 0.01). The cutoff value of the KRS for all-cause mortality determined by ROC analysis was 2.0. Kaplan–Meier analysis demonstrated a significantly higher incidence of mortality in the KRS ≥2 group than in the KRS 0-1 group (log-rank: P < 0.01). Conclusions The KRS was useful in Japanese patients with cancer and might be a potentially useful marker for the prediction of mortality. Establishing optimal scores for Japanese subjects is mandatory because of its low diagnostic ability. (KUMAMON Cancer registry; UMIN000047554)
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Affiliation(s)
- Alok A. Khorana
- Address for correspondence: Dr Alok A. Khorana, Taussig Cancer Institute, Cleveland Clinic Foundation, 10201 Carnegie Avenue, CA60, Cleveland, Ohio 44195, USA.
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Kumar V, Grant M, Martin KA. Risk, Racial Disparity, and Outcomes Among Patients With Cancer and COVID-19 Infection. JAMA Oncol 2021; 7:1065. [PMID: 33956053 DOI: 10.1001/jamaoncol.2021.0768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Vaibhav Kumar
- Divisions of Hematology and Oncology, University of North Carolina at Chapel Hill
| | - Megan Grant
- Divisions of Hematology and Oncology, University of North Carolina at Chapel Hill
| | - Karlyn A Martin
- Division of Hematology and Oncology, Northwestern University, Chicago, Illinois
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