American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

The role of germline and somatic mutations in predicting cancer-associated thrombosis: a narrative review

PURPOSE OF REVIEW

Patients with cancer have an increased risk of venous thromboembolism (VTE). Guidelines suggest to use risk assessment tools to guide decisions about thromboprophylaxis, but current tools have modest discriminatory ability. Genetic information from the germline or tumor has the potential to improve VTE prediction. Here, we provide a clinical overview of the current role of genetics in cancer-associated VTE.

RECENT FINDINGS

Germline mutations, such as factor V Leiden and prothrombin G20210A, are associated with a 2- to 2.5-fold increased VTE risk in patients with cancer. Tumor-specific somatic mutations also contribute to VTE risk, such as ALK rearrangements increasing the risk in nonsmall cell lung cancer and IDH1 mutations decreasing the risk in gliomas. Other somatic mutations associated with VTE independent of tumor type include KRAS , STK11 , MET , KEAP1 , CTNNB1 , and CDKN2B . Incorporating data on germline or somatic mutations in risk scores improves discriminatory ability compared with the Khorana score.

SUMMARY

Specific germline and somatic mutations are associated with an increased VTE risk in patients with cancer and potentially improve performance of clinical risk scores. The increasing and widespread use of genetic testing in cancer care provides an opportunity for further development of prediction models incorporating genetic predictors.

How I approach the treatment of thrombotic complications in patients with myeloproliferative neoplasms

ABSTRACT

Arterial and venous thromboses are the most significant complications in patients with myeloproliferative neoplasms (MPNs), with the primary treatment goal being thrombotic risk reduction. In MPN with no history of thrombosis, primary prevention mainly involves the use of aspirin, and cytoreduction is added in high-risk patients. However, thrombotic complications can unveil an MPN in ∼20% of cases, necessitating the initiation of both antithrombotic therapy for the thrombosis and cytoreductive treatment for the MPN. The duration of anticoagulant therapy after an initial venous thromboembolic event is subject to discussion. Furthermore, the occurrence of a thrombotic complication in patients with a known diagnosis of MPN prompts a reconsideration of both antithrombotic and hematologic management. This review uses case-based discussions to explore the management of thrombotic complications in patients with MPN. It addresses the nature and duration of antithrombotic treatments, as well as the approach to cytoreduction. Special attention is given to the place of direct oral anticoagulants and to the management of patients with MPN with splanchnic vein thrombosis, which is disproportionately common in this group.

Cancer-associated venous thromboembolism: a comprehensive review

It has been 200 years since the first case of cancer-associated thrombosis (CAT) was reported. Venous thromboembolism (VTE) remains a leading cause of morbidity and mortality in cancer patients. Malignant tumors interact with the coagulation system in complex ways. CAT continues to pose a significant challenge in clinical practice. The risk factors for CAT are complex and multifactorial, primarily including patient, cancer, and therapy-related factors. We have introduced assessment models for CAT and bleeding risk, but the performance of these models has been less than satisfactory. Currently, the main anticoagulant drugs for treating CAT include vitamin K antagonists (VKAs), low molecular weight heparin (LMWH), and direct oral anticoagulants (DOACs). We have provided a detailed overview of the advantages and disadvantages of these three types of drugs and suggestions on choosing the appropriate type of medication for different clinical scenarios. CAT incidence, pathophysiology, risk factors, risk prediction models, and recent advancements in treatment and management are summarized in this review.

Anticoagulant effects of edoxaban in cancer and noncancer patients with venous thromboembolism

BACKGROUND

Edoxaban, a direct oral anticoagulant (DOAC), is a first-line treatment for venous thromboembolism (VTE) and the suppression of VTE recurrence. In patients with cancer, however, recurrent VTE after DOAC treatment may be more common than in noncancer patients. To evaluate our hypothesis that the anticoagulation effect of edoxaban is lower in VTE patients with cancer than in noncancer patients.

METHODS

This study was a prospective, multicenter, observational study including patients treated with edoxaban for VTE in Japan. The primary outcome was the difference in the prothrombin time (PT), activated partial thromboplastin time (APTT), and D-dimer level at 5 h after initial edoxaban administration between the cancer and noncancer groups. An additional outcome was the longitudinal change in PT and APTT from 5 h to overnight after edoxaban administration. The incidence of adverse events was further investigated.

RESULTS

PT and APTT at 5 h after initial edoxaban administration were not significantly different between the cancer (n = 84) and noncancer groups (n = 138) (e.g., log-transformed APTT 3.55 vs. 3.55, p = 0.45). However, D-dimer in the cancer groups was significantly greater than that in the noncancer groups (log-transformed 1.83 vs. 1.79, p = 0.009). PT and APTT significantly decreased from 5 h to overnight after edoxaban, but a similar pattern was observed in each group. All adverse events after edoxaban administration were also similar between patients with cancer and noncancer.

CONCLUSION

PT and APTT after edoxaban administration were similar between VTE patients with cancer and noncancer groups, suggesting that edoxaban has anticoagulation effects on cancer-associated VTE similar to those of noncancer patients.

TRIAL REGISTRATION

UMIN000041973; Registration Date: 2020.10.5.

Extended Reduced-Dose Apixaban for Cancer-Associated Venous Thromboembolism

BACKGROUND

In patients with active cancer and venous thromboembolism, whether extended treatment with a reduced dose of an oral anticoagulant is effective in preventing recurrent thromboembolic events and decreasing bleeding is unclear.

METHODS

We conducted a randomized, double-blind, noninferiority trial with blinded central outcome adjudication. Consecutive patients with active cancer and proximal deep-vein thrombosis or pulmonary embolism who had completed at least 6 months of anticoagulant therapy were randomly assigned in a 1:1 ratio to receive oral apixaban at a reduced (2.5 mg) or full (5.0 mg) dose twice daily for 12 months. The primary outcome was centrally adjudicated fatal or nonfatal recurrent venous thromboembolism, assessed in a noninferiority analysis (margin of 2.00 for the upper boundary of the 95% confidence interval of the subhazard ratio). The key secondary outcome was clinically relevant bleeding, assessed in a superiority analysis.

RESULTS

A total of 1766 patients underwent randomization at a median time since the index event of 8.0 months (interquartile range, 6.5 to 12.6); 866 patients were assigned to the reduced-dose group, and 900 to the full-dose group. The median treatment duration was 11.8 months (interquartile range, 8.3 to 12.1). Recurrent venous thromboembolism occurred in 18 patients (cumulative incidence, 2.1%) in the reduced-dose group and in 24 (cumulative incidence, 2.8%) in the full-dose group (adjusted subhazard ratio, 0.76; 95% confidence interval [CI], 0.41 to 1.41; P = 0.001 for noninferiority). Clinically relevant bleeding occurred in 102 patients (cumulative incidence, 12.1%) in the reduced-dose group and in 136 (cumulative incidence, 15.6%) in the full-dose group (adjusted subhazard ratio, 0.75; 95% CI, 0.58 to 0.97; P = 0.03). Mortality was 17.7% in the reduced-dose group and 19.6% in the full-dose group (adjusted hazard ratio, 0.96; 95% CI, 0.86 to 1.06).

CONCLUSIONS

Extended anticoagulation with reduced-dose apixaban was noninferior to full-dose apixaban for the prevention of recurrent venous thromboembolism in patients with active cancer. The reduced dose led to a lower incidence of clinically relevant bleeding complications than the full dose. (Funded by the Bristol-Myers Squibb-Pfizer Alliance; API-CAT ClinicalTrials.gov number, NCT03692065.).

Less frequent complications following CAR T-cell therapies: hemophagocytic lymphohistiocytosis, graft-versus-host disease, thrombotic microangiopathy, coagulation disorders and secondary malignancies: best practice recommendations from the EBMT Practice Harmonization and Guidelines Committee

CAR T-cell therapies have revolutionized the treatment of hematologic malignancies; however, alongside the well-known complications of cytokine release syndrome (CRS), neurotoxicity, immune effector cell-associated hematotoxicity (ICAHT), and infections, other non-classical toxicities are emerging. This review, developed by the EBMT Practice Harmonization and Guidelines Committee, addresses the management of other critical post-CAR T-cell complications including hemophagocytic lymphohistiocytosis (HLH), graft-versus-host disease (GvHD), thrombotic microangiopathy (TMA), coagulation disorders and secondary malignancies. These complications, though less frequent, present a significant challenge, often contributing to morbidity and mortality with no standardized management protocols. This review provides best practice recommendations for early identification, risk mitigation, and therapeutic interventions, supported by limited but emerging clinical evidence. Comprehensive expert guidance is essential for optimal management of these under-explored toxicities following CAR T-cell therapies.

Anticoagulation for patients discharged from the emergency department with venous thromboembolism

OBJECTIVE

Direct oral anticoagulants (DOACs) are increasingly being used over low molecular weight heparin (LMWH) and vitamin K antagonists for the treatment of venous thromboembolism (VTE). The objective of this study was to examine predictors of anticoagulant type (DOAC vs. LMWH) prescribed at discharge from the emergency department (ED) among patients diagnosed with VTE in the ED.

METHODS

We conducted a retrospective chart review of adult (>17 years) patients discharged from an Ontario, Canada ED in a tertiary care centre with an ED diagnosis of deep vein thrombosis or pulmonary embolism from January 2019 to December 2021. A multivariable logistic regression model was used to examine the predictors of the anticoagulant (DOAC vs. LMWH) prescribed at discharge. Covariables included: age, sex, history of major bleeding, history of cancer, and previous anticoagulation.

RESULTS

VTE was confirmed in 390 ED visits by 365 unique patients. Among unique patients, 239 (65.5 %) patients were discharged from the ED and included in analysis. Of the 239 patients included, 12.1 % of patients were over the age of 80, 46.4 % were female and 29.7 % had a history of cancer. The majority of patients discharged from the ED were prescribed DOACs (70.7 %,169/239). Cancer history was associated with anticoagulation with LMWH (vs. DOAC) on discharge (adjusted odds ratio [aOR] =12.81, 95 % CI: 6.60-25.90).

CONCLUSIONS

While most patients diagnosed with VTE in the ED setting were discharged with DOACs, most cancer patients included in our study were treated with LMWH over DOACs, despite increasing evidence around the efficacy and safety of DOACs in most cancer patients. Further research is needed to understand longitudinal trends in anticoagulation.

Real-world evaluation of therapeutic anticoagulation for cancer-associated thromboembolism: A retrospective analysis

BackgroundThrombosis is the second leading cause of death in cancer patients and treatment for thrombosis and prevention for secondary prophylaxis is anticoagulation. Low-molecular-weight heparin (LMWH) is more effective than vitamin K antagonists for the treatment of cancer-associated thromboembolism (CAT). Direct oral anticoagulants (DOACs) are non-inferior to dalteparin in treating CAT with similar major bleeding risks. Major guidelines recommend DOACs for CAT; however, data comparing individual DOACs to enoxaparin is lacking. The purpose of this study is to evaluate the efficacy and safety of DOACs compared to LMWH for CAT.MethodsA multi-site retrospective review was conducted in adult cancer patients with a CAT history who received either a DOAC (apixaban or rivaroxaban) or LMWH (enoxaparin). Primary efficacy and safety endpoints were recurrent thromboembolism and major bleeding occurrences. Secondary endpoints included time to subsequent CAT occurrence, time to first bleed event post initial CAT, and incidence of clinically relevant non-major and minor bleeding.ResultsA total of 102 patients were included in the study. There was no significant difference among the groups with respect to time to subsequent CAT (p = 0.5625). However, patients who received apixaban and rivaroxaban had a 2.39 times and 3.26 times higher risk of subsequent CAT respectively compared to those who received enoxaparin. Major bleeding rates were also not statistically significant (p = 0.465), despite enoxaparin having the highest rate at 8.8% and no rivaroxaban patients experiencing major bleeding.ConclusionNo differences were observed between rivaroxaban, apixaban, and enoxaparin in rates of recurrent venous thromboembolism (VTE) and bleeding.

The incidence of venous thromboembolism by type of solid cancer worldwide: A systematic review

There is a well-established relationship between cancer and venous thromboembolism (VTE). Thrombosis in cancer is of major concern as it is a leading cause of mortality, impairs quality of life, and can adversely impact treatment protocols. Despite the role of thrombosis in cancer, no singular source consolidates data on VTE incidence by cancer type worldwide. This systematic review aims to report the incidence of VTE by type of solid cancer worldwide. The current analysis used three databases (MEDLINE, Embase, Cochrane Library) to identify relevant articles. All articles were written in English, assessed solid cancers in adults (≥18; males, females), and reported the incidence of VTE, or information that could be used to calculate incidence. After completing the search and removing duplicates, 3077 articles were assessed. All articles were screened by title and abstract, followed by a full-text review. A total of 124 articles were included in the final evaluation. The cumulative reported incidence of VTE across all types of solid cancer was 9.74 %. The highest reported incidence of VTE was in gastroesophageal cancer (15.43 %), whereas the lowest incidence was in prostate cancer (1.58 %). The two most reported cancers by country within our study cohort were colorectal (n = 23) and lung cancer (n = 23). The reported incidence of VTE in colorectal cancer was highest in Mexico (22.10 %), and lung cancer was highest in Canada (32.91 %). In conclusion, gathering data on global VTE rates in solid cancer identified high-risk cancers and highlighted under-investigated areas that require attention to reduce VTE occurrence in cancer patients.

Basics of diagnosis and treatment of venous thromboembolism

Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism (PE), is common and associated with significant morbidity and mortality. The symptoms and signs of VTE are nonspecific. Well-established integrated diagnostic strategies combining clinical probability scores and D-dimer are used to identify patients with a low probability of VTE, where the diagnosis can be safely excluded without imaging. In patients with confirmed VTE, anticoagulation is the mainstay of treatment. However, patients with high-risk features at presentation may benefit from advanced reperfusion therapies such as thrombolysis and/or interventional approaches to reduce early mortality and/or long-term morbidity. The advent of direct oral anticoagulants has greatly simplified the treatment of VTE for most patients, with a persisting role for low molecular weight heparin and vitamin K antagonists in select patient groups. Following an initial 3 to 6 months of anticoagulation, those with major transient provoking factors can safely discontinue anticoagulation. Balancing the risk of recurrent VTE and bleeding risk is central to decisions regarding long-term anticoagulation, and patients should be included in shared decision-making. Assessment and recognition of common long-term complications such as postthrombotic syndrome and post-PE syndrome are also essential, given they are associated with significant adverse impact on long-term quality of life, with a significant risk of mortality associated with the less frequent complication of chronic thromboembolic pulmonary hypertension. This review provides a basic overview and framework for the diagnostic approach to deep vein thrombosis and PE, risk stratification of confirmed diagnoses, and management.

In Vivo pharmacokinetic interactions of ribociclib with rivaroxaban and apixaban in rats: implications for increased drug exposure and dose adjustments

Background

Apixaban (API) and rivaroxaban (RIVA) are orally available inhibitors of coagulation factor Xa and are commonly used to treat cancer-related venous thrombosis. Ribociclib (RIBO), a first-line treatment for hormone receptor-positive/human epidermal growth factor receptor 2 negative (HR+/HER2-) advanced breast cancer, is an inhibitor of CYP3A4, P-gp, and BCRP. Given the potential for these drugs to be co-administered in clinical settings, there is limited information regarding the pharmacokinetic drug-drug interactions (DDIs) between ribociclib and these anticoagulants. This study aimed to evaluate the extent of DDIs between ribociclib and rivaroxaban or apixaban in rats and to explore the optimization of drug dosing strategies.

Methods

Male Sprague-Dawley rats were divided into 9 groups (n = 6), receiving ribociclib, apixaban, rivaroxaban, ribociclib with rivaroxaban, ribociclib with apixaban, and combinations with reduced doses and time intervals. Blood concentrations were measured using ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). Pharmacokinetic parameters such as AUC, Cmax, CLz/F, and Vz/F.

Results

Ribociclib significantly increased exposure to both rivaroxaban and apixaban, with a greater impact on rivaroxaban. Specifically, ribociclib increased the AUC0-t, AUC0-∞ and Cmax of rivaroxaban (normal dose) by about 2.4-fold, 2.1-fold and 1.8-fold, while increasing apixaban exposure by about 60.82%, with a trend towards an increase in Cmax that was not statistically significant. When co-administered with ribociclib, even at a reduced dosage of 1 mg/kg, rivaroxaban exhibited a significant increase in exposure, with the AUC increasing by 2.3-fold and Cmax by 1.3-fold. Despite the reduction in dosage, the pharmacokinetic effect of ribociclib on rivaroxaban persisted. While administration of rivaroxaban 12 h after ribociclib resulted in a less pronounced increase in exposure compared to the normal-dose group. The results of qRT-PCR showed that ribociclib reduced the expression of Cyp3a1 and Abcg2 in rat intestine.

Discussion

This research highlights the need for careful consideration of dosing regimens to minimize toxicity risk and optimize the safety of clinical co-administration of ribociclib with rivaroxaban.

Expanding the Role of Heparin Derivatives in Oncology: From Anticoagulation to Antitumor Activity

Current research demonstrates the expanding therapeutic potential of heparin derivatives in oncology, extending beyond traditional anticoagulation mechanisms. This systematic analysis examines the structural characteristics, molecular mechanisms, and therapeutic applications of heparin-based compounds in malignancy treatment. The essential antithrombin binding pentasaccharide sequence has enabled development of specialized molecular variants, particularly fractionated heparins and their non-anticoagulant counterparts. These agents exert antineoplastic effects via multiple pathways, particularly through modulation of heparanase enzymatic activity and specific protein-glycosaminoglycan interactions. Evidence from pivotal clinical trials (FRAGMATIC, MAGNOLIA, GASTRANOX) confirms efficacy in managing cancer-associated thrombosis while indicating potential enhancement of chemotherapeutic outcomes. The preparation methods utilize enzymatic cleavage reactions and selective chemical derivatization to generate structurally modified heparins exhibiting unique molecular characteristics and biological activities. Analysis of the glycosaminoglycan analog dociparstat sodium reveals significant activity in myeloid malignancies, mediated by specific interference with CXCL12/CXCR4 signaling cascades. Significant challenges remain in manufacturing scale-up, analytical validation, and long-term safety assessment. Future studies must address dose optimization, combination strategies, and controlled clinical trials to determine the full therapeutic potential of these compounds in clinical oncology.

Treatment and outcomes after on-treatment recurrent venous thromboembolism in patients with cancer: a post hoc analysis of the Hokusai venous thromboembolism cancer study

BACKGROUND

The management of recurrent venous thromboembolism (VTE) despite anticoagulant treatment in patients with cancer is uncertain. To address this, we used data from the Hokusai VTE Cancer trial, which compared edoxaban with dalteparin to treat cancer-associated VTE.

OBJECTIVES

To characterize and evaluate anticoagulant treatment strategies during and after on-treatment recurrent VTE, including the type and dose of anticoagulant.

METHODS

In this post hoc analysis, all patients with adjudicated on-treatment recurrent VTE within 12 months after randomization were included. Outcomes were second recurrent VTE and major bleeding within 3 months after the first recurrent VTE.

RESULTS

A total of 67 patients developed on-treatment recurrent VTE while receiving therapeutic-dose edoxaban (31%), therapeutic-dose low-molecular-weight heparin (LMWH) (34%), maintenance-dose LMWH (21%), or other therapies (14%). After the recurrent event, 28 patients (42%) received an increased dose, 35 (52%) a comparable dose, and 4 (6%) a reduced dose or stopped anticoagulants. Common treatment regimens included supratherapeutic-dose LMWH (21%), therapeutic-dose LMWH (51%), direct oral anticoagulants (16%), or another treatment strategy (12%). In the 3 months after recurrent VTE, 6 (9%) patients had a second recurrence and 7 (10%) had major bleeding.

CONCLUSION

Treatment strategies for recurrent VTE in patients with cancer are heterogeneous. The risk of a second recurrence and major bleeding are considerable. More studies are needed to determine the optimal treatment strategy for recurrent cancer-associated thrombosis.

Delphi panel consensus on recommendations for thromboprophylaxis of venous thromboembolism in endogenous Cushing's syndrome: a position statement

The objective of this study was to establish recommendations for thromboprophylaxis in patients with endogenous Cushing's syndrome (CS), addressing the elevated risk of venous thromboembolism (VTE) associated with hypercortisolism. A Delphi method was used, consisting of 4 rounds of voting and subsequent discussions. The panel included 18 international experts from 11 countries and 4 continents. Consensus was defined as ≥75% agreement among participants. Recommendations were structured into the following categories: thromboprophylaxis, perioperative management, and VTE treatment. Consensus was reached on several critical areas, resulting in 14 recommendations. Key recommendations include: thromboprophylaxis should be considered at time of CS diagnosis and continued for 3 months after biochemical remission, provided there are no obvious contraindications. The standard weight-based prophylactic dose of low molecular-weight heparin is the preferred agent for thromboprophylaxis in patients with CS. Additionally, perioperatively and around inferior petrosal sinus sampling, thromboprophylaxis should be reconsidered if not already initiated at diagnosis. For VTE treatment, extended thromboprophylaxis is advised continuing for 3 months after Cushing is resolved. These Delphi consensus-based recommendations aim to standardize care practices and enhance patient outcomes in CS by providing guidance on thromboprophylaxis, including its initiation and continuation across various disease states, as well as the preferred agents to use. The panel also highlighted key areas for further research, particularly regarding the use of direct oral anticoagulants in CS and the management of mild CS and mild autonomous cortisol secretion. Additionally, the optimal duration of anticoagulant prophylaxis following curative treatment remains uncertain.

Comparison of Clinical Outcomes in Patients with Active Cancer Receiving Rivaroxaban or Low-Molecular-Weight Heparin: The OSCAR-UK Study

BACKGROUND

 In most patients with cancer-associated venous thromboembolism (CT), essentially those not at high risk of bleeding, guidelines recommend treatment with direct oral anticoagulants as an alternative to low-molecular-weight heparins (LMWHs). Population-based studies comparing these therapies are scarce.

OBJECTIVES

 To compare the risk of venous thromboembolism (VTE) recurrences, significant bleeding, and all-cause mortality in patients with CT receiving rivaroxaban or LMWHs.

PATIENTS/METHODS

 Using UK Clinical Practice Research Datalink data from 2013 to 2020, we generated a cohort of patients with first CT treated initially with either rivaroxaban or LMWH. Patients were observed 12 months for VTE recurrences, significant bleeds (major bleeds or clinically relevant nonmajor bleeding requiring hospitalization), and all-cause mortality. Overlap weighted sub-distribution hazard ratios (SHRs) compared rivaroxaban with LMWH in an intention-to-treat analysis.

RESULTS

 The cohort consisted of 2,259 patients with first CT, 314 receiving rivaroxaban, and 1,945 LMWH, mean age 72.4 and 66.9 years, respectively. In the 12-month observational period, 184 person-years following rivaroxaban and 1,057 following LMWH, 10 and 66 incident recurrent VTE events, 20 and 102 significant bleeds, and 10 and 133 deaths were observed in rivaroxaban and LMWH users, respectively. The weighted SHR at 12 months for VTE recurrences in rivaroxaban compared with LMWH were 0.80 (0.37-1.73); for significant bleeds 1.01 (0.57-1.81); and for all-cause mortality 0.49 (0.23-1.06).

CONCLUSION

 Patients with CT, not at high risk of bleeding, treated with either rivaroxaban or LMWH have comparable effectiveness and safety outcomes. This supports the recommendation that rivaroxaban is a reasonable alternative to LMWH for the treatment of CT.

Why patients fail to seek information on OTC product interactions with a direct-acting oral anticoagulant: perspectives on information-seeking

BACKGROUND

Many patients taking direct-acting oral anticoagulants (DOACs) also consume over-the-counter (OTC) products (dietary supplements and OTC medications), yet many lack knowledge of potential interactions that may increase or decrease DOAC efficacy and may not seek information about OTC products. The objective of this study was to describe patient attitudes and beliefs that inhibited information seeking about potential apixaban-OTC product interactions.

METHODS

Participants included English-, Spanish-, Mandarin-, and Cantonese-speaking adults from two large academic medical centers who reported taking apixaban (a frequently prescribed DOAC) in the past month. Thematic analysis was performed on semi-structured interviews.

RESULTS

Sixty patients aged 24-93 years (mean = 65.3; SD = 15.6) were interviewed; 55% were women. Participants took a total of 236 OTC products. Those with potential interactions with apixaban warranting consideration for therapy modification included: ibuprofen (n = 14; 5.9%), aspirin (n = 8; 3.4%), and naproxen (n = 3; 1.3%). Interviews revealed 5 major themes related to a lack of information-seeking about OTC products: (1) patients lack awareness of the potential for interactions; (2) patients believe that OTC products are safe and/or regulated (largely because they were familiar with the products, had previously taken them, or assumed that dietary supplements were regulated by the Food and Drug Administration); (3) patients believe that providers are responsible for alerting patients about potential interactions (as patients assumed that providers were aware of their OTC product use); (4) patients had prior knowledge of and/or used OTC products infrequently; and (5) obtaining information can be inconvenient. Inquiries regarding preferred information sources revealed 59 (98.3%) patients most frequently sought or would seek information from physicians and 34 (56.7%) from the internet.

CONCLUSIONS

Patients taking apixaban raised reasons for not seeking information about potential OTC product interactions that included poor awareness, perceptions regarding the safety of OTC products, and beliefs in provider responsibility for informing them about interactions. Greater patient education is needed regarding the potential for OTC product-DOAC interactions and the regulation of OTC products, particularly dietary supplements.

Efficacy and safety of extended duration postoperative thromboprophylaxis with low molecular weight heparin among subgroups of patients undergoing surgical resection of colorectal cancer: A post-hoc analysis of the PERIOP-01 trial

BACKGROUND

Extended duration postoperative thromboprophylaxis is suggested by clinical practice guidelines after any cancer-related major abdominal surgeries. However, recent evidence reported relatively low rates of symptomatic venous thromboembolism (VTE) after colorectal cancer surgeries, suggesting the need of a careful risk-benefit assessment in this setting.

METHODS

This is a pre-planned post-hoc analysis of the PERIOP-01 trial which compared extended to standard thromboprophylaxis in patients undergoing surgical resection of localized colorectal cancer. Subgroup analyses were performed based on different baseline characteristics. The primary efficacy and safety outcomes were major VTE and clinically relevant bleeding events, respectively.

RESULTS

A total of 614 patients were included in the modified intention-to-treat analysis (307 patients in each group). Major VTE events occurred in 2 % and 1 % of the extended and standard-duration thromboprophylaxis groups, respectively. Clinically relevant bleeding events occurred in 3 % of each group. No specific characteristics were found to be associated with a decreased incidence of major VTE among patients receiving extended thromboprophylaxis. Patients with colon cancer resection receiving extended thromboprophylaxis were at an increased risk of clinically relevant bleeding (HR 2.57, 95%CI 1.25-5.30). Other characteristics that may be associated with an increased incidence of bleeding included age (≥75) (HR 2.37, 95%CI 0.47-11.98) and sex (HR 2.13, 95%CI 0.20-23.17).

CONCLUSIONS

In the PERIOP-01 trial, extended thromboprophylaxis did not reduce the incidence of major VTE in any subgroups of patients. However, this strategy may be associated with an increased incidence of bleeding among patients with colon cancer, and perhaps among male and elderly patients.

Comparison between arm port and chest port: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to compare the efficacy and safety of arm ports (APs) and chest ports (CPs) in clinical practice.

METHODS

Randomized controlled trials (RCTs), controlled clinical trials, and retrospective studies were searched in both English and Chinese databases, encompassing PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang Database, and SinoMed up to November 27, 2023. Data analysis was performed using Stata 15.0.

RESULTS

Seventeen studies, including two RCTs, three cohort studies, and twelve case-control studies, were finally included, involving a total of 4168 participants, with 2151 participants in the CP group and 2017 in the AP group. The meta-analysis showed that there was no significant difference between CP and AP in the incidence rates of infections [OR = 0.98, 95% CI (0.68, 1.41)], catheter occlusion[OR = 0.95, 95% CI (0.55, 1.64)], thrombosis [OR = 0.85, 95% CI (0.60, 1.21)], exudation [OR = 1.32, 95% CI (0.52, 3.36)], fibrin sheath [OR = 1.68, 95% CI (0.46, 6.19)], catheter malposition [OR = 0.62, 95% CI (0.30, 1.29)], fracture[OR = 1.84, 95% CI (0.49, 6.96)], pneumothorax [OR = 5.73, 95% CI (0.94, 35.11)], and malfunction [OR = 1.87, 95% CI (0.65, 5.42)].

CONCLUSION

This study reveals no significant differences in the incidence of infections, catheter occlusion, thrombosis, exudation, fibrin sheath, catheter malposition, fracture, pneumothorax, and malfunction between the two implanted venous access ports. Thus, it can be concluded that AP is as safe as CP.

Comparison of efficacy and safety of thrombus prevention strategies after abdominal and pelvic cancer surgery: Bayesian network based meta-analysis

Background

The occurrence of venous thromboembolism (VTE) after abdominal and pelvic cancer surgery increases the risk of mortality and disability. However, there is insufficient evidence supporting the choice of anticoagulation strategies.

Methods

We searched PubMed, The Cochrane Library, Embase, and Web of Science for randomized controlled trials from inception to January 2024. Studies concerning thrombosis prevention after abdominal and pelvic surgery were included. Network meta-analysis(NMA) and direct meta-analysis (DMA) methods were employed to evaluate the efficacy and safety of various prophylactic strategies.

Results

Twenty clinical trials involving a total of 4923 patients were included. The DMA results showed that low molecular weight heparin (LMWH) was more effective in preventing VTE compared to no treatment (OR = 1.96; 95% CI: 1.21 to 3.19), and LMWH plus physiotherapy was more effective than LMWH (OR = 10.95; 95% CI: 1.33 to 90.40). The NMA results indicated that DOACs (OR = 0.34; 95% CI: 0.11 to 0.76) and LMWH (OR = 0.51; 95% CI: 0.32 to 0.77) were significantly effective in preventing venous thrombosis compared with no treatment. The cumulative ranking probability curve (SUCRA) showed that direct oral anticoagulants (DOACs) were the best intervention. In terms of major bleeding, unfractionated heparin (UFH) had a higher risk than LMWH, physiotherapy, and no treatment, with statistically significant differences. The SUCRA analysis indicated that physiotherapy was the best intervention for major bleeding.

Conclusion

Existing evidence suggests that DOACs can provide better thromboprophylaxis efficacy for patients after abdominal and pelvic cancer surgery, achieving an optimal balance between efficacy and safety. LMWH has become an intervention with efficacy second only to DOACs, with similar safety.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/ , identifier CRD42024513090.

The Risk of Haematoma and Venous Thrombosis Associated With Thromboprophylaxis Use in Breast Cancer Surgery: A Meta-Analysis and Systematic Review

Background: The routine use of venous thromboembolism (VTE) prophylaxis in breast cancer surgery has caused substantial polarity among breast cancer surgeons across the globe. The aim of this study is to assess the use of VTE prophylaxis in breast cancer surgery outcomes. Methods: A comprehensive electronic search was undertaken of all comparative studies that described the role of VTE prophylaxis in breast cancer surgery. Studies that reported on postoperative outcomes between patients who received VTE prophylaxis (prophylaxis) and those who did not (no prophylaxis) were included in the review. A meta-analysis using random-effect model was used to analyse key outcomes, with data presented as odd ratio (OR). Results: A total of 2470 patients from 6 studies were included in this study. Among these patients, 60.9% (n: 1504) received prophylaxis. The haematoma rate in this study is 0.05% (n: 133). The incidence of haematoma was significantly associated with the use of prophylaxis (6.85% versus 3.11%, p : 0.001). Surgical intervention for haematomas was also significantly associated in this group (3.15% versus 0.83%, p : 0.004). However, there was no difference in VTE events between both groups (0.26% versus 0.36%, p : 0.88). Conclusions: The use of VTE prophylaxis in breast cancer surgery is associated with increased haematomas without any benefit in preventing VTE events. Future studies that examine the use of risk assessment tools for VTE prophylaxis in high risk patients may be beneficial.

Solid Tumors, Liquid Challenges: The Impact of Coagulation Disorders

Coagulation disorders are increasingly recognized as significant complications in patients with solid tumors, affecting morbidity and mortality outcomes. Solid tumors can provoke a hypercoagulable state through the release of pro-coagulant factors, endothelial activation, and inflammation, leading to a heightened risk of coagulation disorders. These coagulation disorders may manifest as venous thromboembolism, arterial thromboembolism, thrombotic microangiopathy, or disseminated intravascular coagulation. These disorders can complicate surgical interventions and impact treatments, including chemotherapy and immunotherapy efficacy, leading to poor outcomes. Understanding the implications of coagulation disorders in solid tumors is essential for optimizing patient management, including identifying high-risk patients, implementing prophylactic measures, elucidating biomarkers for clinical outcomes, and exploring novel therapeutic agents. This review aims to provide insights into the current knowledge surrounding coagulation disorders in solid tumors and their clinical implications.

Validation of clinical risk assessment scores for venous thromboembolism in patients with cancer: a population-based cohort study

BACKGROUND

Guidelines recommend using risk assessment tools to identify ambulatory patients with cancer at high risk of venous thromboembolism (VTE).

OBJECTIVES

We aimed to validate a new cancer-associated thrombosis (CAT) risk score in a population-based healthcare setting.

METHODS

We used healthcare registry data and electronic medical records from the Central Denmark Region to calculate the new CAT risk score and the guideline-recommended Khorana score in patients with a first-time cancer diagnosis who initiated systemic cancer therapy. Patients were followed for 6 months after initiation of therapy. The outcome was any VTE identified through hospital discharge diagnoses. Discrimination was assessed using C statistics.

RESULTS

We included 12 471 patients from 2012 to 2020. Of these, 416 (3.3%) developed VTE. The C statistic was 0.71 (95% CI, 0.68-0.74) for the new CAT score and 0.66 (95% CI, 0.63-0.70) for the Khorana score. The 6-month cumulative VTE incidence was 5.0% in 6175 patients classified as high risk by the new CAT score compared with 1.7% in 6296 patients classified as low risk. The 6-month cumulative VTE incidence was 5.2% in 4263 patients classified as high risk by the Khorana score compared with 2.4% in 8208 patients classified as low risk.

CONCLUSION

The new CAT score had a discriminatory ability similar to that reported in the derivation study. The C statistic was numerically higher than that of the Khorana score. Our findings support the implementation of the new CAT score to identify ambulatory patients with cancer who are at high risk of VTE.

The Vienna CATScore for predicting cancer-associated venous thromboembolism: an external validation across multiple time points

BACKGROUND

Patients with cancer undergoing systemic therapies have a high risk for venous thromboembolism (VTE). Risk assessment models were developed to select high-risk subgroups that might benefit from primary thromboprophylaxis, yet currently available models reportedly underperform in contemporary cancer treatment populations and risk models across multiple time points throughout therapy are not available.

PATIENTS AND METHODS

We, therefore, aimed to validate the Vienna CATScore, a nomogram-based model including tumor type and continuous D-dimer levels, in a prospective cohort study of patients initiating contemporary systemic anticancer therapies. The validity of the model was tested at study inclusion, 3 weeks, and 3 months after start of therapy.

RESULTS

Overall, 598 patients were included [49% women, median age 62 years (interquartile range 53-70 years)]. Most patients had stage IV disease (68.2%). The 6-month cumulative incidence of VTE was 9.2% [95% confidence interval (CI) 6.8% to 11.5%]. The Vienna CATScore demonstrated good discriminatory ability (c-statistics: 0.69, 95% CI 0.61-0.76) at study baseline and across all evaluated time points (c-statistics: 0.68, 95% CI 0.63-0.73). Applying a 6-month predicted VTE risk threshold of 8%, the CATScore effectively distinguished between low- and high-risk groups at study inclusion (7.1% versus 15.1% observed VTE risk, P = 0.004) and across all three time points (6.3% versus 13.6% observed VTE risk, P < 0.001). Assuming a 50% risk reduction with thromboprophylaxis, this threshold resulted in a number needed to treat (NNT) of 13 and 15, respectively, in the high-risk group, while the NNT was 28 and 32, respectively, in the low-risk group.

CONCLUSIONS

This external validation of the Vienna CATScore confirms its effectiveness in predicting VTE risk in the initial months of state-of-the-art systemic anticancer therapies and across multiple time points.

Effect of drug interactions with apixaban on clinical outcomes in cancer patients with venous thromboembolism

Introduction

It is unclear how drug-interaction with apixaban influences recurrent venous thromboembolism (VTE) and bleedings in cancer patients.

Methods

A post-hoc analysis of a single-arm interventional clinical trial on apixaban treatment of cancer patients with VTE to investigate whether the occurrence of any of the endpoints could be associated with the concurrent use of an interacting drug. Drugs taken by the patients during the trial period were categorized as either increasing bleeding risk, increasing thrombosis risk, both or neither.

Results

298 patients were divided into groups based on whether they used no interacting drugs (controls, n=74), drugs increasing bleeding risk (n=55), drugs increasing thrombosis risk (n=8), or both (n=161). Odds ratios (OR) were calculated for recurrent VTE, clinically relevant non-major bleeding (CRNMB), and major bleeding during the 36-month follow-up period. Each patient took a median of 13 different drugs over the study period. 67% of the patients used drugs expected to both increase bleeding and thrombosis. The use of fluconazole appeared associated with CRNMB (OR 3.6, 95% confidence interval (CI) 0.99-13), but not with major bleeding (OR 0.56, 95% CI 0.06 - 4.8). Non-steroid anti-inflammatory drugs were not associated with CRNMB (OR 1.0, 95% CI 0.25-4.1) or major bleedings (OR 0.72, 95% CI 0.14 - 3.6). Use of antiplatelet therapy was not associated with CRNMB (OR 0.75, 95% CI, 0.22 - 2.58) or major bleeding (OR 0.2, 95% CI, 0.02-1.6). There were no major bleedings in 23 patients using aprepitant nor in the 10 patients taking macrolides. We found no association between drugs and recurrent VTE, except that there were no recurrent VTE in 19 patients using bevacizumab.

Conclusions

Despite the high number of drugs taken that could potentially interact with apixaban, none were found to clearly influence clinical outcomes, except that fluconazole may increase the risk of CRNMB.

Non-bacterial thrombotic endocarditis: a clinical and pathophysiological reappraisal

Non-bacterial thrombotic endocarditis (NBTE), formerly recognized as marantic endocarditis, represents a rare cardiovascular pathology intricately linked with hypercoagulable states, notably malignancy and autoimmune disorders. Characterized by the development of sterile vegetations comprised of fibrin and platelets on cardiac valves, NBTE poses a diagnostic challenge due to its resemblance to infective endocarditis. Therapeutic endeavours primarily revolve around addressing the underlying aetiology and instituting anticoagulant regimens to forestall embolic events, with surgical intervention seldom warranted. Non-bacterial thrombotic endocarditis frequently coexists with malignancies and autoimmune conditions, such as lupus and antiphospholipid antibody syndrome, and, more recently, has been associated with COVID-19. Its pathogenesis is underpinned by a complex interplay of endothelial dysfunction, hypercoagulability, hypoxia, and immune complex deposition. Clinical manifestations typically manifest as embolic phenomena, particularly cerebrovascular accidents, bearing substantial mortality rates. Diagnosis necessitates a high index of suspicion and meticulous exclusion of infective endocarditis, often facilitated by advanced cardiac imaging modalities. Anticoagulation, typically employing low molecular weight heparin or warfarin, constitutes the cornerstone of pharmacological intervention. Surgical recourse may be warranted in instances of refractory heart failure or recurrent embolic events. Given its multifaceted nature, the management of NBTE mandates a multidisciplinary approach, with prognosis contingent upon individual clinical intricacies. Future endeavours should prioritize further research to refine therapeutic strategies and enhance patient outcomes.

Use of antithrombotic therapy and the risk of cardiovascular outcomes and bleeding in cancer patients at the end of life: a Danish nationwide cohort study

BACKGROUND

Despite uncertain benefit-risk profile near the end of life, antithrombotic therapy (ATT) is prevalent in patients with terminal cancer.

OBJECTIVES

To examine adherence and persistence with ATT in terminally ill cancer patients and investigate risks of major and clinically relevant bleeding, venous thromboembolism (VTE), and arterial thromboembolism (ATE) by ATT exposure.

METHODS

Using a Danish nationwide cohort of terminal cancer patients, ATT adherence in the year following terminal illness declaration was measured by the proportion of days covered (PDC) by prescription. Discontinuation was defined as a treatment gap of ≥30 days between prescription renewals. One-year cumulative incidences of bleeding complications, VTE, and ATE were calculated, considering the competing risk of death.

RESULTS

During 2013-2022, 86 732 terminally ill cancer patients were identified (median age, 75 years; 47% female; median survival, 57 days). At terminal illness declaration, 37.5% were receiving ATT (66.6% platelet inhibitors, 23.0% direct oral anticoagulants, and 10.4% vitamin K antagonists [VKAs]). The mean PDC with ATT was 88% (SD, 30%), highest among platelet inhibitor users (mean PDC, 89%) and lowest among VKA users (73%). One-year ATT discontinuation incidence was 7.9% (95% CI, 7.7%-8.1%). Most patients continued ATT until death (74.8% platelet inhibitors, 58.8% direct oral anticoagulants, and 61.6% VKAs). Patients receiving ATT had a lower 1-year VTE risk but higher risks of ATE and major bleeding.

CONCLUSION

Despite uncertain benefit-risk profile, most terminally ill cancer patients continue ATT until the end of life. These findings provide insights into current ATT utilization and discontinuation dynamics in the challenging context of terminal illness.

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

Risk assessment and prevention of cancer-associated venous thromboembolism in ambulatory patients with solid malignancies

Venous thromboembolism remains a major cause of morbidity and mortality among ambulatory cancer patients, necessitating effective risk assessment and prevention strategies. Despite the availability of risk assessment models and guidelines recommending primary thromboprophylaxis with low-molecular-weight heparins or direct oral anticoagulants, the application of these strategies is inconsistent. This review provides an overview of the current state-of-the-art venous thromboembolism risk assessment and thromboprophylaxis in ambulatory patients with cancer, focusing on existing risk assessment models and the latest guideline recommendations. Finally, it summarizes gaps in knowledge, discusses future directions, and highlights recent advances and state-of-the-art research presented at the 2024 International Society on Thrombosis and Haemostasis Congress in Bangkok, Thailand.

Occurrence and management of thrombosis recurrence and bleeding in low-molecular-weight heparin-treated patients with cancer-associated thrombosis: a French nationwide cohort study

Background

Rates of venous thromboembolism (VTE) recurrence and bleeding remain high in patients with cancer who are prescribed anticoagulants (ACs) such as low-molecular-weight heparin (LMWH) after an initial VTE event.

Objectives

To identify patient characteristics associated with VTE recurrence and bleeding in patients receiving LMWH for cancer-associated VTE and to explore secondary AC management and clinical outcomes in these patients.

Methods

An observational study was conducted using nationwide French data for adults with active cancer who were hospitalized with VTE in 2013-2018 and were reimbursed for LMWH ≤ 30 days after hospital discharge. The main outcomes were VTE recurrence and bleeding. For both outcomes, the proportions of patients who experienced the outcome were calculated for different patient characteristics. AC switching following VTE recurrence and bleeding was tracked using Anatomical Therapeutic Chemical codes.

Results

A total of 31,771 patients received LMWH, of whom 1925 (6.1%) experienced VTE recurrence and 1804 (5.7%) bleeding. Most recurrent VTE and bleeding events occurred within 6 months after the initial VTE event. The proportion of patients with VTE recurrence and bleeding varied between cancer types. Most patients who experienced VTE recurrence or bleeding continued to receive LMWH. Eleven percent of patients with VTE recurrence experienced a further recurrent VTE event within 3 months.

Conclusion

More than 10% of patients who received LMWH for cancer-associated VTE experienced VTE recurrence or bleeding. AC management options in this patient population should be prospectively assessed in clinical trials.

Relevance of recurrent venous thromboembolism according to location of metastasis in patients with cancer-associated thrombosis. A cohort study

BACKGROUND

Risk of VTE recurrence (VTEr) in patients with cancer-associated thrombosis (CAT) is high. Cancer-related risk factors for VTEr have been studied, but information about the importance of location of metastasis is scarce.

OBJECTIVES

1) Evaluate rate of VTEr in CAT patients according to location of metastasis, and 2) Identify variables associated to VTEr during long-term follow-up.

METHODS

A retrospective, single-center, non-interventional study of consecutives patients with CAT conducted between 2007 and 2022. Haematological neoplasms were excluded.

RESULTS

Among 1248 patients with CAT (age 64.1 ± 12.8 years; 48.2 % female) followed-up for 13.19 months (p25-75, 5.6-26.9) there were 141 VTEr. The rate of VTE recurrence in patients without and with metastasis were 4.72 per 100 patient-years (95%CI: 3.66-6) and 10.05 per 100 patient-years (95 % CI: 7.89-12.61), respectively. The metastases locations associated with VTEr, compared to those without metastasis, were lung (rate ratio [RR]: 2.21; 95 % CI: 1.42-3.43), liver (RR: 2.02; 95%CI: 1.26-3.24), pancreas (RR: 6.21; 95 % CI: 1.52-25.35), pleura (RR: 2.93; 95%CI: 1.58-5.41), bone (RR: 2.16; 95 % CI: 1.29-3.64) and adrenal (RR: 6.18; 95%CI: 2.97-12.86). Multivariate analysis of variables associated with VTEr beyond 12 months were male sex (hazard ratio [HR] 1.54, 95%CI: 1.08-2.19), ECOG performance status >1 (HR 1.74, 95%CI: 1.03-2.94), metastasis in 1-2 locations (HR 2.38, 95%CI: 1.68-3.37) and metastasis in >2 locations (HR 3.88, 95%CI: 1.68-8.98).

CONCLUSIONS

The rate of VTEr differs according to the location of metastasis. We identified variables related to VTEr during long-term follow-up which may help clinicians decide whether to continue anticoagulation.

Management and outcomes in patients with tumor thrombus: a retrospective cohort study

BACKGROUND

Tumor thrombus can be associated with an increased risk of venous thromboembolism (VTE) and poor prognosis. The risks and benefits of anticoagulation remain unclear.

OBJECTIVES

To evaluate the role of anticoagulation and associated outcomes in patients with tumor thrombus.

METHODS

We conducted a single-center retrospective cohort study in patients with tumor thrombus from 2019 to 2022. All patients were followed for 12 months from the diagnosis of tumor thrombus or until death if death occurred earlier. The primary outcome was the percentage of patients prescribed any dose of anticoagulation for tumor thrombus (or concurrent bland thrombus/VTE). The secondary outcomes included new thrombosis, major bleeding, clinically relevant nonmajor bleeding, and mortality. We calculated the 6- and 12-month cumulative incidence of outcomes with 95% CI and compared those given anticoagulation vs not, considering death as a competing risk.

RESULTS

We included 211 patients, among whom 106 (50.2%; 95% CI, 47.9%-52.6%) were given anticoagulation for tumor thrombus or concurrent VTE (present in 21.8%). The most common type of cancer was hepatocellular carcinoma (28%). Splanchnic veins were the most commonly involved (49.3%). Anticoagulation was more likely used if tumor thrombus involved the inferior vena cava and/or the heart, with concurrent VTE, or if thrombosis service was consulted. The overall 12-month incidence of new VTE was 11.4% (95% CI, 7.3%-16.5%), that of major bleeding + clinically relevant nonmajor bleeding was 36.6% (95% CI, 29.6%-43.5%), and mortality of 52.5% (95% CI, 44.8%-59.6%), with no significant differences among groups given anticoagulation or not.

CONCLUSION

Patients with tumor thrombus carry high risks of VTE, bleeding, and mortality. The impact of anticoagulation remains unclear.

Impact of thrombocytopenia on bleeding and thrombotic outcomes in adults with cancer-associated splanchnic vein thrombosis

ABSTRACT

Malignancy is a risk factor for splanchnic vein thrombosis (SpVT). Data on the natural history of cancer-associated SpVT are limited. This was a single-center, retrospective cohort study of 581 adult patients with cancer and SpVT. We aimed to characterize the impact of thrombocytopenia on major bleeding and progression or recurrence of SpVT within 1 year of an initial cancer-associated SpVT diagnosis. Baseline thrombocytopenia (platelet <100 × 103/μL within 15 days of SpVT diagnosis) was present in 39.5% of patients. A total of 39.2% of patients received therapeutic anticoagulation within 2 weeks of an SpVT diagnosis. The cumulative 1-year incidence of major bleeding was 10.7% (95% confidence interval [CI], 8.2-13.2) and 16.2% (95% CI, 13.2-19.2) for SpVT recurrence/progression. In the multivariable regression analysis, therapeutic anticoagulation was associated with increased major bleeding (adjusted risk ratio [aRR], 1.74; 95% CI, 1.08-2.81) and decreased progression/recurrence of SpVT (aRR, 0.55; 95% CI, 0.35-0.86). Baseline thrombocytopenia was not independently associated with either major bleeding (aRR, 0.76; 95% CI, 0.43-1.34) or progression/recurrence of SpVT (aRR, 1.14; 95% CI, 0.73-1.78). A secondary analysis using inverse probability of treatment weighting with propensity scores for baseline thrombocytopenia corroborated that patients with thrombocytopenia did not have an increased bleeding risk (adjusted hazard ratio [aHR], 0.81; 95% CI, 0.48-1.39). The multivariable analysis in which platelets were treated as a time varying covariate also did not reveal an association with major bleeding (aHR, 0.89; 95% CI, 0.55-1.45). Bleeding and thrombosis progression were frequent in patients with cancer-associated SpVT. Anticoagulation was associated with increased major bleeding and decreased thrombotic progression; thrombocytopenia did not impact the outcomes.

A Comprehensive Review of Catheter-Related Thrombosis

Catheter-related thrombosis (CRT) is a frequent and potentially serious complication associated with the widespread use of intravascular devices such as central venous catheters, including peripherally inserted central catheters and implantable port systems, pacemakers or implantable cardioverter-defibrillators. Although CRT management has been informed by guidelines extrapolated from lower extremity deep vein thrombosis (DVT), unique challenges remain due to the distinct anatomical, pathophysiological, and clinical characteristics of upper extremity DVT. Risk factors for CRT are multifactorial, encompassing patient-related characteristics such as cancer, prior venous thromboembolism, and infection, as well as catheter-specific factors like device type, lumens, and insertion site. The diagnosis of CRT relies primarily on ultrasonography; however, computed tomography angiography and magnetic resonance imaging play a complementary role, particularly in anatomically challenging cases or when complications such as pulmonary embolism or superior vena cava syndrome are suspected. Treatment strategies for CRT include anticoagulation, catheter removal when feasible, and, in select cases, local thrombolysis or catheter-directed interventions. Anticoagulation remains the cornerstone of therapy, with direct oral anticoagulants increasingly favored due to their safety profile and efficacy. This article provides a detailed review of CRT, focusing on clinical features, diagnostic methods, and treatment strategies while addressing specific challenges in managing pacemaker and hemodialysis catheter-related thrombosis.

Anticoagulation approach in morbid obesity: a comprehensive review on venous thromboembolism management

Obesity is a recognized risk factor for venous thromboembolism (VTE), associated with distinct challenges in managing anticoagulation therapy. There is still limited evidence regarding the impact of extreme body weight on the pharmacokinetics, pharmacodynamics, efficacy, and safety of various anticoagulant medications. To our knowledge, this is the first comprehensive review to address both prophylactic and therapeutic anticoagulant dosages specifically for managing VTE in patients with a body mass index (BMI) ≥40 kg/m2 or weight ≥120 kg. Our aim was to synthesize the findings of relevant studies alongside the latest recommendations on anticoagulation in this unique population. We gathered and analyzed data on all classes of anticoagulants available for VTE management, including vitamin K antagonists (VKAs), unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, and direct oral anticoagulants (DOACs), offering insights into their efficacy and safety profiles. Additionally, we explored special subpopulations of morbidly obese patients, such as those with cancer, renal dysfunction, or those undergoing bariatric surgery, recognizing the nuanced therapeutic challenges they present. The current evidence for anticoagulant therapy in morbidly obese patients with VTE is evidently insufficient, underscoring the need for a tailored approach and meticulous monitoring to achieve an optimal therapeutic balance.

Gender-affirming hormone therapy in the transgender patient: influence on thrombotic risk

Research regarding the hematologic sequelae of estrogen and testosterone therapy for transgender people is an emerging area. While estrogen therapy has been widely studied in cisgender women, studies in transgender individuals are limited, revealing variable adverse effects influenced by the dose and formulation of estrogen used. Thrombotic risk factors in transgender and gender-diverse individuals are multifactorial, involving both modifiable and nonmodifiable factors. Management of venous thromboembolism (VTE) in individuals receiving gender-affirming estrogen entails standard anticoagulation therapy alongside shared decision-making regarding hormone continuation and risk factor modification. While data and guidance from cisgender women can offer a reference for managing thrombotic risk in transgender individuals on hormone therapy, fully applying these insights can be challenging. The benefits of gender-affirming hormone therapy include significantly reducing the risk of suicide and depression, highlighting the importance of a contemplative approach to the management of hormonal therapy after a VTE event. Although limited, the available data in the literature indicate a low thrombotic risk for transgender individuals undergoing gender-affirming testosterone therapy. However, polycythemia is a common adverse effect necessitating monitoring and, occasionally, adjustments to hormonal therapy. Additionally, iron deficiency may arise due to the physiological effects of testosterone or health care providers' use of phlebotomy, an aspect that remains unstudied in this population. In conclusion, while the set of clinical data is expanding, further research remains vital to refine management strategies and improve hematologic outcomes for transgender individuals undergoing gender-affirming hormone therapy.

Hormone-related thrombosis: duration of anticoagulation, risk of recurrence, and the role of hypercoagulability testing

Hormone-related venous thromboembolism (VTE) is common and entails scenarios in which VTE occurs during exposure to exogenous or endogenous female sex hormones, typically estrogen and progestogen. For the management of hormone-related VTE, it is important to realize that many patients use these hormones for a vital purpose often strongly related to the patient's well-being and quality of life. In this review we discuss clinical cases of VTE related to hormonal contraceptive use and pregnancy to illustrate key considerations for clinical practice. We cover practice points for primary VTE treatment and detail the evidence on the risk of recurrent VTE and bleeding in this population. The potential value of thrombophilia testing is described, including "who, why, when, what, and how." We also discuss key aspects of shared decision-making for anticoagulant duration, including a reduced-dose anticoagulant strategy in hormone-related VTE.

Management of anticoagulation in patients with brain metastasis

Venous thromboembolism (VTE) is a prevalent and serious complication among cancer patients, necessitating therapeutic anticoagulation for many individuals with brain metastases. Simultaneously, patients with brain metastases, particularly those with high-risk primary tumors, have an increased risk of intracranial hemorrhage (ICH). Managing anticoagulation in these patients presents a dual challenge: preventing thromboembolism while avoiding hemorrhagic events. Here, we present our approach to anticoagulation for acute VTE in patients with brain metastases, based on the available evidence. We review potential risk factors for anticoagulation-associated ICH in this population and discuss strategies for managing acute VTE in patients with and without ICH.

Anticoagulation at the end of life: whether, when, and how to treat

Nearly 2 out of 3 patients with venous thromboembolism (VTE) and 1 out of 4 patients with atrial fibrillation (AF) will die within the year. Whether, when, and how to manage anticoagulation at the end of life requires many trade-offs. Patients and clinicians must balance symptom burden, greatly elevated bleeding and thrombosis risks, competing comorbidities and medications, and changing goals over time. This review uses cases of VTE and AF to present a framework for care that draws upon existing disease-specific data and cutting-edge palliative care science. It reviews strategies for the difficult task of estimating a patient's prognosis, characterizes the enormous public health burden of anticoagulation in serious illness, and analyzes the data on anticoagulation outcomes among those with limited life expectancy. Finally, an approach to individualized decision-making that is predicated on patients' priorities and evidence-based strategies for starting, continuing, or stopping anticoagulation at the end of life are presented.

Cancer-Related Coagulopathy and Perioperative Considerations

Cancer-related coagulation abnormalities are characterized by complex dysregulation of the hemostatic system, predisposing patients to increased risk of thrombotic and hemorrhagic complications and associated increased morbidity and mortality. Advances in anticancer therapies with improved outcomes have led to better survival and older age of patients living with or having survived cancer. There is also a significant increase in the number of patients diagnosed with cancer. All these factors will increase the number of patients presenting for surgical procedures, both cancer-related and noncancer related. It is important for the anesthesiologist to understand the magnitude of cancer-related coagulation derangement, its types, pathophysiology, and clinical presentation, to optimize the perioperative management of this high-risk rapidly growing patient population.

Preventative and curative treatment of venous thromboembolic disease in cancer patients

Cancer-associated venous thromboembolism (CAT) is common in patients with cancer and associated with significant morbidity and mortality. The incidence of CAT continues to rise, complicating patient care and burdening healthcare systems. Patients with cancer experiencing VTE face poorer prognoses, making prevention and effective management imperative. This narrative review synthesizes evidence on thromboprophylaxis in ambulatory patients with cancer receiving systemic therapy and acute treatment strategies for CAT. Risk assessment models (e.g., Khorana score) aid in identifying high-risk patients who may benefit from thromboprophylaxis. Pharmacological thromboprophylaxis with low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs) has been shown to reduce the risk of CAT without significantly increasing the risk of bleeding complications. However, implementation of risk-based strategies remains limited in clinical practice. For acute CAT management, LMWHs have been the standard of care, but DOACs are increasingly favored due to their convenience and efficacy. However, challenges persist, including bleeding risks and drug interactions. Emerging therapies targeting Factor XI inhibitors present promising alternatives, potentially addressing current limitations in anticoagulation management for CAT.

Utility of the modified Ottawa score for identification of more preferable candidates of extended anticoagulation therapy in cancer-associated isolated distal deep vein thrombosis: insight from the ONCO DVT Study

BACKGROUND

The ONCO DVT study (Edoxaban for 12 Months Versus 3 Months in Patients With Cancer With Isolated Distal Deep Vein Thrombosis) revealed superiority of 12-month relative to 3-month edoxaban treatment for the thrombotic risk in cancer-associated isolated distal deep vein thrombosis. However, it is unknown whether the superiority could be common in different modified Ottawa score subgroups.

OBJECTIVES

To identify more preferable candidates for extended anticoagulation in patients with cancer-associated isolated distal deep vein thrombosis using the modified Ottawa score.

METHODS

In this post-hoc subgroup analysis of the ONCO DVT study, we stratified 601 patients into the low (≤-1, N = 126), intermediate (0, N = 323), and high (≥1, N = 152) modified Ottawa score subgroups and compared clinical outcomes between the 12-month and 3-month edoxaban treatment groups.

RESULTS

The cumulative incidence of symptomatic recurrent venous thromboembolism or venous thromboembolism-related death was not different between the 12-month and 3-month edoxaban treatment groups in the low score subgroup (0.0% vs 2.2%), whereas it was lower in the 12-month than in the 3-month edoxaban treatment group in the intermediate (0.8% vs 7.6%) and high (3.1% vs 15.6%) score subgroups. There were no significant differences in the cumulative incidences of the major bleeding between the 12-month and 3-month edoxaban treatment groups in the low (10.1% vs 7.6%), intermediate (8.8% vs 5.0%), and high (13.9% vs 12.6%) score subgroups.

CONCLUSION

A 12-month compared with 3-month edoxaban treatment showed a lower risk of thrombotic events in patients with cancer-associated isolated distal deep vein thrombosis in the intermediate and high modified Ottawa score subgroups but not in the low score subgroup, suggesting a limited benefit of extended anticoagulation therapy beyond 3 months in patients with low modified Ottawa score.

Predictors of recurrent venous thromboembolism and major bleeding in patients with cancer: A secondary analysis of the CANVAS trial

INTRODUCTION

Patients with cancer have an increased risk of developing venous thromboembolism (VTE) but also have an increased risk of both recurrent VTE and bleeding with anticoagulation compared to anticoagulated patients without cancer. CANVAS, a randomized pragmatic effectiveness trial, compared the direct oral anticoagulants a class to low molecular weight heparin for treatment of a new VTE in patients with cancer. The aim of this prespecified secondary analysis of the CANVAS trial is to identify predictors of both recurrent VTE and major bleeding in patients with cancer and new VTE.

METHODS

Data from the 671 participants in the analysis population were used to identify predictors of recurrent VTE and bleeding during the 6-month treatment period. Significant predictors identified in the univariable models were carried forward in the multivariable models to identify independent predictors of both risks.

RESULTS

Independent predictors of recurrent VTE include ECOG performance status ≥2 (HR, 3.19 [95 % CI, 1.45-7.02]; P < .005), presence of metastatic disease (HR, 2.57 [95 % CI, 1.14-5.80]; P = .023), treatment with bevacizumab (HR, 2.50 [95 % CI, 1.04-5.99]; P = .041), and deep vein thrombosis without pulmonary embolus as index VTE (HR, 1.86 [95 % CI, 1.04-3.33]; P = .037). Independent predictors of major bleeding include serum albumin <3.5 g/dL (HR 1.97 [95 % CI, 1.02-3.79]; P = .044) and metastatic disease (HR 2.80 [95 % CI, 1.08-7.22]; P = .034).

CONCLUSION

Findings from this pre-specified analysis of the CANVAS trial identified risk factors for recurrent VTE and major bleeding in a population of participants with cancer and new VTE that reflect current oncology clinical practice. Results can be used to identify at risk patients in practice and inform new risk prediction models to improve the care of these patients.

Circulating Blood Biomarkers and Risk of Venous Thromboembolism in Cancer Patients: A Systematic Review and Meta-Analysis

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.

Epidemiology, Pathophysiology, and Management of Cancer-Associated Ischemic Stroke

Cancer and stroke are leading causes of global disability and mortality. With improvements in cancer-associated mortality and advancements in treatment of active malignancy, it is more common to encounter patients with ischemic stroke and active malignancy. Evidence suggests that cancer-associated ischemic stroke is a unique subtype of stroke; however, there is limited guidance when considering diagnostic workup, secondary prevention, rehabilitation, and future directions within this population. In this narrative review, we aim to describe the epidemiology, pathophysiological mechanisms, management, and future directions regarding understanding of cancer-associated ischemic stroke.