Antithrombotic Therapy in Cancer

Plasma D-dimer level in the perioperative period in non-small-cell lung cancer

BACKGROUND

  There has been little research on perioperative hypercoagulability in non-small-cell lung cancer patients. The D-dimer can be used to evaluate the hypercoagulability in cancer patients.

METHODS

  Eighty-five non-small-cell lung cancer patients were included in the study. The plasma D-dimer levels during the preoperative and 3rd and 9th day postoperative period were prospectively examined and analyzed along with the clinicopathological characteristics.

RESULTS

  The medians (interquartile range) of the preoperative, 3rd and 9th day postoperative D-dimer levels were 1.09 (0.77) mg/L, 3.35 (2.31) mg/L and 4.1 (2.55) mg/L respectively (P= 0.00). The preoperative D-dimer level was related with the stage (P= 0.004). The preoperative and the 3rd day postoperative D-dimer levels were both related to patient age (P= 0.014, P= 0.034). The 3rd day postoperative D-dimer levels were arbitrarily stratified into three groups, adenocarcinoma dominated the high and low groups while squamous cell carcinoma dominated the median one (exact P= 0.02). The pneumonectomy group did not show a higher 3rd day postoperative D-dimer level than the lobectomy group (P= 0.064).

CONCLUSION

  Non-small-cell lung cancer patients had increasing hypercoagulability within the first 9 postoperative days. Preoperative hypercoagulability was close related with tumor stage. Heterogeneity existed among postoperative hypercoagulability.

Parenteral anticoagulation in ambulatory patients with cancer

BACKGROUND

Anticoagulation may improve survival in patients with cancer through a speculated anti-tumour effect, in addition to the antithrombotic effect, although may increase the risk of bleeding.

OBJECTIVES

To evaluate the efficacy and safety of parenteral anticoagulants in ambulatory patients with cancer who, typically, are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation.

SEARCH METHODS

A comprehensive search included (1) a major electronic search (February 2016) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 1), MEDLINE (1946 to February 2016; accessed via OVID) and Embase (1980 to February 2016; accessed via OVID); (2) handsearching of conference proceedings; (3) checking of references of included studies; (4) use of the 'related citation' feature in PubMed and (5) a search for ongoing studies in trial registries. As part of the living systematic review approach, we are running searches continually and we will incorporate new evidence rapidly after it is identified. This update of the systematic review is based on the findings of a literature search conducted on 14 August, 2017.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in ambulatory patients with cancer. Typically, these patients are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation.

DATA COLLECTION AND ANALYSIS

Using a standardized form we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interested included all-cause mortality, symptomatic venous thromboembolism (VTE), symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, minor bleeding, and quality of life. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE handbook).

MAIN RESULTS

Of 6947 identified citations, 18 RCTs fulfilled the eligibility criteria. These trials enrolled 9575 participants. Trial registries' searches identified nine registered but unpublished trials, two of which were labeled as 'ongoing trials'. In all included RCTs, the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin appears to have no effect on mortality at 12 months (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.93 to 1.03; risk difference (RD) 10 fewer per 1000; 95% CI 35 fewer to 15 more; moderate certainty of evidence) and mortality at 24 months (RR 0.99; 95% CI 0.96 to 1.01; RD 8 fewer per 1000; 95% CI 31 fewer to 8 more; moderate certainty of evidence). Heparin therapy reduces the risk of symptomatic VTE (RR 0.56; 95% CI 0.47 to 0.68; RD 30 fewer per 1000; 95% CI 36 fewer to 22 fewer; high certainty of evidence), while it increases in the risks of major bleeding (RR 1.30; 95% 0.94 to 1.79; RD 4 more per 1000; 95% CI 1 fewer to 11 more; moderate certainty of evidence) and minor bleeding (RR 1.70; 95% 1.13 to 2.55; RD 17 more per 1000; 95% CI 3 more to 37 more; high certainty of evidence). Results failed to confirm or to exclude a beneficial or detrimental effect of heparin on thrombocytopenia (RR 0.69; 95% CI 0.37 to 1.27; RD 33 fewer per 1000; 95% CI 66 fewer to 28 more; moderate certainty of evidence); quality of life (moderate certainty of evidence).

AUTHORS' CONCLUSIONS

Heparin appears to have no effect on mortality at 12 months and 24 months. It reduces symptomatic VTE and likely increases major and minor bleeding. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy should balance the benefits and downsides, and should integrate the patient's values and preferences.Editorial note:This is a living systematic review. Living systematic reviews offer a new approach to review updating in which the review is continually updated, incorporating relevant new evidence, as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Parenteral anticoagulation in ambulatory patients with cancer

BACKGROUND

Anticoagulation may improve survival in patients with cancer through an antitumor effect in addition to the perceived antithrombotic effect.

OBJECTIVES

To evaluate the efficacy and safety of parenteral anticoagulants in ambulatory patients with cancer who, typically, are undergoing chemotherapy, hormonal therapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation.

SEARCH METHODS

A comprehensive search included (1) an electronic search (February 2013) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to February 2013; accessed via OVID) and EMBASE(1980 to February 2013; accessed via OVID); (2) handsearching of conference proceedings; (3) checking of references of included studies; (4) use of the 'related citation' feature in PubMed and (5) a search for ongoing studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in ambulatory patients with cancer. Typically, these patients are undergoing chemotherapy, hormonal therapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation.

DATA COLLECTION AND ANALYSIS

Using a standardized form we extracted data in duplicate on methodological quality, participants, interventions and outcomes of interest including all-cause mortality, symptomatic venous thromboembolism (VTE), symptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE), arterial thrombosis (e.g. stroke, myocardial infarction), major bleeding, minor bleeding and quality of life.

MAIN RESULTS

Of 9559 identified citations, 15 RCTs fulfilled the eligibility criteria. These trials enrolled 7622 participants for whom follow-up data were available. In all included RCTs the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin may have a small effect on mortality at 12 months and 24 months (risk ratio (RR) 0.97; 95% confidence interval (CI) 0.92 to 1.01 and RR 0.95; 95% CI 0.90 to 1.00, respectively). Heparin therapy was associated with a statistically and clinically important reduction in venous thromboembolism (RR 0.56; 95% CI 0.42 to 0.74) and a clinically important increase in the risk of minor bleeding (RR 1.32; 95% 1.02 to 1.71). Results failed to show or to exclude a beneficial or detrimental effect of heparin on major bleeding (RR 1.14; 95% CI 0.70 to 1.85) or quality of life. Our confidence in the effect estimates (i.e. quality of evidence) was high for symptomatic venous thromboembolism, moderate for mortality, major bleeding and minor bleeding, and low for quality of life.

AUTHORS' CONCLUSIONS

Heparin may have a small effect on mortality at 12 months and 24 months. It is associated with a reduction in venous thromboembolism and a likely increase in minor bleeding. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy for survival benefit should balance the benefits and downsides, and should integrate the patient's values and preferences.

The functional role of platelets in the regulation of angiogenesis

Functionally, platelets are primarily recognized as key regulators of thrombosis and hemostasis. Upon vessel injury, the typically quiescent platelet interacts with subendothelial matrix to regulate platelet adhesion, activation and aggregation, with subsequent induction of the coagulation cascade forming a thrombus. Recently, however, newly described roles for platelets in the regulation of angiogenesis have emerged. Platelets possess an armory of pro- and anti-angiogenic proteins, which are actively sequestered and highly organized in α-granule populations. Platelet activation facilitates their release, eliciting potent angiogenic responses through mechanisms that appear to be tightly regulated. In conjunction, the release of platelet-derived phospholipids and microparticles has also earned merit as synergistic regulators of angiogenesis. Consequently, platelets have been functionally implicated in a range of angiogenesis-dependent processes, including physiological roles in wound healing, vascular development and blood/lymphatic vessel separation, whilst facilitating aberrant angiogenesis in a range of diseases including cancer, atherosclerosis and diabetic retinopathy. Whilst the underlying mechanisms are only starting to be elucidated, significant insights have been established, suggesting that platelets represent a promising therapeutic strategy in diseases requiring angiogenic modulation. Moreover, anti-platelet therapies targeting thrombotic complications also exert protective effects in disorders characterized by persistent angiogenesis.

Prognostic value of the D-dimer test in oesophageal cancer during the perioperative period

BACKGROUND

There has been little research on the perioperative D-dimer levels in oesophageal cancer patients. Plasma D-dimer levels can be used to predict the outcome in cancer patients.

METHODS

A cancer group of 66 oesophageal cancer patients and a control group of 12 patients with benign disease were enrolled in this cohort study. The plasma D-dimer levels during the pre-operation and 3rd and 9th day post-operation periods were prospectively examined and analysed between the two groups. Plasma D-dimer levels were also compared with the clinicopathological characteristics and 3-year survival of the oesophageal cancer patients.

RESULTS

Plasma D-dimer levels increased in both groups after surgery, but they were significantly higher in the cancer group. In oesophageal cancer patients, pre-operation plasma D-dimer levels were significantly higher in TNM stage IV patients. Perioperative plasma D-dimer levels significantly increased after surgery, and the survival was shortened in those patients whose D-dimer levels on the 3rd and 9th post-operative day above the median. In addition, increased plasma D-dimer levels at the 3rd and 9th days after surgery were influenced by the patient's age.

CONCLUSION

In oesophageal cancer patients, D-dimer levels increased after surgery, and the increases were associated with poor outcomes.

Parenteral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation

BACKGROUND

Anticoagulation may improve survival in patients with cancer through an antitumor effect in addition to the perceived antithrombotic effect.

OBJECTIVES

To evaluate the efficacy and safety of parenteral anticoagulants in patients with cancer with no therapeutic or prophylactic indication for anticoagulation.

SEARCH STRATEGY

A comprehensive search included (1) an electronic search (February 2010) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 1, 2010, MEDLINE, EMBASE and ISI the Web of Science; (2) handsearch of conference proceedings; (3) checking of references of included studies; and (4) use of the 'related citation' feature in PubMed.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in patients with cancer but no therapeutic or prophylactic indication for anticoagulation.

DATA COLLECTION AND ANALYSIS

Using a standardized form we extracted in duplicate data on methodological quality, participants, interventions and outcomes of interest including all-cause mortality, symptomatic thromboembolism, major bleeding, minor bleeding and quality of life (QoL).

MAIN RESULTS

Of 8187 identified citations, nine RCTs enrolling 2857 patients fulfilled the inclusion criteria. In all included RCTs the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, the effect of heparin therapy on mortality was not statistically significant at 12 months (risk ratio (RR) 0.93; 95% CI 0.85 to 1.02) but it was statistically significant at 24 months (RR 0.92; 95% CI 0.88 to 0.97). Heparin therapy was associated with a statistically and clinically important reduction in venous thromboembolism (RR 0.55; 95% CI 0.37 to 0.82). There were no statistically significant effects on major bleeding (RR 1.30; 95% CI 0.59 to 2.88), minor bleeding (RR 1.05; 95% 0.75 to 1.46) or QoL. The quality of evidence was high for symptomatic venous thromboembolism, moderate for mortality, major bleeding and minor bleeding, and low for QoL.

AUTHORS' CONCLUSIONS

Heparin was associated with a significant reduction of death at 24 months but not 12 months. It was also associated with a reduction in venous thromboembolism but based on the RCTs in this review it had no significant effect on major bleeding, minor bleeding or QoL. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy for survival benefit should balance the benefits and downsides and integrate the patient's values and preferences.

Parenteral anticoagulation in patients with cancer who have no therapeutic or prophylactic indication for anticoagulation

BACKGROUND

Anticoagulation may improve survival in patients with cancer through an antitumor effect in addition to the perceived antithrombotic effect.

OBJECTIVES

To evaluate the efficacy and safety of parenteral anticoagulants in patients with cancer with no therapeutic or prophylactic indication for anticoagulation.

SEARCH STRATEGY

A comprehensive search included (1) an electronic search (February 2010) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) Issue 1, 2010, MEDLINE, EMBASE and ISI the Web of Science; (2) handsearch of conference proceedings; (3) checking of references of included studies; and (4) use of the 'related citation' feature in PubMed.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in patients with cancer but no therapeutic or prophylactic indication for anticoagulation.

DATA COLLECTION AND ANALYSIS

Using a standardized form we extracted in duplicate data on methodological quality, participants, interventions and outcomes of interest including all-cause mortality, symptomatic thromboembolism, major bleeding, minor bleeding and quality of life (QoL).

MAIN RESULTS

Of 8187 identified citations, nine RCTs enrolling 2857 patients fulfilled the inclusion criteria. In all included RCTs the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, the effect of heparin therapy on mortality was not statistically significant at 12 months (risk ratio (RR) 0.93; 95% CI 0.85 to 1.02) but it was statistically significant at 24 months (RR 0.92; 95% CI 0.88 to 0.97). Heparin therapy was associated with a statistically and clinically important reduction in venous thromboembolism (RR 0.55; 95% CI 0.37 to 0.82). There were no statistically significant effects on major bleeding (RR 1.30; 95% CI 0.59 to 2.88), minor bleeding (RR 1.05; 95% 0.75 to 1.46) or QoL. The quality of evidence was high for symptomatic venous thromboembolism, moderate for mortality, major bleeding and minor bleeding, and low for QoL.

AUTHORS' CONCLUSIONS

Heparin was associated with a significant reduction of death at 24 months but not 12 months. It was also associated with a reduction in venous thromboembolism but based on the RCTs in this review it had no significant effect on major bleeding, minor bleeding or QoL. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy for survival benefit should balance the benefits and downsides and integrate the patient's values and preferences.

Venous Thromboembolism in Patients With Cancer

Clinicians must always maintain a heightened suspicion for the development of venous thromboembolism (VTE) in the cancer patient population. VTE is common in this population and often results in morbidity and mortality. The pathophysiology is complex and likely multifactorial. Risk factors for VTE include patient-associated, cancer-associated, and treatment-associated factors as well as biomarkers. Low-molecular-weight heparin (LMWH) is a cornerstone for VTE prophylaxis and treatment. Studies have shown that LMWH may decrease VTE recurrence and impart a survival benefit. Organizational guidelines are available to assist the clinician in choosing appropriate anticoagulant agents, dosing, and duration of prophylaxis and treatment. Pharmacists serve an important role for the safe and effective management of anticoagulation in this complex patient population. In addition, pharmacists can be important providers of patient education about VTE and anticoagulation.

Carbohydrate-based experimental therapeutics for cancer, HIV/AIDS and other diseases

This review, primarily for general readers, briefly presents experimental approaches to therapeutics of cancer, HIV/AIDS and various other diseases based on advances in glycobiology and glycochemistry. Experimental cancer and HIV/AIDS vaccines are being developed in attempts to overcome weak immunological responses to carbohydrate-rich surface antigens using carriers, adjuvants and novel carbohydrate antigen constructs. Current carbohydrate-based vaccines are used for typhus, pneumonia, meningitis; vaccines for anthrax, malaria and leishmaniasis are under development. The link between O-linked beta-N-acetylglucosamine glycosylation and protein phosphorylation in diseases including diabetes and Alzheimer's disease is also explored. Carbohydrate-associated drugs that are in current use or under development, such as heparan sulfate binders, lectins, acarbose, aminoglycosides, tamiflu and heparin, and technologies using carbohydrate and lectin microarrays that offer improved diagnostic and drug development possibilities, are described. Advances in carbohydrate synthesis, analysis and manipulation through the emerging fields of glycochemistry and glycobiology are providing new approaches to disease therapeutics.

[Disseminated intravascular coagulation syndrome and thromboembolic complications of non-small-cell lung cancer. A case report]

Hemostatic disorders can be found in approximately 90% of cancer patients, but clinical expression in only 15%. Hemorrhagic complications are more frequent in acute leukaemia; solid tumors are often associated with deep venous thromboses (DVP). Disseminated intravascular coagulation syndrome (DICS) can be latent or acute, and has various clinical presentations, occurring in the course of many serious conditions including cancer. Patients have higher morbidity and mortality. Irrespective of the etiology, DICS can be revealed by a wide variety of clinical manifestations, from mild biological hemostasis disorders, to intravascular or extravascular microthromboses or lethal hemorrhagic events. We report the case of a 45-year-old female with non-small-cell lung cancer with metastases at diagnosis. The patient developed and finally died of numberous thromboembolic events subsequent to DICS. This case illustrates some rather rare complications of DICS and offers the opportunity to discuss the main therapeutic goal in this situation, i.e. to modulate the disproportionate production of thrombin, inducing thromboses and/or hemorrhages by consumption of the cellular and plasmatic coagulation factors. This means a symptomatic and mostly etiologic treatment, especially chemotherapy which can in itself provoke thromboembolic events.

Association of pretreatment thrombocytosis with disease progression and survival in oral squamous cell carcinoma

The objective of this study was to review the prevalence and prognostic impact of pretreatment thrombocytosis in patients with oral squamous cell carcinoma (OSCC). Medical records of 253 patients with OSCC were retrospectively reviewed. The relationship between the platelet count, TNM stage, histologic differentiation, recurrence rate, metastasis, and survival were analyzed. Pretreatment thrombocytosis was found in 61 (24.1%) of 253 patients and was associated with aggressive tumour growth (p=0.015), lymph node metastasis (p=0.009), and distant metastasis (p=0.001). Association with tumour recurrence fell just short of statistical significance (p=0.058). Patients with preoperative thrombocytosis had a poorer survival than those with normal platelet counts (p=0.004). Multivariate analysis using Cox's proportional hazards model indicated that thrombocytosis was an independent predictor of shorter survival (RR 2.48, 95% CI 1.30- 4.73, p=0.006).

Cellular basis of cancer metastasis: A review of fundamentals and new advances

This review provides an introduction to fundamentals and new advances in cancer metastasis for general readers. The first segment includes topics such as cell adhesion, cell migration, proteases, inflammation, coagulation and site selection in metastasis. Then follows a discussion of an interesting report by Kaplan et al. [VEGFR1-positive haematopoietic bone marrow progenitors initiate the pre-metastatic niche. Nature 2005;438:820-7] that provides evidence for a role of VEGFR1+bone marrow cells in preparing pre-metastatic niches in specific organs that host the arrival and growth of metastatic cancer cells. The therapeutic implications of this study are explored.

Prevention and Management of Venous Thromboembolism in People with Cancer: A Review of the Evidence

Venous thromboembolism (VTE) constitutes an important health problem in developed countries. Owing to their underlying malignancies, people with cancer are at particularly high risk of VTE. The level of this risk is influenced by several factors, including type of cancer and the presence or absence of metastases. However, different types of oncology treatment can also further increase the thrombotic risk. Consequently, primary and secondary thromboprophylaxis in people with cancer should be considered as part of any integrated oncology treatment. Moreover, recent exciting studies have suggested that low molecular weight heparins (LMWH) may also influence overall survival in people with cancer. Clearly, these findings raise the likelihood that the use of LMWH in oncology practice may increase significantly in the near future. However, it is important to appreciate that the use of thromboprophylaxis in people with cancer is complicated by a number of specific problems. In this overview, we have systematically addressed the difficult clinical issues that are involved in the selection of appropriate primary and secondary thromboprophylaxis for people with cancer.