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Huang X, Chen H, Meng S, Pu L, Xu X, Xu P, He S, Hu X, Li Y, Wang G. External validation of the Khorana score for the prediction of venous thromboembolism in cancer patients: A systematic review and meta-analysis. Int J Nurs Stud 2024; 159:104867. [PMID: 39151210 DOI: 10.1016/j.ijnurstu.2024.104867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/18/2024]
Abstract
BACKGROUND Venous thromboembolism is the leading cause of death in cancer patients, second only to tumor progression. The Khorana score is recommended by clinical guidelines for identifying ambulatory cancer patients at high risk of venous thromboembolism during chemotherapy. However, its predictive performance is debated among cancer patients. OBJECTIVES To map the applicability of the Khorana score in cancer patients and to assess its predictive performance across various cancer types, providing guidance for clinicians and nurses to use it more appropriately. DESIGN Systematic review and meta-analysis. METHODS A comprehensive literature search of the electronic database was first conducted on August 30, 2023, and updated on May 20, 2024. Studies examining the Khorana score's predictive performance (including but not limited to the areas under the curve, C-index, and calibration plot) in cancer patients were included. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was applied to evaluate the methodological quality of the included studies. Data synthesis was achieved via random-effects meta-analysis using the R studio software. The subgroup analysis was performed according to the study design, clinical setting, cancer type, anti-cancer treatment stage, and country. RESULTS The review incorporated 67 studies, including 58 observational studies and nine randomized controlled trials. All included studies assessed the Khorana score's discrimination, with the C-index ranging from 0.40 to 0.84. The pooled C-index for randomized controlled trials was 0.61 (95 % CI 0.51-0.70), while observational studies showed a pooled C-index of 0.59 (95 % CI 0.57-0.60). Subgroup analyses revealed the pooled C-index for lung cancer, lymphoma, gastrointestinal cancer, and mixed cancer patients as 0.60 (95 % CI 0.53-0.67), 0.56 (95 % CI 0.51-0.61), 0.59 (95 % CI 0.39-0.76), and 0.60 (95 % CI 0.58-0.61), respectively. Inpatient and outpatient settings had the pooled C-index of 0.60 (95 % CI 0.58-0.63) and 0.58 (95 % CI 0.55-0.61), respectively. Calibration was assessed in only four studies. All included studies were identified to have a high risk of bias according to PROBAST. CONCLUSION The Khorana score has been widely validated in various types of cancer patients; however, it exhibited poor capability (pooled C-index<0.7) in accurately discriminating VTE risk among most types of cancer patients either in inpatient or outpatient settings. The Khorana score should be used with caution, and high-quality studies are needed to further validate its predictive performance. REGISTRATION The protocol for this study is registered with PROSPERO (registration number: CRD42023470320).
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Affiliation(s)
- Xuan Huang
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Hongxiu Chen
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Sha Meng
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Lihui Pu
- Erasmus MC, University Medical Center Rotterdam, Department Internal Medicine, Section Nursing Science, Rotterdam, the Netherlands
| | - Xueqiong Xu
- The First People's Hospital of Longquanyi District, Chengdu, China
| | - Ping Xu
- Emergency Department, Zigong Fourth People's Hospital, Zigong, China
| | - Shengyuan He
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Xiuying Hu
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
| | - Yong Li
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
| | - Guan Wang
- Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, State Key Laboratory of Biotherapy and Cancer Center, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China.
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Englisch C, Vladic N, Ay C. Bleeding Risk in Patients with Cancer. Hamostaseologie 2024. [PMID: 39227022 DOI: 10.1055/a-2347-6507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024] Open
Abstract
The hemostatic system and cancer display a tight interconnection, and hemostatic imbalance frequently occurs in patients with cancer. While extensive knowledge about thrombotic risk has been generated, less is known about bleeding risk and associated risk factors. However, bleeding risk is of high significance as patients with cancer frequently receive therapeutic anticoagulation for various indications and/or are candidates for primary thromboprophylaxis. The risk of bleeding in patients with cancer is variable and difficult to assess in clinical practice. Certain clinical settings such as hospitalization, specific underlying risk factors (e.g., tumor type), and medications (e.g., anticoagulation) can contribute to the individual bleeding risk of a patient with cancer. In addition, some dynamic factors such as platelet count or kidney function have an impact. Particularly, data on baseline risk of bleeding are lacking to allow for risk assessment in cancer patients without anticoagulation. In contrast, risk assessment models for the prediction of bleeding events in cancer patients receiving anticoagulation have been developed; however, these have yet to be validated. The recognition of the importance of bleeding risk in cancer patients is growing, leading to an increasing number of studies investigating and reporting bleeding complications. As study designs and reporting of bleeding events vary, it is challenging to offer a clear synthesis of evidence. In this narrative review, we provide an overview of currently available data about incidence, risk factors, and clinical impact of bleeding events in patients with cancer, and critically review risk assessment models for bleeding in cancer patients during anticoagulant therapy.
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Affiliation(s)
- Cornelia Englisch
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
| | - Nikola Vladic
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
| | - Cihan Ay
- Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna; Vienna, Austria
- Department of Obstetrics, Gynecology and Perinatal Medicine, I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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Heffley J, Ganguly E, Tompkins BJ, Ades S, Holmes CE, Zubarik R. Venous thromboembolism in patients with pancreatic adenocarcinoma: Disease burden and initiation of ambulatory thromboprophylaxis. Pancreatology 2024; 24:894-898. [PMID: 38960779 DOI: 10.1016/j.pan.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 05/07/2024] [Accepted: 06/15/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND/OBJECTIVES Ambulatory thromboprophylaxis (AT) in patients with pancreatic adenocarcinoma (PAC) reduces venous thromboembolism (VTE) risk and is recommended for patients receiving systemic chemotherapy. We evaluated VTE rates, severity, timing, and risk factors in PAC patients as well as AT rates and initiation times. METHODS Patients diagnosed with PAC were included. Data collected included patient demographics, medical history, PAC diagnosis, development of VTE, AT, and bleeding episodes. VTE was defined as a DVT or a PE. Patients were classified as receiving AT for VTE prevention if they received a prescription for outpatient anticoagulation. RESULTS The cohort included 243 PAC patients. VTE occurred in 24 %. Overall, 52 % developing VTE were hospitalized and 5 % died as a result of the VTE. Of those who developed VTE 50 % were diagnosed within the first 2 months of PAC diagnosis. Univariate predictors of elevated VTE risk included an elevated Onkotev score, metastasis at diagnosis, male gender and not receiving AT. Multivariate predictors of elevated VTE risk included male gender (P = 0.014) and not receiving AT (P = 0.001). Overall, 30 % of patients received AT. The median time from diagnosis to initiation of AT was 43 days. Major bleeding occurred in 5.8 %. Patients receiving AT were not at a significantly increased risk of major bleeding (p = 0.5). Patients with intestinal tumor invasion were at significantly increased risk of major bleeding (P = 0.021). CONCLUSION VTE risk is significant and morbid in PAC patients. AT rates are low, and initiation is often delayed. Therapeutic endoscopists diagnosing PAC may be helpful in AT initiation.
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Affiliation(s)
- J Heffley
- Division of Gastroenterology at the University of Vermont Medical Center, USA
| | - E Ganguly
- Division of Gastroenterology at the University of Vermont Medical Center, USA
| | - B J Tompkins
- Division of Medicine at the University of Vermont Medical Center, USA
| | - S Ades
- Division of Hematology and Oncology at the University of Vermont Medical Center, USA
| | - C E Holmes
- Division of Hematology and Oncology at the University of Vermont Medical Center, USA
| | - R Zubarik
- Division of Gastroenterology at the University of Vermont Medical Center, USA.
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Nardi E, Santoro C, Prastaro M, Canonico ME, Paolillo S, Gargiulo G, Gargiulo P, Parlati ALM, Basile C, Bardi L, Giuliano M, Esposito G. Crosslink between atrial fibrillation and cancer: a therapeutic conundrum. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:48. [PMID: 39113118 PMCID: PMC11304574 DOI: 10.1186/s40959-024-00243-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/21/2024] [Indexed: 08/10/2024]
Abstract
Atrial fibrillation (AF) is more common in patients with malignancies than in general population. The pathophysiological processes include the pro-inflammatory condition and the exaggerated inflammatory reaction to chemotherapy, radiotherapy, and surgery interventions. Thus, it is pivotal to decrease morbidity and mortality in this group by providing appropriate care and prevention. In this subset, the risk of thromboembolic and bleeding events is high and the common risk score such as CHA2DS2-VASc and HAS-BLED employed in non-oncologic patients have limited evidence in cancer patients. A paucity of evidence in the setting in individuals having both malignancies and atrial fibrillation entangle the clinician when it comes to therapeutic management. Tailored management is recommended of anticoagulation treatment could be difficult, and there is. In this review, we try to explain the mechanism of AF in cancer patients as well as its management in this setting.
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Affiliation(s)
- Ermanno Nardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Maria Prastaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mario Enrico Canonico
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Giuseppe Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Paola Gargiulo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Antonio L M Parlati
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Christian Basile
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Luca Bardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University Federico II Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
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Alikhan R, Gomez K, Maraveyas A, Noble S, Young A, Thomas M. Cancer-associated venous thrombosis in adults (second edition): A British Society for Haematology Guideline. Br J Haematol 2024; 205:71-87. [PMID: 38664942 DOI: 10.1111/bjh.19414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 07/13/2024]
Abstract
A shared decision on the most appropriate agent for the treatment of cancer-associated thrombosis should consider the following factors, which should be reassessed as patients continue along their cancer care pathway: risk of bleeding; tumour site; suitability of oral medications; potential for drug-drug interactions; and patient preference and values regarding choice of drug. Continuing anticoagulation beyond 6 months in patients with cancer-associated venous thromboembolism and active cancer is recommended.
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Affiliation(s)
- Raza Alikhan
- University Hospital of Wales, Cardiff, UK
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Keith Gomez
- Haemophilia Centre and Thrombosis Unit, Royal Free London NHS Foundation Trust, London, UK
| | - Anthony Maraveyas
- Centre for Clinical Sciences, The Hull York Medical School, York, UK
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Annie Young
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mari Thomas
- University College London Hospitals NHS Foundation Trust, London, UK
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Dinerman AJ, Klemen ND. Results of the TARGET-TP Randomized Clinical Trial. JAMA Oncol 2024; 10:988-989. [PMID: 38814579 DOI: 10.1001/jamaoncol.2024.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Affiliation(s)
- Aaron J Dinerman
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nicholas D Klemen
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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Liz-Pimenta J, Tavares V, Gramaça J, Rato J, Menezes M, Baleiras M, Guedes H, Reis J, Guedes C, Gomes R, Barbosa M, Sousa M, Khorana AA, Medeiros R. Primary thromboprophylaxis in cancer outpatients - real-world evidence. J Thromb Thrombolysis 2024; 57:805-814. [PMID: 38643312 DOI: 10.1007/s11239-024-02984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION Cancer-associated thrombosis (CAT) is a significant concern among patients with malignant diseases, leading to increased mortality. While current guidelines recommend primary thromboprophylaxis for venous thromboembolism (VTE) in medium-to-high-risk outpatients, this practice remains controversial. A better understanding of primary thromboprophylaxis is crucial, yet there is a lack of Real-World Evidence (RWE) in Portugal. AIMS This RWE study aimed to elucidate primary thromboprophylaxis practices among cancer outpatients in Portugal. METHODS A five-year observational multicentric study in eight Portuguese health institutions enrolled 124 adult cancer outpatients under primary thromboprophylaxis for VTE. The endpoints were CAT, bleeding, cancer progression and death. RESULTS High thrombotic risk tumours were prevalent, with 57% (71) of the patients presenting with pancreatic and gastric cancers. Regarding primary thromboprophylaxis, 55% (68) received Low-Molecular-Weight Heparin (LMWH). VTE was presented in 11% (14) of the patients and major bleeding in 2% (2). Vascular compression, elevated D-dimer and previous VTE were significantly associated with VTE occurrence under primary thromboprophylaxis. The Onkotev model was shown to be the best risk assessment model (RAM) in this population (p = 0.007). CAT patients exhibited a lower progression-free survival than non-CAT patients (p = 0.021), while thrombosis did not influence overall survival (p = 0.542). CONCLUSION Primary thromboprophylaxis in medium-to-high-risk cancer outpatients is a safe and effective practice in real-world settings. This study is the first Portuguese RWE on primary thromboprophylaxis, highlighting evidence for improving prophylactic strategies in this population.
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Affiliation(s)
- Joana Liz-Pimenta
- Department of Medical Oncology, Hospital Center of Trás-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
- Faculty of Medicine of University of Porto (FMUP), 4200-072, Porto, Portugal
| | - Valéria Tavares
- Faculty of Medicine of University of Porto (FMUP), 4200-072, Porto, Portugal
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP) / Pathology and Laboratory Medicine Dep., Clinical Pathology SV / RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center (Porto. CCC), 4200-072, Porto, Portugal
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal
| | - João Gramaça
- Department of Medical Oncology, Hospital Center of Barreiro Montijo, 2830-003, Barreiro, Portugal
| | - João Rato
- Department of Medical Oncology, Hospital of Luz Setúbal, 2900-722, Setúbal, Portugal
| | - Maria Menezes
- Department of Medical Oncology, Hospital of Espírito Santo de Évora, 7000-811, Évora, Portugal
| | - Mafalda Baleiras
- Department of Medical Oncology, Hospital Center of Lisboa Ocidental, 1449-005, Lisbon, Portugal
| | - Helena Guedes
- Department of Medical Oncology, Hospital Center of Vila Nova de Gaia / Espinho, 4434-502, Vila Nova de Gaia, Portugal
| | - Joana Reis
- Department of Medical Oncology, University Hospital Center of São João, 4200-319, Porto, Portugal
| | - Catarina Guedes
- Department of Imunohemotherapy, Hospital of Senhora da Oliveira, 4835-044, Guimarães, Portugal
| | - Rosa Gomes
- Department of Medical Oncology, Hospital Center of Trás-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
| | - Miguel Barbosa
- Department of Medical Oncology, University Hospital Center of São João, 4200-319, Porto, Portugal
| | - Marta Sousa
- Department of Medical Oncology, Hospital Center of Trás-Os-Montes E Alto Douro, 5000-508, Vila Real, Portugal
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, 44106, USA
| | - Rui Medeiros
- Faculty of Medicine of University of Porto (FMUP), 4200-072, Porto, Portugal.
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP) / Pathology and Laboratory Medicine Dep., Clinical Pathology SV / RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center (Porto. CCC), 4200-072, Porto, Portugal.
- ICBAS - Instituto de Ciências Biomédicas Abel Salazar, Universidade Do Porto, Porto, Portugal.
- Research Department, Portuguese League Against Cancer - Regional Nucleus of the North, 4200-172, Porto, Portugal.
- Biomedical Research Center, Faculty of Health Sciences of the Fernando Pessoa University, 4249-004, Porto, Portugal.
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Prouse T, Mohammad MA, Ghosh S, Kumar N, Duhaylungsod ML, Majumder R, Majumder S. Pancreatic Cancer and Venous Thromboembolism. Int J Mol Sci 2024; 25:5661. [PMID: 38891849 PMCID: PMC11171482 DOI: 10.3390/ijms25115661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
Pancreatic ductal adenocarcinoma (PDAC) accounts for more than 90% of all pancreatic cancers and is the most fatal of all cancers. The treatment response from combination chemotherapies is far from satisfactory and surgery remains the mainstay of curative strategies. These challenges warrant identifying effective treatments for combating this deadly cancer. PDAC tumor progression is associated with the robust activation of the coagulation system. Notably, cancer-associated thrombosis (CAT) is a significant risk factor in PDAC. CAT is a concept whereby cancer cells promote thromboembolism, primarily venous thromboembolism (VTE). Of all cancer types, PDAC is associated with the highest risk of developing VTE. Hypoxia in a PDAC tumor microenvironment also elevates thrombotic risk. Direct oral anticoagulants (DOACs) or low-molecular-weight heparin (LMWH) are used only as thromboprophylaxis in PDAC. However, a precision medicine approach is recommended to determine the precise dose and duration of thromboprophylaxis in clinical setting.
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Affiliation(s)
- Teagan Prouse
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Mohammad A. Mohammad
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Sonali Ghosh
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Narender Kumar
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Ma. Lorena Duhaylungsod
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Rinku Majumder
- Department of Interdisciplinary Oncology, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA; (T.P.); (M.A.M.); (S.G.); (N.K.); (M.L.D.)
| | - Samarpan Majumder
- Department of Genetics, Louisiana State University Health Sciences Center, New Orleans, LA 70112, USA
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Ji Y, Qin Y, Tan Q, Qiu Y, Han S, Qi X. Development of a chemiluminescence assay for tissue plasminogen activator inhibitor complex and its applicability to gastric cancer. BMC Biotechnol 2024; 24:30. [PMID: 38720310 PMCID: PMC11080135 DOI: 10.1186/s12896-024-00850-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), is a noteworthy complication in individuals with gastric cancer, but the current diagnosis and treatment methods lack accuracy. In this study, we developed a t-PAIC chemiluminescence kit and employed chemiluminescence to detect the tissue plasminogen activator inhibitor complex (t-PAIC), thrombin-antithrombin III complex (TAT), plasmin-α2-plasmin inhibitor complex (PIC) and thrombomodulin (TM), combined with D-dimer and fibrin degradation products (FDP), to investigate their diagnostic potential for venous thrombosis in gastric cancer patients. The study assessed variations in six indicators among gastric cancer patients at different stages. RESULTS The t-PAIC reagent showed LOD is 1.2 ng/mL and a linear factor R greater than 0.99. The reagents demonstrated accurate results, with all accuracy deviations being within 5%. The intra-batch and inter-batch CVs for the t-PAIC reagent were both within 8%. The correlation coefficient R between this method and Sysmex was 0.979. Gastric cancer patients exhibited elevated levels of TAT, PIC, TM, D-D, FDP compared to the healthy population, while no significant difference was observed in t-PAIC. In the staging of gastric cancer, patients in III-IV stages exhibit higher levels of the six markers compared to those in I-II stages. The ROC curve indicates an enhancement in sensitivity and specificity of the combined diagnosis of four or six indicators. CONCLUSION Our chemiluminescence assay performs comparably to Sysmex's method and at a reduced cost. The use of multiple markers, including t-PAIC, TM, TAT, PIC, D-D, and FDP, is superior to the use of single markers for diagnosing VTE in patients with malignant tumors. Gastric cancer patients should be screened for the six markers to facilitate proactive prophylaxis, determine the most appropriate treatment timing, ameliorate their prognosis, decrease the occurrence of venous thrombosis and mortality, and extend their survival.
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Affiliation(s)
- Yu Ji
- Department of Pathology, Affiliated Hospital of Jiangnan University, No.1000, Hefeng Road, Wuxi, 214122, Jiangsu, China
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China
| | - Yan Qin
- Department of Pathology, Affiliated Hospital of Jiangnan University, No.1000, Hefeng Road, Wuxi, 214122, Jiangsu, China
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China
| | - Qi Tan
- Department of Pathology, Affiliated Hospital of Jiangnan University, No.1000, Hefeng Road, Wuxi, 214122, Jiangsu, China
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China
| | - Yanru Qiu
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China
| | - Shuang Han
- Department of Pathology, Affiliated Hospital of Jiangnan University, No.1000, Hefeng Road, Wuxi, 214122, Jiangsu, China.
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China.
| | - Xiaowei Qi
- Department of Pathology, Affiliated Hospital of Jiangnan University, No.1000, Hefeng Road, Wuxi, 214122, Jiangsu, China.
- Wuxi Medical College, Jiangnan University, Wuxi, Jiangsu, China.
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Tatsumi K. The pathogenesis of cancer-associated thrombosis. Int J Hematol 2024; 119:495-504. [PMID: 38421488 DOI: 10.1007/s12185-024-03735-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/02/2024]
Abstract
Patients with cancer have a higher risk of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), compared to the general population. Cancer-associated thrombosis (CAT) is a thrombotic event that occurs as a complication of cancer or cancer therapy. Major factors determining VTE risk in cancer patients include not only treatment history and patient characteristics, but also cancer type and site. Cancer types can be broadly divided into three groups based on VTE risk: high risk (pancreatic, ovarian, brain, stomach, gynecologic, and hematologic), intermediate risk (colon and lung), and low risk (breast and prostate). This implies that the mechanism of VTE differs between cancer types and that specific VTE pathways may exist for different cancer types. This review summarizes the specific pathways that contribute to VTE in cancer patients, with a particular focus on leukocytosis, neutrophil extracellular traps (NETs), tissue factor (TF), thrombocytosis, podoplanin (PDPN), plasminogen activator inhibitor-1 (PAI-1), the intrinsic coagulation pathway, and von Willebrand factor (VWF).
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Affiliation(s)
- Kohei Tatsumi
- Advanced Medical Science of Thrombosis and Hemostasis, Nara Medical University, 840 Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
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Bodea IC, Ciocan A, Zaharie FV, Bodea R, Graur F, Ursu Ș, Ciocan RA, Al Hajjar N. HER2 Overexpression in Periampullary Tumors According to Anatomical and Histological Classification-A Systematic Review. J Pers Med 2024; 14:463. [PMID: 38793045 PMCID: PMC11122564 DOI: 10.3390/jpm14050463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 04/25/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Pancreatic cancer is one of the most aggressive, heterogeneous, and fatal types of human cancer; therefore, more effective therapeutic drugs are urgently needed. Human epidermal growth factor receptor 2 (HER2) overexpression and amplification have been identified as a cornerstone in this pathology. The aim of this review is to identify HER2 membrane overexpression in relation to pancreatic cancer pathways that can be used in order to develop a targeted therapy. After searching the keywords, 174 articles were found during a time span of 10 years, between 2013 and 2023, but only twelve scientific papers were qualified for this investigation. The new era of biomolecular research found a significant relationship between HER2 overexpression and pancreatic cancer cells in 25-30% of cases. The variables are dependent on tumor-derived cells, with differences in receptor overexpression between PDAC (pancreatic ductal adenocarcinoma), BTC (biliary tract cancer), ampullary carcinoma, and PNETs (pancreatic neuroendocrine tumors). HER2 overexpression is frequently encountered in human pancreatic carcinoma cell lines, and the ERBB family is one of the targets in the near future of therapy, with good results in phase I, II, and III studies evaluating downregulation and tumor downstaging, respectively.
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Affiliation(s)
- Ioan Cătălin Bodea
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Andra Ciocan
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Florin Vasile Zaharie
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Raluca Bodea
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Florin Graur
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Ștefan Ursu
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
| | - Răzvan Alexandru Ciocan
- Department of Surgery-Practical Abilities, “Iuliu Hațieganu” University of Medicine and Pharmacy, Marinescu Street, No. 23, 400337 Cluj-Napoca, Romania;
| | - Nadim Al Hajjar
- Department of Surgery, “Iuliu Hațieganu” University of Medicine and Pharmacy, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania; (I.C.B.); (F.V.Z.); (F.G.); (Ș.U.); (N.A.H.)
- “Octavian Fodor” Regional Institute of Gastroenterology and Hepatology, Croitorilor Street, No. 19–21, 400162 Cluj-Napoca, Romania;
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Kouvela M, Livanou ME, Stefanou DT, Vathiotis IA, Sarropoulou F, Grammoustianou M, Dimakakos E, Syrigos N. Efficacy and Safety of Tinzaparin Thromboprophylaxis in Lung Cancer Patients with High Thromboembolic Risk: A Prospective, Observational, Single-Center Cohort Study. Cancers (Basel) 2024; 16:1442. [PMID: 38611118 PMCID: PMC11011428 DOI: 10.3390/cancers16071442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/01/2024] [Accepted: 04/03/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The aim of this study was to record and assess the efficacy and safety ofthromboprophylaxis with an intermediate dose of Tinzaparin in lung cancer patients with high thrombotic risk. METHODS This was a non-interventional, single-arm, prospective cohort study of lung cancer patients who received thromboprophylaxis with Tinzaparin 10.000 Anti-Xa IU in 0.5 mL, OD, used in current clinical practice. Enrolled ambulatory patients signed informed consent. Anti-Xa levels were tested. RESULTS In total, 140 patients were included in the study, of which 81.4% were males. The histology of the tumor was mainly adenocarcinoma. Lung cancer patients with high thrombotic risk based on tumor, patient, treatment, and laboratory-related factors were enrolled. Only one patient experienced a thrombotic event (0.7%), and 10 patients had bleeding events (7.1%), including only one major event. Anti-Xa levels measured at 10 days and 3 months did not differ significantly between patients who developed hemorrhagic events and those who did not (p = 0.26 and p = 0.32, respectively). CONCLUSION Thromboprophylaxis with an intermediate Tinzaparin dose in high thrombotic-risk lung cancer patients is a safe and effective choice for the prevention of VTE.
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Affiliation(s)
- Marousa Kouvela
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Maria Effrosyni Livanou
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Dimitra T. Stefanou
- First Department of Internal Medicine, Laikon General Hospital, School of Medicine, National Kapodistrian University of Athens, 11527 Athens, Greece;
| | - Ioannis A. Vathiotis
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Fotini Sarropoulou
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Maria Grammoustianou
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Evangelos Dimakakos
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
| | - Nikolaos Syrigos
- Oncology Unit, Third Department of Internal Medicine, Sotiria General Hospital for Chest Diseases, National and Kapodistrian University of Athens, 11527 Athens, Greece; (M.E.L.); (I.A.V.); (F.S.); (M.G.); (E.D.); (N.S.)
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13
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Willems RAL, Biesmans C, Campello E, Simioni P, de Laat B, de Vos-Geelen J, Roest M, Ten Cate H. Cellular Components Contributing to the Development of Venous Thrombosis in Patients with Pancreatic Cancer. Semin Thromb Hemost 2024; 50:429-442. [PMID: 38049115 DOI: 10.1055/s-0043-1777304] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is an aggressive type of cancer and has a poor prognosis. Patients with PDAC are at high risk of developing thromboembolic events, which is a leading cause of morbidity and mortality following cancer progression. Plasma-derived coagulation is the most studied process in cancer-associated thrombosis. Other blood components, such as platelets, red blood cells, and white blood cells, have been gaining less attention. This narrative review addresses the literature on the role of cellular components in the development of venous thromboembolism (VTE) in patients with PDAC. Blood cells seem to play an important role in the development of VTE. Altered blood cell counts, i.e., leukocytosis, thrombocytosis, and anemia, have been found to associate with VTE risk. Tumor-related activation of leukocytes leads to the release of tissue factor-expressing microvesicles and the formation of neutrophil extracellular traps, initiating coagulation and forming a scaffold for thrombi. Tissue factor-expressing microvesicles are also thought to be released by PDAC cells. PDAC cells have been shown to stimulate platelet activation and aggregation, proposedly via the secretion of podoplanin and mucins. Hypofibrinolysis, partially explained by increased plasminogen activator inhibitor-1 activity, is observed in PDAC. In short, PDAC-associated hypercoagulability is a complex and multifactorial process. A better understanding of cellular contributions to hypercoagulability might lead to the improvement of diagnostic tests to identify PDAC patients at highest risk of VTE.
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Affiliation(s)
- Ruth Anne Laura Willems
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Charlotte Biesmans
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Elena Campello
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Paolo Simioni
- General Medicine and Thrombotic and Hemorrhagic Diseases Unit, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Bas de Laat
- Department of Functional Coagulation, Synapse Research Institute, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Judith de Vos-Geelen
- Division of Medical Oncology, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
- Division of Vascular Medicine, Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, Maastricht, The Netherlands
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14
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Wang Y, Li Q, Zhou Y, Dong Y, Li J, Liang T. A systematic review of risk prediction model of venous thromboembolism for patients with lung cancer. Thorac Cancer 2024; 15:277-285. [PMID: 38233997 PMCID: PMC10834197 DOI: 10.1111/1759-7714.15219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) increases the risk of death or adverse outcomes in patients with lung cancer. Therefore, early identification and treatment of high-risk groups of VTE have been the research focus. In this systematic review, the risk assessment tools of VTE in patients with lung cancer were systematically analyzed and evaluated to provide a reference for VTE management. METHODS Relevant studies were retrieved from major English databases (The Cochrane Library, Embase, Web of Science, PubMed, Scopus, Medline) and Chinese databases (China National Knowledge Infrastructure [CNKI] and WanFang Data) until July 2023 and extracted by two researchers. This systematic review was registered at PROSPERO (no. CRD42023409748). RESULTS Finally, two prospective cohort studies and four retrospective cohort studies were included from 2019. There was a high risk of bias in all included studies according to the Prediction Model Risk of Bias Assessment tool (PROBAST). In the included studies, Cox and logistic regression were used to construct models. The area under the receiver operating characteristic curve (AUC) of the model ranged from 0.670 to 0.904, and the number of predictors ranged from 4 to 11. The D-dimer index was included in five studies, but significant differences existed in optimal cutoff values from 0.0005 mg/L to 2.06 mg/L. Then, three studies validated the model externally, two studies only validated the model internally, and only one study validated the model using a combination of internal and external validation. CONCLUSION VTE risk prediction models for patients with lung cancer have received attention for no more than 5 years. The included model shows a good predictive effect and may help identify the risk population of VTE at an early stage. In the future, it is necessary to improve data modeling and statistical analysis methods, develop predictive models with good performance and low risk of bias, and focus on external validation and recalibration of models.
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Affiliation(s)
- Yan Wang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Qiuyue Li
- School of NursingPeking Union Medical CollegeBeijingChina
| | - Yanjun Zhou
- Department of Nursing, Beijing Children's HospitalCapital Medical University, National Center for Children's HealthBeijingChina
| | - Yiting Dong
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Jinping Li
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Tao Liang
- School of NursingPeking Union Medical CollegeBeijingChina
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15
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Tavares V, Neto BV, Marques IS, Assis J, Pereira D, Medeiros R. Cancer-associated thrombosis: What about microRNAs targeting the tissue factor coagulation pathway? Biochim Biophys Acta Rev Cancer 2024; 1879:189053. [PMID: 38092078 DOI: 10.1016/j.bbcan.2023.189053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 12/18/2023]
Abstract
Cancer patients are often diagnosed with venous thromboembolism (VTE), a cardiovascular disease that substantially decreases their quality of life and survival rate. Haemostasis in these patients is deregulated, which is reflected in the common presentation of a blood hypercoagulation state. Despite the inconsistent results, existing evidence suggests that the expression of microRNAs (miRNAs) is deregulated in the context of venous thrombogenesis in the general population. However, few miRNAs are known to be linked to cancer-associated VTE due to the lack of studies with oncological patients. Parallelly, coagulation factor III, also known as tissue factor (TF), tissue factor pathway inhibitor 1 (TFPI1) and tissue factor pathway inhibitor 2 (TFPI2) have been proposed to have a central role in cancer-associated VTE and tumour progression. Yet, contrary to what was expected, the role of miRNAs targeting the TF coagulation pathway (or extrinsic coagulation pathway) is poorly explored in cancer-induced thrombogenesis. In this review, in addition to miRNAs implicated in VTE, TF and TFPI1/2-targeting miRNAs were revised. Future studies should clarify the implications of these non-coding RNAs in tumour coagulome.
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Affiliation(s)
- Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Medicine of University of Porto (FMUP), 4200-072 Porto, Portugal; Abel Salazar Institute for the Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal
| | - Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Research Department, Portuguese League Against Cancer (NRNorte), 4200-172 Porto, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Sciences of University of Porto (FCUP), 4169-007 Porto, Portugal
| | - Joana Assis
- Clinical Research Unit, Research Center of IPO Porto (CI-IPOP) / RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center (Porto.CCC), 4200-072 Porto, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPO Porto), 4200-072 Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Medicine of University of Porto (FMUP), 4200-072 Porto, Portugal; Abel Salazar Institute for the Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal; Research Department, Portuguese League Against Cancer (NRNorte), 4200-172 Porto, Portugal; Faculty of Health Sciences, Fernando Pessoa University, 4200-150 Porto, Portugal.
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16
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Shoji M, Yamashita Y, Ishii M, Inoue H, Kato H, Fujita S, Matsui K, Tajiri K, Nameki M, Muraoka N, Nonaka A, Sugino H, Kono M, Oka T, Sueta D, Komuro I, Tsujita K. A Predictive Model for Cancer-Associated Thrombosis in Japanese Cancer Patients: Findings from the J-Khorana Registry. TH OPEN 2024; 8:e9-e18. [PMID: 38197014 PMCID: PMC10774015 DOI: 10.1055/a-2207-7715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
Background Although the close relationship between cancer and venous thromboembolism (VTE) has been identified, risk stratification for VTE in Japanese patients with cancer remains unclear. Objectives This study aimed to validate the Khorana VTE risk assessment score (KRS) for VTE diagnosis and establish an optimal predictive model for VTE in Japanese patients with cancer. Methods A total of 7,955 Japanese patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups according to the KRS. Using 37 explanatory variables, a total of 2,833 patients with cancer were divided into derivation and validation cohorts (5:5). A risk model for Japanese participants was developed using the derivation cohort data. Results The prevalence of VTE in low-, intermediate-, and high-score patients was 1.2, 2.5, and 4.3%, respectively. Logistic regression analysis demonstrated that cancer stage (III-IV) and KRS ≥ 2 were independent and significant predictors of VTE onset. The risk model for VTE assigned 1 point to body mass index ≥25 kg/m 2 and 2 points each to the prevalence of osteochondral cancer and D-dimer level ≥1.47 µg/mL. The areas under the curve of the risk model were 0.763 and 0.656 in the derivation and validation cohorts, respectively. Conclusion The KRS was useful in Japanese patients, and our new predictive model may be helpful for the diagnosis of VTE in Japanese patients with cancer.
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Affiliation(s)
- Masaaki Shoji
- Department of General Internal Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Hitoki Inoue
- Department of Cardiology, National Hospital Organization (NHO) Hokkaido Cancer Center, Hokkaido, Japan
| | - Hiroshi Kato
- Division of Onco-Cardiology, Miyagi Cancer Center, Miyagi, Japan
| | - Shin Fujita
- Department of Surgery, Tochigi Cancer Center, Tochigi, Japan
| | - Kazuhiro Matsui
- Department of Internal Medicine, Onco-Cardiology Unit, Saitama Cancer Center, Saitama, Japan
| | - Kazuko Tajiri
- Department of Cardiology, National Cancer Center Hospital East, Chiba, Japan
| | - Mizuo Nameki
- Division of Cardiology, Chiba Cancer Center, Chiba, Japan
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan.
| | - Akiko Nonaka
- Division of Onco-Cardiology, Hyogo Cancer Center, Hyogo, Japan
| | - Hiroshi Sugino
- Division of Cardiology, NHO Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Mihoko Kono
- Department of Onco-Cardiology, NHO Kyushu Cancer Center, Fukuoka, Japan
| | - Toru Oka
- Department of Internal Medicine, Onco-Cardiology Unit, Saitama Cancer Center, Saitama, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
| | - Issei Komuro
- Department of Frontier Cardiovascular Science, International University of Health and Welfare, Tokyo, Japan
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Kumamoto University School of Medicine, Kumamoto, Japan
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García Vallejo O, Aicart Bort MD, Babiano Fernández MÁ, Caballer Rodilla J, Cabrera Ferriols MÁ, Carrasco Carrasco E, Gil Gil I, Lahera García AM, Martos Cárdenas T, Piera Carbonell A. [Recommendations for thromboembolic disease in oncological processes. A view from primary care]. Semergen 2023; 49:102030. [PMID: 37487423 DOI: 10.1016/j.semerg.2023.102030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/25/2023] [Accepted: 06/06/2023] [Indexed: 07/26/2023]
Abstract
Venous thromboembolic disease (VTE) is a frequent complication in patients diagnosed with cancer and a cause of morbidity and mortality. Approximately 20% of thromboembolic episodes develop in association with active cancer. On the other hand, it is estimated that about 2-12% of cases, the thromboembolic episode is the first manifestation of an occult cancer, diagnosed at that time or subsequently, which offers an opportunity for early diagnosis and treatment. There are multiple factors that contribute to increase the risk of VTE in oncological patients in relation to specific characteristics of the patient, the tumor and the treatments. Knowledge of these risk factors will contribute to early diagnosis when signs of VTE appear, as well as the assessment of thromboprophylaxis if indicated. The diagnosis of VTE in patients with cancer does not differ of those who do not suffer from it. Regarding the treatment of VTE in these patients, low molecular weight heparin (LMWH), direct acting anticoagulants (DACs) and antivitamin K (VKA) are the most commonly used, although the dosing regimen and length are not clear yet. The management of these patients should be interdisciplinary and early, so the primary care physician plays a key role in this process as he/she is liaise with his/her patients. It is also necessary to update knowledge in order to improve the care of these patients. For these reasons, this document has been prepared by the Working Group on Vasculopathies of the Spanish Society of Primary Care Physicians (SEMERGEN) whose objective is to present the available information regarding the management of VTE that may appear in oncological patients, as well as the assessment of thromboprophylaxis and treatment, if appropriate, from an approach focused on a primary care field.
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Affiliation(s)
- O García Vallejo
- Medicina Familiar y Comunitaria, Centro de Salud Comillas, Madrid, España.
| | | | - M Á Babiano Fernández
- Medicina Familiar y Comunitaria, Centro de Salud Argamasilla de Calatrava, Argamasilla de Calatrava, Ciudad Real, España
| | - J Caballer Rodilla
- Medicina Familiar y Comunitaria. Centro de Salud Algete, Algete, Madrid, España
| | | | - E Carrasco Carrasco
- Medicina Familiar y Comunitaria, Centro de Salud de Abarán, Abarán, Murcia, España
| | - I Gil Gil
- Medicina Familiar y Comunitaria, Centro de Salud Vielha, Vielha, Lleida, España
| | | | | | - A Piera Carbonell
- Medicina Familiar y Comunitaria, Centro de Salud Corredoria, Oviedo, Asturias, España
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18
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Verso M, Muñoz A, Connors JM. Ambulatory cancer patients: who should definitely receive antithrombotic prophylaxis and who should never receive. Intern Emerg Med 2023; 18:1619-1634. [PMID: 37227679 DOI: 10.1007/s11739-023-03306-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
Up to 15-20% of cancer patients experience one or more episodes of venous thromboembolism during cancer disease. Approximately 80% of all cancer-associated venous thromboembolic events occur in non-hospitalized patients. Routine thromboprophylaxis for outpatients with cancer who start new anticancer treatment is currently not recommended by the international guidelines due to the high heterogeneity of these patients in terms of VTE or bleeding risks, the difficulties in selecting patients at high risk, and the uncertainty of duration of prophylaxis. Although the international guidelines endorsed the Khorana score for estimating the thrombotic risk in ambulatory cancer patients, the discriminatory performance of this score is not completely convincing and varies according to the cancer type. Consequently, a minority of ambulatory patients with cancer receive an accurate screening for primary prophylaxis of VTE. The aim of this review is to provide support to physicians in identifying those ambulatory patients with cancer for whom thromboprophylaxis should be prescribed and those that should not be candidate to thromboprophylaxis. In absence of high bleeding risk, primary thromboprophylaxis should be recommended in patients with pancreatic cancer and, probably, in patients with lung cancer harboring ALK/ROS1 translocations. Patients with upper gastrointestinal cancers are at high risk of VTE, but a careful assessment of bleeding risk should be made before deciding on antithrombotic prophylaxis. Primary prevention of VTE is not recommended in cancer patients at increased risk of bleeding as patients with brain cancer, with moderate-to-severe thrombocytopenia or severe renal impairment.
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Affiliation(s)
- Melina Verso
- Internal, Vascular and Emergency Medicine-Stroke Unit, University of Perugia, Perugia, Italy.
| | - Andres Muñoz
- Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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19
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Wahab R, Hasan MM, Azam Z, Grippo PJ, Al-Hilal TA. The role of coagulome in the tumor immune microenvironment. Adv Drug Deliv Rev 2023; 200:115027. [PMID: 37517779 PMCID: PMC11099942 DOI: 10.1016/j.addr.2023.115027] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
The rising incidence and persistent thrombosis in multiple cancers including those that are immunosuppressive highlight the need for understanding the tumor coagulome system and its role beyond hemostatic complications. Immunotherapy has shown significant benefits in solid organ tumors but has been disappointing in the treatment of hypercoagulable cancers, such as glioblastoma and pancreatic ductal adenocarcinomas. Thus, targeting thrombosis to prevent immunosuppression seems a clinically viable approach in cancer treatment. Hypercoagulable tumors often develop fibrin clots within the tumor microenvironment (TME) that dictates the biophysical characteristics of the tumor tissue. The application of systems biology and single-cell approaches highlight the potential role of coagulome or thrombocytosis in shaping the tumor immune microenvironment (TIME). In-depth knowledge of the tumor coagulome would provide unprecedented opportunities to better predict the hemostatic complications, explore how thrombotic stroma modulates tumor immunity, reexamine the significance of clinical biomarkers, and enable steering the stromal versus systemic immune response for boosting the effectiveness of immune checkpoint inhibitors in cancer treatment. We focus on the role of coagulation factors in priming a suppressive TIME and the huge potential of existing anticoagulant drugs in the clinical settings of cancer immunotherapy.
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Affiliation(s)
- Riajul Wahab
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Md Mahedi Hasan
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA; Department of Environmental Science & Engineering, College of Science, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Zulfikar Azam
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA
| | - Paul J Grippo
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Taslim A Al-Hilal
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Texas at El Paso, El Paso, TX 79968, USA; Department of Environmental Science & Engineering, College of Science, University of Texas at El Paso, El Paso, TX 79968, USA.
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20
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Giustozzi M, Franco L, Agnelli G, Verso M. Unmet clinical needs in the prevention and treatment of cancer-associated venous thromboembolism. Trends Cardiovasc Med 2023; 33:336-343. [PMID: 35150850 DOI: 10.1016/j.tcm.2022.02.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/31/2022] [Accepted: 02/06/2022] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a leading cause of morbidity and mortality in patients with cancer. Based on accumulating evidence, the prophylaxis and treatment of cancer-associated VTE have been changed over the years. Recently, the introduction in clinical practice of the direct oral anticoagulants has radically changed the management of cancer-associated VTE for their easier use and non-inferior efficacy-safety profile compared to low-molecular-weight heparins. However, the heterogeneity of the cancer population in terms of site, type and stage of the malignancy, the presence of comorbidities, and the variability in cancer treatment and prognosis represent major challenges in the management of VTE in patients with cancer. In the present review, we will discuss clinical questions that represent unsolved issues in the setting of cancer-associated VTE and provide an overview on recent evidence on this topic: primary prophylaxis in ambulatory cancer patients treated with chemotherapy and in cancer surgical patients, need of long-term anticoagulation in cancer patients, treatment of VTE in cancer patients at increased bleeding risk and in special categories such as incidental VTE, splanchnic vein thrombosis or catheter-related thrombosis.
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Affiliation(s)
- Michela Giustozzi
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy.
| | - Laura Franco
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
| | - Melina Verso
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Menghini 1, Perugia 06129, Italy
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21
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Willems RAL, Michiels N, Lanting VR, Bouwense S, van den Broek BLJ, Graus M, Klok FA, Groot Koerkamp B, de Laat B, Roest M, Wilmink JW, van Es N, Mieog JSD, Ten Cate H, de Vos-Geelen J. Venous Thromboembolism and Primary Thromboprophylaxis in Perioperative Pancreatic Cancer Care. Cancers (Basel) 2023; 15:3546. [PMID: 37509209 PMCID: PMC10376958 DOI: 10.3390/cancers15143546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/27/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Recent studies have shown that patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemo(radio)therapy followed by surgery have an improved outcome compared to patients treated with upfront surgery. Hence, patients with PDAC are more and more frequently treated with chemotherapy in the neoadjuvant setting. PDAC patients are at a high risk of developing venous thromboembolism (VTE), which is associated with decreased survival rates. As patients with PDAC were historically offered immediate surgical resection, data on VTE incidence and associated preoperative risk factors are scarce. Current guidelines recommend primary prophylactic anticoagulation in selected groups of patients with advanced PDAC. However, recommendations for patients with (borderline) resectable PDAC treated with chemotherapy in the neoadjuvant setting are lacking. Nevertheless, the prevention of complications is crucial to maintain the best possible condition for surgery. This narrative review summarizes current literature on VTE incidence, associated risk factors, risk assessment tools, and primary thromboprophylaxis in PDAC patients treated with neoadjuvant chemo(radio)therapy.
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Affiliation(s)
- R A L Willems
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - N Michiels
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - V R Lanting
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
- Tergooi Hospitals, Internal Medicine, 1201 DA Hilversum, The Netherlands
| | - S Bouwense
- Department of Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- NUTRIM, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - B L J van den Broek
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - M Graus
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - F A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - B Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center, 3015 CN Rotterdam, The Netherlands
| | - B de Laat
- Department of Functional Coagulation, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - M Roest
- Department of Platelet Pathophysiology, Synapse Research Institute, 6217 KD Maastricht, The Netherlands
| | - J W Wilmink
- Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
- Department of Medical Oncology, Amsterdam University Medical Center, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - N van Es
- Department of Internal Medicine, Section Vascular Medicine, University of Amsterdam, Amsterdam UMC Location, 1105 AZ Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, 1081 HV Amsterdam, The Netherlands
| | - J S D Mieog
- Department of Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - H Ten Cate
- Thrombosis Expert Center Maastricht, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- CARIM, School for Cardiovascular Diseases, 6229 ER Maastricht, The Netherlands
| | - J de Vos-Geelen
- Department of Internal Medicine, Section Medical Oncology, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
- GROW, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
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22
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Elalamy I, Cohen-Solal A, Hanon O, Mirabel M, Mismetti P, Spano JP. Primary prevention of cancer-associated venous thrombosis: Rationale and challenges in clinical practice. Curr Res Transl Med 2023; 71:103405. [PMID: 37478777 DOI: 10.1016/j.retram.2023.103405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
Cancer-associated venous thrombosis (CAT) is a common, multifactor event known to complicate the course of cancer and jeopardize a patient's prognosis. The current guidelines regarding the prevention of CAT are sometimes considered insufficiently precise about specific situations, or are poorly applied. The expected benefits of thromboprophylaxis are balanced by the risk of major bleeding induced by anticoagulation, which implies a need to accurately identify ambulatory patients at high risk of thrombosis or hemorrhage. The Khorana score is commonly used for this, but is limited by the non-reproducibility of predicted performance across cancer types, and by the fact that antitumor treatment and cardiovascular risks are not included. The COMPASS-CAT score, which includes those two aspects, was found to be a more accurate predictor of venous thromboembolism in patients with lung cancer, and to better distinguish between patients at low or high risk of thrombosis. The frailty of patients with cancer is also a major issue, and should be taken into account when thromboprophylaxis is considered. According to current guidelines, CAT prophylaxis should be considered for hospitalized patients, those for whom surgery is scheduled, or those with pancreatic cancers. In ambulatory patients, decisions should be made according to patient, cancer and antitumoral treatment characteristics. Low molecular weight heparin is the gold standard of CAT prophylaxis. Despite increased risks of bleeding or drug-drug interactions in cancer patients, direct oral anticoagulants could be alternate options for high-risk ambulatory patients that should be accompanied by a careful global analysis of benefits, harms, and patient preferences.
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Affiliation(s)
- Ismail Elalamy
- Thrombosis Center, Hematology Department (DMU BioGeM), Assistance Publique Hôpitaux de Paris, Sorbonne University of Medicine, Paris, France; Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Research Centre Saint-Antoine, University Institute of Cancerology, Sorbonne University of Medicine, Paris, France; The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM Unité 942 MASCOT, AP-HP, Département de cardiologie et maladies vasculaires, Hôpital Lariboisière, Paris, France
| | - Olivier Hanon
- Université Paris Cité, EA4468, AP-HP, hôpitaux Universitaires Paris Centre, Département de Gériatrie, Hôpital Broca, Paris, France
| | - Mariana Mirabel
- Département de Cardiologie, Institut mutualiste Montsouris, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire, Saint Etienne, France
| | - Jean-Philippe Spano
- Service d'Oncologie médicale, APHP-SU, IUC, Hôpital La Pitié-Salpêtrière, Paris, France
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23
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Nwagha T, Nweke M. Stratification of Risk Factors of Lung Cancer-Associated Venous Thromboembolism and Determining the Critical Point for Preemptive Intervention: A Systematic Review With Meta-analysis. Clin Med Insights Oncol 2023; 17:11795549231175221. [PMID: 37426681 PMCID: PMC10328178 DOI: 10.1177/11795549231175221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 04/20/2023] [Indexed: 07/11/2023] Open
Abstract
Background Several biomarkers or risk factors have been identified and several prediction models exist. The major limitations inherent in these models include cost-ineffectiveness and lack of systematic stratification of risk factors resulting in the inclusion of clinically insignificant biomarkers in the models. This review aimed to systematically stratify the risk factors of lung cancer-associated venous thromboembolism (VTE) and determine the critical point for preemptive intervention. Methods This systematic review was structured as per the Preferred Reporting Item for Systematic Reviews and Meta-analyses. We searched MEDLINE, PubMed, Cochrane Library, CINAHL, Academic Search Complete, and PsycINFO from the onset to June 2022. We included studies that reported the risk factors of lung cancer-associated VTE and corresponding risk estimates, irrespective of treatment status but studies were excluded if patients were on anti-VTE medications. We employed random effects models of meta-analysis and computed risk stability index and risk weight (Rw) to achieve the review objectives. The review protocol is registered with PROSPERO (CRD42022336476). Results The clinically significant risk factors of VTE in lung cancer patients were D-dimer (odds ratio [OR] = 5.510, 95% CI = 2.6-11.7; Rw = 5.0), albumin (OR = 2.2, 95% CI = 1.0-4.8; Rw = 1.79), leukocyte (OR = 2.48, 95% CI = 1.9-3.2; Rw = 1.77), histological type (OR = 1.69 , 95% CI = 1.2-2.4; Rw = 1.3), age (OR = 1.56; Rw = 0.99), and hemoglobin (OR = 1.85, 95% CI = 1.3-2.6; Rw = 0.92). Based on the distribution of Rw across risk factors, the critical point (upper third of the upper quartile class) was 4.5 and may mark the point at which preemptive intervention should be commenced. Conclusions Targeted screening for VTE in lung cancer patients could be patient-specific and should be based on a combination of the most significant risk factors required to meet the critical point, provided that such a combination is affordable as illustrated in the ALBAH model. Registration The review protocol is registered with PROSPERO (ID: CRD42022336476).
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Affiliation(s)
- Theresa Nwagha
- Department of Haematology and
Immunology, Faculty of Medicine, University of Nigeria Teaching Hospital
Ituku-Ozalla, Enugu, Nigeria
| | - Martins Nweke
- Department of Physiotherapy, Evangel
University, Akaeze, Nigeria
- Fledgelight Evidence Consult, Enugu,
Nigeria
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24
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Guntupalli SR, Spinosa D, Wethington S, Eskander R, Khorana AA. Prevention of venous thromboembolism in patients with cancer. BMJ 2023; 381:e072715. [PMID: 37263632 DOI: 10.1136/bmj-2022-072715] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Venous thromboembolism (VTE) is a major cause of both morbidity and mortality in patients with cancer. Venous thromboembolism, which includes both deep vein thrombosis and pulmonary embolism, affects a sizable portion of patients with malignancy and can have potentially life threatening complications. Accurate assessment of risk as well as diagnosis and treatment of this process is paramount to preventing death in this high risk population. Various risk models predictive of venous thromboembolism in patients with cancer have been developed, and knowledge of these rubrics is essential for the treating oncologist. Subgroups of particular interest are inpatients receiving chemotherapy, postoperative patients after surgical debulking, and patients undergoing radiotherapy. Numerous newer drugs have become available for the prevention of venous thromboembolism in patients with cancer who are at high risk of developing the disease. These include the class of drugs called direct oral anticoagulants, (DOACs) which do not require the same monitoring that other modalities have previously required and are taken by mouth, preventing the discomfort associated with subcutaneous strategies. The appropriate risk stratification and intervention to prevent venous thromboembolism are vital to the treatment of patients with cancer.
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Affiliation(s)
- Saketh R Guntupalli
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniel Spinosa
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Stephanie Wethington
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ramez Eskander
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology University of California School of Medicine, San Diego, CA, USA
| | - Alok A Khorana
- Department of Hematology Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA
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25
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Muñoz A, Ay C, Grilz E, López S, Font C, Pachón V, Castellón V, Martínez-Marín V, Salgado M, Martínez E, Calzas J, Ortega L, Rupérez A, Salas E, Pabinger I, Soria JM. A Clinical-Genetic Risk Score for Predicting Cancer-Associated Venous Thromboembolism: A Development and Validation Study Involving Two Independent Prospective Cohorts. J Clin Oncol 2023; 41:2911-2925. [PMID: 36730884 PMCID: PMC10414737 DOI: 10.1200/jco.22.00255] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/25/2022] [Accepted: 12/01/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a leading cause of death among patients with cancer. The Khorana score was developed for assessing the risk of VTE in outpatients with cancer receiving chemotherapy, but its accuracy in identifying patients at high risk has been questioned. The aim of this study was to develop and validate a clinical-genetic score that improves the assessment of VTE risk in oncology outpatients within 6 months of diagnosis. METHODS The new score was developed using the data of 364 outpatients belonging to the Spanish ONCOTHROMB 12-01 population. In this cohort, clinical data associated with the risk of VTE were collected at the time of diagnosis, including the Khorana score. These patients were also genotyped for the 51 genetic variants known to be associated with VTE. Multivariate logistic regression was performed to determine the weight of each genetic and clinical variable in relation to VTE risk, allowing a clinical-genetic risk score (the ONCOTHROMB score) to be developed. The Khorana and the ONCOTHROMB scores were then compared via the area under the receiver operating characteristic curve (AUC), calibration, and the number of patients needed to treat. The new score was then validated in a study of 263 patients in the Vienna Cancer and Thrombosis Study population. RESULTS Nine genetic variants, tumor site, TNM stage, and a body mass index of > 25 kg/m2 were found to be associated with VTE and were used to build the ONCOTHROMB score, which better predicted the overall risk of VTE than did the Khorana score (AUC, 0.781 v 0.580; P < .001). Similar AUC results were recorded in the validation study the Vienna Cancer and Thrombosis Study cohort involving patients with the same type of tumor (AUC for the ONCOTHROMB score v the Khorana score: 0.686 v 0.577; P < .001) and with all type of tumors (AUC for the ONCOTHROMB score v the Khorana score: 0.720 v 0.561; P < .0001). CONCLUSION The ONCOTHROMB score for VTE risk in outpatients with cancer, which takes into account both clinical and genetic variables, better identifies patients who might benefit from primary thromboprophylaxis than does the Khorana score.
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Affiliation(s)
- Andrés Muñoz
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Ella Grilz
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sonia López
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Carme Font
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Vanesa Pachón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Ramón y Cajal Madrid, Madrid, Spain
| | - Victoria Castellón
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario de Torrecárdenas, Almería, Spain
| | - Virginia Martínez-Marín
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario La Paz, Madrid, Spain
| | - Mercedes Salgado
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Eva Martínez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Julia Calzas
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Laura Ortega
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
| | - Ana Rupérez
- Cancer and Thrombosis Working Section, Spanish Society of Medical Oncology (SEOM), Madrid, Spain
- Medical Oncology, Fundación Jiménez Díaz, Madrid, Spain
| | - Eduardo Salas
- Scientific Department, Gendiag.exe, Barcelona, Spain
| | - Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Jose Manuel Soria
- Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
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26
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Watson NW, Shatzel JJ, Al-Samkari H. Cyclin-dependent kinase 4/6 inhibitor-associated thromboembolism: a critical evaluation of the current evidence. J Thromb Haemost 2023; 21:758-770. [PMID: 36696184 PMCID: PMC10065951 DOI: 10.1016/j.jtha.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/07/2022] [Accepted: 12/01/2022] [Indexed: 01/09/2023]
Abstract
Cyclin-dependent kinase 4/6 (CDK 4/6) inhibitors are an essential treatment modality for hormone receptor-positive breast cancer. As the rates of breast cancer continue to rise globally and the indications for CDK 4/6 inhibitors now extend beyond metastatic disease, more patients than ever are receiving these agents. Thrombosis is an emerging clinical concern with this class of agents, particularly venous thromboembolism. Although venous thromboembolism initially emerged as an adverse effect of interest in early trials, more recent studies have demonstrated even higher incidences of thrombosis in real-world clinical practice. In this review, we summarize the evidence to date that has informed the thrombosis risk for these agents both in clinical trials and real-world studies. We review data describing the venous and arterial thromboembolic risks in clinical trials of CDK 4/6 inhibitors as well as the now rather extensive real-world evidence available, including a comparison of risk for each of the 3 agents approved for use in breast cancer: palcociclib, ribociclib, and abemaciclib. As the role of prophylactic anticoagulation continues to remain unknown in women receiving CDK 4/6 inhibitors, future efforts directed at carefully investigating the risks and benefits of thromboprophylaxis may lead to improved outcomes in these patients.
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Affiliation(s)
| | - Joseph J Shatzel
- Knight Cancer Institute, Oregon Health and Sciences University, Portland, Oregon, USA; Division of Biomedical Engineering, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, Massachusetts, USA; Division of Hematology and Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.
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27
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Cella CA, Knoedler M, Hall M, Arcopinto M, Bagnardi V, Gervaso L, Pellicori S, Spada F, Zampino MG, Ravenda PS, Frassoni S, Passaro A, Milano M, Laffi A, Fazio N, Lordick F. Validation of the ONKOTEV Risk Prediction Model for Venous Thromboembolism in Outpatients With Cancer. JAMA Netw Open 2023; 6:e230010. [PMID: 36795409 PMCID: PMC9936336 DOI: 10.1001/jamanetworkopen.2023.0010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
IMPORTANCE The assessment of the risk of venous thromboembolism (VTE) among outpatients with cancer represents an unsolved topic. Current international guidelines recommend primary prophylaxis for patients at intermediate to high risk of VTE, indicated by a Khorana score of 2 or more. A previous prospective study developed the ONKOTEV score, a 4-variable risk assessment model (RAM) consisting of a Khorana score of more than 2, metastatic disease, vascular or lymphatic compression, and previous VTE event. OBJECTIVE To validate the ONKOTEV score as a novel RAM to assess the risk of VTE among outpatients with cancer. DESIGN, SETTING, AND PARTICIPANTS ONKOTEV-2 is a noninterventional prognostic study conducted in 3 European centers located in Italy, Germany, and the United Kingdom among a prospective cohort of 425 ambulatory patients with a histologically confirmed diagnosis of a solid tumor who were receiving active treatments. The total study duration was 52 months, with an accrual period of 28 months (from May 1, 2015, to September 30, 2017) and an overall follow up-period of 24 months (data were censored September 30, 2019). Statistical analysis was performed in October 2019. EXPOSURES The ONKOTEV score was calculated for each patient at baseline by collecting clinical, laboratory, and imaging data from tests performed for routine practice. Each patient was then observed to detect any thromboembolic event throughout the study period. MAIN OUTCOMES AND MEASURES The primary outcome of the study was the incidence of VTE, including deep vein thrombosis and pulmonary embolism. RESULTS A total of 425 patients (242 women [56.9%]; median age, 61 years [range, 20-92 years]) were included in the validation cohort of the study. The cumulative incidences for the risk of developing VTE at 6 months were 2.6% (95% CI, 0.7%-6.9%), 9.1% (95% CI, 5.8%-13.2%), 32.3% (95% CI, 21.0%-44.1%), and 19.3% (95% CI, 2.5%-48.0%), respectively, among 425 patients with an ONKOTEV score of 0, 1, 2, and greater than 2 (P < .001). The time-dependent area under the curve at 3, 6, and 12 months was 70.1% (95% CI, 62.1%-78.7%), 72.9% (95% CI, 65.6%-79.1%), and 72.2% (95% CI, 65.2%-77.3%), respectively. CONCLUSIONS AND RELEVANCE This study suggests that, because the ONKOTEV score has been validated in this independent study population as a novel predictive RAM for cancer-associated thrombosis, it can be adopted into practice and into clinical interventional trials as a decision-making tool for primary prophylaxis.
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Affiliation(s)
- Chiara A Cella
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Maren Knoedler
- University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany
| | - Marcia Hall
- Department of Medical Oncology, Mount Vernon Center for Cancer Treatment, Mount Vernon Hospital, Northwood, United Kingdom
| | - Michele Arcopinto
- Department of Translational Medical Sciences, "Federico II" University Hospital and School of Medicine, Naples, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | | | - Francesca Spada
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Maria G Zampino
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paola S Ravenda
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Monica Milano
- Division of Medical Senology, European Institute of Oncology IRCCS, Milan, Italy
| | - Alice Laffi
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Nicola Fazio
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IRCCS, Milan, Italy
| | - Florian Lordick
- University Cancer Center Leipzig, University Hospital Leipzig, Leipzig, Germany
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García Adrián S, González AR, de Castro EM, Olmos VP, Morán LO, Del Prado PM, Fernández MS, Burón JDC, Escobar IG, Galán JM, Pérez AIF, Neria F, Lavin DC, Hernández BLDSV, Jiménez-Fonseca P, Muñoz Martín AJ. Incidence, risk factors, and evolution of venous thromboembolic events in patients diagnosed with pancreatic carcinoma and treated with chemotherapy on an outpatient basis. Eur J Intern Med 2022; 105:30-37. [PMID: 35931614 DOI: 10.1016/j.ejim.2022.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Pancreatic carcinoma is one of the tumors associated with a higher risk for thromboembolic events, with incidence rates ranging from 5% to 41% in previous retrospective series. PATIENTS AND METHODS We conducted a retrospective study in eleven Spanish hospitals that included 666 patients diagnosed with pancreatic carcinoma (any stage) between 2008 and 2011 and treated with chemotherapy. The main objective was to evaluate the incidence of venous thromboembolic events (VTE) in this population, as well as potential risk factors for thrombosis. The impact of VTE on mortality was also assessed. RESULTS With a median follow-up of 9.3 months, the incidence of VTE was 22.1%; 52% were diagnosed incidentally. Our study was unable to confirm the ability of the Khorana score to discriminate between patients in the intermediate or high risk category for thrombosis. The presence of VTE proved to be an independent prognostic factor associated with increased risk of death (HR 2.39, 95% CI 1.96-2.92). Symptomatic events correlated with higher mortality than asymptomatic events (HR 1.72; 95% CI, 1.21-2.45; p = 0.002), but incidental VTE, including visceral vein thrombosis (VVT), negatively affected survival compared to patients without VTE. Subjects who developed VTE within the first 3 months of diagnosis of pancreatic carcinoma had lower survival rates than those with VTE after 3 months (HR 1.92, 95% CI 1.30-2.84; p<0.001). CONCLUSIONS Pancreatic carcinoma is associated with a high incidence of VTE, which, when present, correlates with worse survival, even when thrombosis is incidental. Early onset VTE has a particularly negative impact.
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Affiliation(s)
- Silvia García Adrián
- Medical Oncology Department, Hospital Universtario de Móstoles, C/ Dr. Luis Montes S/N, Madrid 28935, Spain; Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain.
| | - Adán Rodríguez González
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Eva Martínez de Castro
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Vanessa Pachón Olmos
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Laura Ortega Morán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Purificación Martínez Del Prado
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Mercedes Salgado Fernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Universitario de Orense, Orense, Spain
| | - José David Cumplido Burón
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital de Torrevieja, Torrevieja, Spain
| | - Ignacio García Escobar
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Joaquina Martínez Galán
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Ana Isabel Ferrer Pérez
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Fernando Neria
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - Diego Cacho Lavin
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Santander, Spain
| | - Borja López de San Vicente Hernández
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Paula Jiménez-Fonseca
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Oviedo, Spain
| | - Andrés J Muñoz Martín
- Thrombosis and Cancer Section of the Spanish Society of Medical Oncology (SEOM), Spain; Medical Oncology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
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Htut TW, Thein KZ, Aung KL, Oo TH. Primary ambulatory thromboprophylaxis in patients with pancreatic cancer receiving chemotherapy: hope or hype? Support Care Cancer 2022; 30:8511-8517. [PMID: 35579754 DOI: 10.1007/s00520-022-07138-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/10/2022] [Indexed: 11/29/2022]
Abstract
Thrombosis is the second leading cause of death in cancer patients. Patients with pancreatic cancer (PC) have a very high risk of developing venous thromboembolism (VTE). Even though primary ambulatory thromboprophylaxis (PATP) could decrease this risk, there are uncertain issues with regard to the choice and dose of anticoagulants, duration of anticoagulant therapy, and patient selection criteria. In addition, the current practice guidelines on PATP in PC patients are equivocal. This review critically appraises the evidence on the use of PATP in PC patients receiving chemotherapy.
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Affiliation(s)
- Thura Win Htut
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Kyaw Zin Thein
- Division of Hematology and Medical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, OR, USA
| | - Kyaw Lwin Aung
- Department of Oncology and Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology (Unit 1464), The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, USA.
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30
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King R, Schaefer J, Sahai V, Griffith KA, Sood SL. Retrospective Cohort Analysis of Aspirin Use and Venous Thromboembolism in Patients with Pancreatic Cancer and an Indwelling Central Venous Catheter. TH OPEN 2022; 6:e221-e229. [PMID: 36046199 PMCID: PMC9352440 DOI: 10.1055/s-0042-1747685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/23/2022] [Indexed: 11/01/2022] Open
Abstract
Abstract
Background Patients with pancreatic cancer are at high risk of developing venous thromboembolism (VTE). It is unknown if aspirin reduces the risk of VTE in this setting.
Objectives We sought to determine whether there is an association between aspirin use and VTE risk in patients with pancreatic cancer receiving chemotherapy with a central venous catheter (CVC).
Patients/Methods We conducted a single-center, retrospective cohort study of adult patients diagnosed with pancreatic cancer and treated with chemotherapy using a CVC. Subjects were excluded if they were on anticoagulation at the time of CVC placement. The probability of VTE was analyzed using a time-to-event analysis framework for the development of VTE using the product-limit method of Kaplan and Meier (univariate) and adjusting for important confounding covariates using Cox proportional hazards regression (cause-specific hazard) and again using Fine and Gray regression (subdistributional hazard) with death prior to VTE considered a competing event.
Results The final analysis included 314 cases (125 with any aspirin use and 189 without). Patients with any aspirin use had fewer VTE events (34.4%) compared with those without aspirin use (42.3%; p = 0.021) by log-rank test and after adjustment for multiple covariates using a Cox proportional hazards model (hazard ratio [HR] = 0.60; 95% confidence interval [CI]: 0.40–0.92; p = 0.019). Using Fine and Gray regression to account for death as a competing event, the effect of aspirin remained in the direction of benefit, but was not statistically significant (HR = 0.70; 95% CI: 0.47–1.05, p = 0.083). Higher body mass index, active smoking, and metastatic stage of cancer were associated with VTE events in the Cox proportional hazards model. Rates of major bleeding or clinically relevant minor bleeding were similar between treatment groups.
Conclusions Aspirin may reduce the risk of VTE in patients with pancreatic cancer with a CVC. We did not observe a significant increase in the rates of major bleeding or clinically relevant nonmajor bleeding.
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Affiliation(s)
- Richard King
- Department of Internal Medicine, Division of Hematology and Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, United States
| | - Jordan Schaefer
- Department of Internal Medicine, Division of Hematology and Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, United States
| | - Vaibhav Sahai
- Department of Internal Medicine, Division of Hematology and Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, United States
| | - Kent A. Griffith
- Comprehensive Cancer Center Biostatistics Unit, University of Michigan, Ann Arbor, Michigan, United States
| | - Suman L. Sood
- Department of Internal Medicine, Division of Hematology and Medical Oncology, University of Michigan Rogel Cancer Center, Ann Arbor, Michigan, United States
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31
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Falanga A, Brenner B, Khorana AA, Francis C. Thrombotic complications in patients with cancer: Advances in pathogenesis, prevention, and treatment-A report from ICTHIC 2021. Res Pract Thromb Haemost 2022; 6:e12744. [PMID: 35794962 PMCID: PMC9248072 DOI: 10.1002/rth2.12744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/28/2022] [Accepted: 05/03/2022] [Indexed: 11/05/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in cancer patients, resulting in deep vein thrombosis (DVT) or pulmonary embolism (PE), and is responsible for high morbidity and mortality. This article discusses evidence and future perspectives on pathogenesis and prevention and treatment of thrombotic complications in patients with cancer. In April 2021, international basic researchers and clinicians met for the virtual edition of the 10th International Conference on Thrombosis & Hemostasis Issues in Cancer. Pathogenic mechanisms, markers and scores for risk assessment, diagnosis and therapy issues, current prophylaxis recommendations, and special settings, such as palliative care, pediatrics, and COVID-19 patients were discussed. Emerging areas of interest in cancer associated VTE are the role of immunotherapy, platelet activation markers, genetic alterations and real-world systems-based approaches to prevention and treatment.
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Affiliation(s)
- Anna Falanga
- Division of Immunohematology and Transfusion MedicineHospital Papa Giovanni XXIIIBergamoItaly
- Department of Medicine and SurgeryUniversity of Milan BicoccaMilanItaly
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow TransplantationRambam Health Care CampusHaifaIsrael
| | - Alok A. Khorana
- Taussig Cancer InstituteCleveland Clinic Lerner College of MedicineCleveland ClinicClevelandOhioUSA
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Farge D, Frere C, Connors JM, Khorana AA, Kakkar A, Ay C, Muñoz A, Brenner B, Prata PH, Brilhante D, Antic D, Casais P, Guillermo Esposito MC, Ikezoe T, Abutalib SA, Meillon-García LA, Bounameaux H, Pabinger I, Douketis J. 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19. Lancet Oncol 2022; 23:e334-e347. [PMID: 35772465 PMCID: PMC9236567 DOI: 10.1016/s1470-2045(22)00160-7] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/05/2022] [Accepted: 03/09/2022] [Indexed: 12/14/2022]
Abstract
The International Initiative on Thrombosis and Cancer is an independent academic working group of experts aimed at establishing global consensus for the treatment and prophylaxis of cancer-associated thrombosis. The 2013, 2016, and 2019 International Initiative on Thrombosis and Cancer clinical practice guidelines have been made available through a free, web-based mobile phone application. The 2022 clinical practice guidelines, which are based on a literature review up to Jan 1, 2022, include guidance for patients with cancer and with COVID-19. Key recommendations (grade 1A or 1B) include: (1) low-molecular-weight heparins (LMWHs) for the initial (first 10 days) treatment and maintenance treatment of cancer-associated thrombosis; (2) direct oral anticoagulants for the initial treatment and maintenance treatment of cancer-associated thrombosis in patients who are not at high risk of gastrointestinal or genitourinary bleeding, in the absence of strong drug-drug interactions or of gastrointestinal absorption impairment; (3) LMWHs or direct oral anticoagulants for a minimum of 6 months to treat cancer-associated thrombosis; (4) extended prophylaxis (4 weeks) with LMWHs to prevent postoperative venous thromboembolism after major abdominopelvic surgery in patients not at high risk of bleeding; and (5) primary prophylaxis of venous thromboembolism with LMWHs or direct oral anticoagulants (rivaroxaban or apixaban) in ambulatory patients with locally advanced or metastatic pancreatic cancer who are treated with anticancer therapy and have a low risk of bleeding.
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Affiliation(s)
- Dominique Farge
- Unité de Médecine Interne (UF04): CRMR MATHEC, Maladies Auto-immunes et Thérapie Cellulaire, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Nord-Université de Paris, Paris, France; Faculté de Médecine, Institut de Recherche St-Louis, EA-3518, Université de Paris, Paris, France; Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada.
| | - Corinne Frere
- INSERM UMRS 1166, GRC 27 GRECO, DMU BioGeM, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alok A Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ajay Kakkar
- Thrombosis Research Institute, London, UK; Faculty of Medical Sciences, University College London, London, UK
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Andres Muñoz
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Pedro H Prata
- Hematology-Transplantation Department, Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Nord-Université de Paris, Paris, France
| | - Dialina Brilhante
- Francisco Gentil Portuguese Institute of Oncology, Lisbon Center, Lisbon, Portugal
| | - Darko Antic
- Clinic for Hematology, Clinical Center Serbia, University of Belgrade, Belgrade, Serbia
| | - Patricia Casais
- Instituto de Investigaciones en Salud Pública, Universidad de Buenos, Buenos Aires, Argentina
| | | | - Takayuki Ikezoe
- Department of Hematology, Fukushima Medical University, Fukushima, Japan
| | | | | | | | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Jiménez-Fonseca P, Gallardo E, Arranz Arija F, Blanco JM, Callejo A, Lavin DC, Costa Rivas M, Mosquera J, Rodrigo A, Sánchez Morillas R, Vares Gonzaléz M, Muñoz A, Carmona-Bayonas A. Consensus on prevention and treatment of cancer-associated thrombosis (CAT) in controversial clinical situations with low levels of evidence. Eur J Intern Med 2022; 100:33-45. [PMID: 35227541 DOI: 10.1016/j.ejim.2022.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/23/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cancer patients suffer high risk of venous thromboembolism (VTE). Cancer-associated VTE (CAT) causes hospitalization, morbidity, delayed cancer treatment, and mortality; therefore, exceptional CAT prevention and management are imperative. METHODS This review offers practical recommendations and treatment algorithms for eight complex, clinically relevant situations posing great uncertainty regarding management and requiring an urgent decision: VTE prophylaxis in ambulatory cancer patients with pancreatic pancreas (1) or lung cancer with molecular alterations (2); optimal management of VTE during antineoplastic treatment with antiangiogenics (3) or chemotherapy (4); protracted VTE treatment, determinants; (5) drugs used (6), and optimal VTE management in situations of high bleeding risk (7) or recurrent VTE (8). RESULTS With the evidence available, primary thromboprophylaxis in patients with lung cancer harbouring ALK/ROS1 translocations or pancreatic cancer receiving ambulatory chemotherapy must be appraised. If antiangiogenic therapy can yield a clear benefit and the patient recovers from a grade 3 thrombotic event, it can be cautiously re-introduced in selected cases, provided that the person agrees to assume the risk after being duly informed. Anticoagulation maintenance beyond 6 months is recommended in individuals with metastatic tumours, on active treatment, or at high risk for recurrent VTE without bleeding risk. In such cases, LMWH and DOACs are safe, being mindful that the latter could entail a higher risk of bleeding; consequently, they should be used judiciously in more haemorrhagic tumours, such as gastrointestinal cancers. In cases of recurrent VTE, the presence of active cancer, infra-therapeutic dose, and anticoagulant treatment failure must be ruled out. In individuals with platelet counts of 25,000-50,000 and VTE liable to recur who need anticoagulation, full-dose LMWH and transfusion support can be contemplated to reach values of > 50,000. In CAT unlikely to recur, decreasing the LMWH dose by 25-50% is recommended. Renal impairment associated with thrombosis must be treated with LMWHs; there is no need to adjust the dose in patients with CrCl > 30; with CrCl = 15-30, dose adjustment is advised, and suspended when CrCl is < 15. CONCLUSION We provide useful advice for complex, clinically relevant situations that clinicians treating CAT must face devoid of any unequivocal, strong, evidence-based recommendations.
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Affiliation(s)
- Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Avenida Roma, Oviedo 33011, Spain.
| | - Enrique Gallardo
- Medical Oncology Department, Hospital Universitario Parc Tauli, Sabadell, Spain
| | - Fernando Arranz Arija
- Medical Oncology Department, Complejo Asistencial Universitario de Palencia, Palencia, Spain
| | - Jesús Manuel Blanco
- Medical Oncology Department, Hospital Universitario de Donosti, Donosti-San Sebastián, Spain
| | - Ana Callejo
- Medical Oncology Department, Hospital Universitario Vall d'Hebron, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Diego Cacho Lavin
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Joaquín Mosquera
- Medical Oncology Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Alberto Rodrigo
- Medical Oncology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - María Vares Gonzaléz
- Internal Medicine Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Andrés Muñoz
- Medical Oncology Department, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | - Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, UMU, IMIB, Murcia, Spain
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Ciuffini L, Wang T, Lodigiani C, Carrier M. Thromboprophylaxis of cancer patients undergoing systemic therapy in the ambulatory setting. Best Pract Res Clin Haematol 2022; 35:101351. [DOI: 10.1016/j.beha.2022.101351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/02/2022]
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35
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Klemen ND, Feingold PL, Hashimoto B. Reply to R.A. Snyder et al. J Clin Oncol 2022; 40:2512-2513. [PMID: 35580286 PMCID: PMC9467674 DOI: 10.1200/jco.22.00320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nicholas D Klemen
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Paul L Feingold
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
| | - Barry Hashimoto
- Nicholas D. Klemen, MD, Surgery Branch, National Cancer Institute, Bethesda, MD; Paul L. Feingold, MD, Department of Surgery, Brigham and Women's Hospital, Harvard University, Boston, MA; and Barry Hashimoto, PhD, Division of Social Science, New York University Abu Dhabi, Saadiyat Island, United Arab Emirates
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36
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Snyder RA, O'Reilly EM. Venous Thromboprophylaxis in Surgical Oncology Patients: The Importance of Risk Assessment in the Context of Limited Evidence. J Clin Oncol 2022; 40:2510-2511. [PMID: 35580296 DOI: 10.1200/jco.21.02935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Rebecca A Snyder
- Rebecca A. Snyder, MD, MPH, Brody School of Medicine at East Carolina University, Greenville, NC; and Eileen M. O'Reilly, MD, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eileen M O'Reilly
- Rebecca A. Snyder, MD, MPH, Brody School of Medicine at East Carolina University, Greenville, NC; and Eileen M. O'Reilly, MD, Memorial Sloan Kettering Cancer Center, New York, NY
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Sarantis P, Karamouzis MV. The impact of thromboprophylaxis with LMWHs on the survival of patients with pancreatic cancer. Thromb Res 2022; 213 Suppl 1:S120-S126. [DOI: 10.1016/j.thromres.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/24/2022] [Accepted: 02/04/2022] [Indexed: 11/27/2022]
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A review of latest clinical practice guidelines for the management of cancer-associated thrombosis. Best Pract Res Clin Haematol 2022; 35:101348. [DOI: 10.1016/j.beha.2022.101348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/24/2022] [Indexed: 11/19/2022]
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39
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Risk assessment and primary prevention of VTE in patients with cancer: Advances, challenges, and evidence gaps. Best Pract Res Clin Haematol 2022; 35:101347. [DOI: 10.1016/j.beha.2022.101347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 05/20/2022] [Indexed: 11/21/2022]
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Zaheer A, Naumovski N, Toohey K, Niyonsenga T, Yip D, Brown N, Mortazavi R. Prediction models for venous thromboembolism in ambulatory adults with pancreatic and gastro-oesophageal cancer: protocol for systematic review and meta-analysis. BMJ Open 2022; 12:e056431. [PMID: 35246422 PMCID: PMC8900042 DOI: 10.1136/bmjopen-2021-056431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication of cancer. Pancreatic and gastro-oesophageal cancers are among malignancies that have the highest rates of VTE occurrence. VTE can increase cancer-related morbidity and mortality and disrupt cancer treatment. The risk of VTE can be managed with measures such as using anticoagulant drugs, although the risk of bleeding may be an impeding factor. Therefore, a VTE risk assessment should be performed before the start of anticoagulation in individual patients. Several prediction models have been published, but most of them have low sensitivity and unknown clinical applicability in pancreatic or gastro-oesphageal cancers. We intend to do this systematic review to identify all applicable published predictive models and compare their performance in those types of cancer. METHODS AND ANALYSIS All studies in which a prediction model for VTE have been developed, validated or compared using adult ambulatory patients with pancreatic or gastro-oesphageal cancers will be identified and the reported predictive performance indicators will be extracted. Full text peer-reviewed journal articles of observational or experimental studies published in English will be included. Five databases (Medline, EMBASE, Web of Science, CINAHL and Cochrane) will be searched. Two reviewers will independently undertake each of the phases of screening, data extraction and risk of bias assessment. The quality of the selected studies will be assessed using Prediction model Risk Of Bias Assessment Tool. The results from the review will be used for a narrative information synthesis, and if the same models have been validated in multiple studies, meta-analyses will be done to pool the predictive performance measures. ETHICS AND DISSEMINATION There is no need for ethics approval because the review will use previously peer-reviewed articles. The results will be published. PROSPERO REGISTRATION NUMBER CRD42021253887.
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Affiliation(s)
- Asma Zaheer
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Nenad Naumovski
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Functional Foods and Nutritional Research (FFNR) Laboratory, University of Canberra Faculty of Health Sciences, Canberra, Australian Capital Territory, Australia
| | - Kellie Toohey
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- School of Health Sciences, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Theophile Niyonsenga
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Desmond Yip
- Department of Medical Oncology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas Brown
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Office of Executive Director of Allied Health,Canberra Health Services, Garran, Canberra, Australian Capital Territory, Australia
| | - Reza Mortazavi
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
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Yamai T, Ikezawa K, Hiraga E, Kawamoto Y, Hirao T, Higashi S, Daiku K, Maeda S, Abe Y, Urabe M, Kai Y, Takada R, Nakabori T, Fukutake N, Uehara H, Fujita M, Ohkawa K. Early detection of venous thromboembolism after the initiation of chemotherapy predicts a poor prognosis in patients with unresectable metastatic pancreatic cancer who underwent first-line chemotherapy with gemcitabine plus nab-paclitaxel. PLoS One 2022; 17:e0264653. [PMID: 35231078 PMCID: PMC8887762 DOI: 10.1371/journal.pone.0264653] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 02/14/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pancreatic cancer is associated with a high thromboembolism risk. We investigated the significance of early venous thromboembolism (VTE) detection in patients with unresectable metastatic pancreatic cancer (UR-MPC) who received first-line chemotherapy with gemcitabine plus nab-paclitaxel (GnP). METHODS This single-center retrospective study enrolled 174 patients with UR-MPC who underwent GnP as a first-line chemotherapy from April 2017 to March 2020. The early detection of VTE (deep venous thrombosis and pulmonary thromboembolism) was defined as diagnosis by the first follow-up CT scan after the initiation of chemotherapy. We compared the patients with early detection of VTE (VTE (+) group) with the others (VTE (-) group). We examined overall survival (OS), progress free survival (PFS), severe adverse events, and predictors associated with OS using the Cox proportional hazards model. RESULTS Early detection of VTE was observed in 17 patients (9.8%). Thirteen patients were diagnosed with VTE at treatment initiation, and four patients were diagnosed after treatment initiation. The median time to diagnosis after treatment initiation was 55 days (range: 31-71 days). Only 3 patients were symptomatic. The VTE (+) group exhibited worse OS and PFS than the VTE (-) group (OS: 259 days vs. 400 days, P < 0.001; PFS: 120 days vs. 162 days, P = 0.008). The frequency of grade 3-4 adverse events was not significantly different. Although the performance status was poorer in the VTE (+) group, VTE was identified as a statistically significant independent predictor for OS in multivariate analyses (HR, 1.87; 95% CI, 1.02-3.44; P = 0.041). CONCLUSIONS Early VTE detection is a predictor of a poor prognosis in UR-MPC patients who receive GnP as first-line chemotherapy, suggesting that screening VTE for patients with UR-MPC is crucial, even if patients are asymptomatic.
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Affiliation(s)
- Takuo Yamai
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Erika Hiraga
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yasuharu Kawamoto
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takeru Hirao
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Sena Higashi
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuma Daiku
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Shingo Maeda
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yutaro Abe
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Makiko Urabe
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yugo Kai
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryoji Takada
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tasuku Nakabori
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Nobuyasu Fukutake
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyuki Uehara
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masashi Fujita
- Department of Onco-Cardiology, Osaka International Cancer Institute, Osaka, Japan
| | - Kazuyoshi Ohkawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
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Salgado M, Brozos-Vázquez E, Campos B, González-Villarroel P, Pérez ME, Vázquez-Tuñas ML, Arias D. Venous Thromboembolism In Cancer Patients: "From Evidence to Care". Clin Appl Thromb Hemost 2022; 28:10760296221098717. [PMID: 35538861 PMCID: PMC9102132 DOI: 10.1177/10760296221098717] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/02/2022] Open
Abstract
This article seeks to review the current status of treatment and prevention of venous thromboembolic disease (VTE) in cancer patients after the addition of direct oral anticoagulants (DOAC) to the therapeutic arsenal available. The suitability of DOAC use in complex clinical situations, poorly represented in clinical trials, is controversial and difficult for care activity, making the recommendations in clinical practice guidelines the focus of special attention in this area. Recently, several randomized trials have compared low molecular weight heparin (LMWH) to DOAC for the management of CAT. Potential drug interactions with DOACs or the increased risk of bleeding in intraluminal tumors require special precautions, as do metastatic or primary brain disease and comorbid conditions, such as renal or liver failure, which are not suitably represented in pivotal studies. Furthermore, few data are available for situations involving elevated bleeding risk, with thrombocytopenia levels below the inclusion criterion of clinical trials, or recurrence during active anticoagulant therapy. Similarly, it is less clear that patients and physicians accept the presumption that oral DOAC administration is more convenient than subcutaneous LMWH, particularly when drug absorption may be compromised. The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials, makes their use complex in certain situations in health care. This paper provides a practical review of current clinical guideline recommendations regarding LMWH and/ or DOAC to treat and prevent CAT, as well as the most controversial clinical conditions for their use.
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Affiliation(s)
- Mercedes Salgado
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Elena Brozos-Vázquez
- Medical Oncology Department, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Begoña Campos
- Medical Oncology Department, Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | - María Eva Pérez
- Medical Oncology Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | - David Arias
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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Htut TW, Thein KZ, Quick DP, Oo TH. Meta-analysis of randomized controlled trials on primary ambulatory thromboprophylaxis in patients with nonpancreatic gastrointestinal cancers receiving chemotherapy. Proc AMIA Symp 2022; 35:51-55. [PMID: 34970032 DOI: 10.1080/08998280.2021.1973340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Primary ambulatory thromboprophylaxis (PATP) in patients with solid malignancies is not routinely indicated. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the benefit and risk of PATP in patients with nonpancreatic gastrointestinal cancers receiving chemotherapy. RCTs with venous thromboembolism (VTE) reduction as primary or secondary endpoints were included. A total of 1932 patients from subgroups of 3 RCTs were eligible. The VTE incidence was 1.26% and 2.55% in PATP and control arms, respectively (risk ratio 0.49; confidence interval 0.25 to 0.96; P = 0.04), with a number needed to treat of 78 to prevent one VTE event. In gastric and gastroesophageal junction cancer patients, the VTE incidence was 1.37% and 3.40% in PATP and control arms, respectively (risk ratio 0.40; confidence interval 0.13 to 1.24; P = 0.11). PATP should not be recommended in patients with nonpancreatic gastrointestinal cancers on chemotherapy.
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Affiliation(s)
- Thura Win Htut
- Department of Hematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Kyaw Zin Thein
- Department of Investigational Cancer Therapeutics, The University of Texas M. D. Anderson Cancer Center, Houston, Texas.,Division of Hematology and Medical Oncology, Oregon Health and Science University/Knight Cancer Institute, Portland, Oregon
| | - Donald Paul Quick
- Joe Arrington Cancer Research and Treatment Center, Lubbock, Texas.,Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas
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Kahale LA, Matar CF, Hakoum MB, Tsolakian IG, Yosuico VE, Terrenato I, Sperati F, Barba M, Schünemann H, Akl EA. Anticoagulation for the initial treatment of venous thromboembolism in people with cancer. Cochrane Database Syst Rev 2021; 12:CD006649. [PMID: 34878173 PMCID: PMC8653422 DOI: 10.1002/14651858.cd006649.pub8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Compared with people without cancer, people with cancer who receive anticoagulant treatment for venous thromboembolism (VTE) are more likely to develop recurrent VTE. OBJECTIVES To compare the efficacy and safety of three types of parenteral anticoagulants (i.e. fixed-dose low molecular weight heparin (LMWH), adjusted-dose unfractionated heparin (UFH), and fondaparinux) for the initial treatment of VTE in people with cancer. SEARCH METHODS We performed a comprehensive search in the following major databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via Ovid) and Embase (via Ovid). We also handsearched conference proceedings, checked references of included studies, and searched for ongoing studies. This update of the systematic review is based on the findings of a literature search conducted on 14 August 2021. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the benefits and harms of LMWH, UFH, and fondaparinux in people with cancer and objectively confirmed VTE. DATA COLLECTION AND ANALYSIS Using a standardised form, we extracted data - in duplicate - on study design, participants, interventions, outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, symptomatic VTE, major bleeding, minor bleeding, postphlebitic syndrome, quality of life, and thrombocytopenia. We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS Of 11,484 identified citations, 3073 were unique citations and 15 RCTs fulfilled the eligibility criteria, none of which were identified in the latest search. These trials enrolled 1615 participants with cancer and VTE: 13 compared LMWH with UFH; one compared fondaparinux with UFH and LMWH; and one compared dalteparin with tinzaparin, two different types of low molecular weight heparin. The meta-analyses showed that LMWH may reduce mortality at three months compared to UFH (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.40 to 1.10; risk difference (RD) 57 fewer per 1000, 95% CI 101 fewer to 17 more; low certainty evidence) and may reduce VTE recurrence slightly (RR 0.69, 95% CI 0.27 to 1.76; RD 30 fewer per 1000, 95% CI 70 fewer to 73 more; low certainty evidence). There were no data available for bleeding outcomes, postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing fondaparinux with heparin (UFH or LMWH) found that fondaparinux may increase mortality at three months (RR 1.25, 95% CI 0.86 to 1.81; RD 43 more per 1000, 95% CI 24 fewer to 139 more; low certainty evidence), may result in little to no difference in recurrent VTE (RR 0.93, 95% CI 0.56 to 1.54; RD 8 fewer per 1000, 95% CI 52 fewer to 63 more; low certainty evidence), may result in little to no difference in major bleeding (RR 0.82, 95% CI 0.40 to 1.66; RD 12 fewer per 1000, 95% CI 40 fewer to 44 more; low certainty evidence), and probably increases minor bleeding (RR 1.53, 95% CI 0.88 to 2.66; RD 42 more per 1000, 95% CI 10 fewer to 132 more; moderate certainty evidence). There were no data available for postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing dalteparin with tinzaparin found that dalteparin may reduce mortality slightly (RR 0.86, 95% CI 0.43 to 1.73; RD 33 fewer per 1000, 95% CI 135 fewer to 173 more; low certainty evidence), may reduce recurrent VTE (RR 0.44, 95% CI 0.09 to 2.16; RD 47 fewer per 1000, 95% CI 77 fewer to 98 more; low certainty evidence), may increase major bleeding slightly (RR 2.19, 95% CI 0.20 to 23.42; RD 20 more per 1000, 95% CI 14 fewer to 380 more; low certainty evidence), and may reduce minor bleeding slightly (RR 0.82, 95% CI 0.30 to 2.21; RD 24 fewer per 1000, 95% CI 95 fewer to 164 more; low certainty evidence). There were no data available for postphlebitic syndrome, quality of life, or thrombocytopenia. AUTHORS' CONCLUSIONS Low molecular weight heparin (LMWH) is probably superior to UFH in the initial treatment of VTE in people with cancer. Additional trials focusing on patient-important outcomes will further inform the questions addressed in this review. The decision for a person with cancer to start LMWH therapy should balance the benefits and harms and consider the person's values and preferences.
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Affiliation(s)
- Lara A Kahale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Charbel F Matar
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Maram B Hakoum
- Department of Family Medicine, Cornerstone Care Teaching Health Center, Mt. Morris, Pennsylvania, USA
| | - Ibrahim G Tsolakian
- Department of Obstetrics and Gynaecology, Univeristy of Toledo, Toledo, Ohio, USA
| | | | - Irene Terrenato
- Biostatistics-Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesca Sperati
- Biostatistics-Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Division of Medical Oncology 2 - Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Holger Schünemann
- Departments of Health Research Methods, Evidence, and Impact and of Medicine, McMaster University, Hamilton, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Kahale LA, Matar CF, Tsolakian I, Hakoum MB, Barba M, Yosuico VE, Terrenato I, Sperati F, Schünemann H, Akl EA. Oral anticoagulation in people with cancer who have no therapeutic or prophylactic indication for anticoagulation. Cochrane Database Syst Rev 2021; 10:CD006466. [PMID: 34622445 PMCID: PMC8498286 DOI: 10.1002/14651858.cd006466.pub7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Oral anticoagulants may improve the survival of people with cancer through an antithrombotic effect, yet increase the risk of bleeding. OBJECTIVES To evaluate the efficacy and safety of oral anticoagulants in ambulatory people with cancer undergoing chemotherapy, targeted therapy, immunotherapy, or radiotherapy (either alone or in combination), with no standard therapeutic or prophylactic indication for anticoagulation. SEARCH METHODS We conducted comprehensive searches on 14 June 2021, following the original electronic searches performed in February 2016 (last major search). We electronically searched the following databases: CENTRAL, MEDLINE, Embase. In addition, we handsearched conference proceedings, checked references of included studies, and searched for ongoing studies. As part of the living systematic review approach, we are running continual searches and will incorporate new evidence rapidly after it is identified. SELECTION CRITERIA We included randomised controlled trials (RCTs) assessing the benefits and harms of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) in ambulatory people with cancer (i.e., not hospital inpatients during the time of their participation in trials) These people are typically undergoing systemic anticancer therapy, possibly including chemotherapy, targeted therapy, immunotherapy, or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. DATA COLLECTION AND ANALYSIS Using a standardised form, two review authors independently extracted data on study design, participants, intervention outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, pulmonary embolism, symptomatic deep vein thrombosis (DVT), major bleeding, minor bleeding and health-related quality of life. We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS Of 12,620 identified citations, 10 RCTs fulfilled the inclusion criteria. The oral anticoagulant was a vitamin K antagonist (VKA) in six of these RCTs, and a direct oral anticoagulant (DOAC) in the remaining four RCTs (three studies used apixaban; one used rivaroxaban). The comparator was either placebo or no prophylaxis. Compared to no prophylaxis, vitamin K antagonists (VKAs) probably reduce mortality at six months slightly (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.77 to 1.13; risk difference (RD) 22 fewer per 1000, 95% CI 72 fewer to 41 more; moderate-certainty evidence), and probably reduce mortality at 12 months slightly (RR 0.95, 95% CI 0.87 to 1.03; RD 29 fewer per 1000, 95% CI 75 fewer to 17 more; moderate-certainty evidence). One study assessed the effect of a VKA compared to no prophylaxis on thrombosis; the evidence was very uncertain about the effect of VKA compared to no VKA on pulmonary embolism and symptomatic DVT (RR 1.05, 95% CI 0.07 to 16.58; RD 0 fewer per 1000, 95% CI 6 fewer to 98 more; very low-certainty evidence; RR 0.08, 95% CI 0.01 to 1.42; RD 35 fewer per 1000, 95% CI 37 fewer to 16 more; very low-certainty evidence, respectively). Also, VKAs probably increase major and minor bleeding at 12 months (RR 2.93, 95% CI 1.86 to 4.62; RD 107 more per 1000, 95% CI 48 more to 201 more; moderate-certainty evidence for major bleeding, and RR 3.14, 95% CI 1.85 to 5.32; RD 167 more per 1000, 95% CI 66 more to 337 more; moderate-certainty evidence for minor bleeding). Compared to no prophylaxis, at three to six months, direct oral anticoagulants (DOACs) probably reduce mortality slightly (RR 0.94, 95% CI 0.64 to 1.38, RD 11 fewer per 1000, 95% CI 67 fewer to 70 more; moderate-certainty evidence), probably reduce the risk of pulmonary embolism slightly compared to no prophylaxis (RR 0.48, 95% CI 0.24 to 0.98; RD 24 fewer per 1000, 95% CI 35 fewer to 1 fewer; moderate-certainty evidence), probably reduce symptomatic DVT slightly (RR 0.58, 95% CI 0.30 to 1.15; RD 21 fewer per 1000, 95% CI 35 fewer to 8 more; moderate-certainty evidence), probably do not increase major bleeding (RR 1.65, 95% CI 0.72 to 3.80; RD 9 more per 1000, 95% CI 4 fewer to 40 more; moderate-certainty evidence), and may increase minor bleeding (RR 3.58, 95% CI 0.55 to 23.44; RD 55 more per 1000, 95% CI 10 fewer to 482 more; low-certainty evidence). AUTHORS' CONCLUSIONS In ambulatory people with cancer undergoing chemotherapy, targeted therapy, immunotherapy, or radiotherapy (either alone or in combination), the current evidence on VKA thromboprophylaxis suggests that the harm of major bleeding might outweigh the benefit of reduction in venous thromboembolism. With DOACs, the benefit of reduction in venous thromboembolic events outweighs the risk of major bleeding. 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 'What's new' section in the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Lara A Kahale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Charbel F Matar
- Department of Internal Medicine, University of Connecticut, Hartford, Connecticut, USA
| | | | - Maram B Hakoum
- Family Medicine, American University of Beirut, Beirut, Lebanon
| | - Maddalena Barba
- Division of Medical Oncology 2 - Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | | | - Irene Terrenato
- Biostatistics-Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesca Sperati
- Biostatistics-Scientific Direction, Regina Elena National Cancer Institute, Rome, Italy
| | - Holger Schünemann
- Departments of Health Research Methods, Evidence, and Impact and of Medicine, McMaster University, Hamilton, Canada
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Pfrepper C, Knödler M, Schorling RM, Seehofer D, Petros S, Lordick F. Predictors for thromboembolism in patients with cholangiocarcinoma. J Cancer Res Clin Oncol 2021; 148:2415-2426. [PMID: 34499224 PMCID: PMC9349130 DOI: 10.1007/s00432-021-03794-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with cancer are at increased risk of thromboembolic events contributing significantly to cancer-related morbidity and mortality. Because cholangiocarcinoma is a rare type of cancer, the incidence of thromboembolism in this patient population is not well defined. METHODS Patients with cholangiocarcinoma treated at the University Cancer Center Leipzig between January 2014 and December 2018 were analyzed retrospectively regarding the incidence of arterial and venous thromboembolism. RESULTS A total of 133 newly and consecutively diagnosed patients were included, of whom 22% had stage IV disease. Thromboembolism was diagnosed in 39 (29.3%), with 48% of the events occurring between 60 days prior and 30 days after the initial diagnosis. Arterial thrombosis accounted for 19% and portal venous thrombosis for 33% of the events, while the rest of events occurred in the non-portal venous system. In multivariable analysis, an ONKOTEV score ≥ 2 was the only independent predictor for thromboembolism. Serum CA 19-9 was available in 87 patients (65.4%). In this subgroup, CA 19-9 above the median of 97.7 U/ml and vascular or lymphatic compression were independent predictors for thromboembolism in the first year and CA 19-9 alone remained a significant predictor over the whole observation period. An ONKOTEV score ≥ 2 and increasing age were predictors of survival. CONCLUSIONS A very high thromboembolic risk was observed in cholangiocarcinoma, comparable to the risk situation in pancreatic and gastric cancer. The ONKOTEV score and serum CA 19-9 are independent predictors of thromboembolic events. Prospective validation of our observations in this patient population is warranted.
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Affiliation(s)
- Christian Pfrepper
- Department of Hematology, Cellular Therapy and Hemostaseology, Division of Hemostaseology, University of Leipzig Medical Center, Liebigstr. 20, 04103, Leipzig, Germany.
| | - Maren Knödler
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
| | - Ruth Maria Schorling
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
| | - Daniel Seehofer
- Department of Visceral, Vascular, Thoracic and Transplant Surgery, University of Leipzig Medical Center, Leipzig, Germany
| | - Sirak Petros
- Department of Hematology, Cellular Therapy and Hemostaseology, Division of Hemostaseology, University of Leipzig Medical Center, Liebigstr. 20, 04103, Leipzig, Germany.,Medical ICU, University of Leipzig Medical Center, Leipzig, Germany
| | - Florian Lordick
- Department of Medicine (Oncology, Gastroenterology, Hepatology, Pulmonology, and Infectious Diseases), University Cancer Center Leipzig (UCCL), University of Leipzig Medical Center, Leipzig, Germany
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Validation of the Khorana Venous Thromboembolism Risk Score in Japanese Cancer Patients. JACC: ASIA 2021; 1:259-270. [PMID: 36338156 PMCID: PMC9627826 DOI: 10.1016/j.jacasi.2021.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/17/2021] [Accepted: 07/07/2021] [Indexed: 11/24/2022]
Abstract
Background Although the Khorana venous thromboembolism (VTE) risk score (KRS) is well recognized as a simple VTE risk assessment method in patients with cancer, whether it is suitable for Asian populations is unclear. Objectives This study validated KRS for the prediction of VTE and investigated the value of the KRS in predicting mortality in Japanese patients with cancer. Methods A body mass index value of 25 kg/m2 or more was defined as obesity according to World Health Organization consensus. A total of 27,687 patients with cancer were subdivided into low- (0), intermediate- (1-2), and high-score (3) groups by the KRS. The primary and secondary endpoints were VTE and all-cause mortality, respectively. Results The prevalence of VTE was 1.7%, 7.3%, and 11.0% for low-, intermediate-, and high-score patients, respectively. Receiver operating characteristic (ROC) analysis showed that the KRS significantly predicted VTE (area under the curve, 0.679; 95% confidence interval [CI] 0.666-0.692; P < 0.001). The cutoff value for the KRS was 1.0. Logistic regression analysis demonstrated that the KRS was an independent predictor of VTE (odds ratio 1.766; 95% CI 1.673-1.865; P < 0.01). The cutoff value of the KRS for all-cause mortality determined by ROC analysis was 2.0. Kaplan–Meier analysis demonstrated a significantly higher incidence of mortality in the KRS ≥2 group than in the KRS 0-1 group (log-rank: P < 0.01). Conclusions The KRS was useful in Japanese patients with cancer and might be a potentially useful marker for the prediction of mortality. Establishing optimal scores for Japanese subjects is mandatory because of its low diagnostic ability. (KUMAMON Cancer registry; UMIN000047554)
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Mosaad M, Elnaem MH, Cheema E, Ibrahim I, Ab Rahman J, Kori AN, Hin HS. Cancer-Associated Thrombosis: A Clinical Scoping Review of the Risk Assessment Models Across Solid Tumours and Haematological Malignancies. Int J Gen Med 2021; 14:3881-3897. [PMID: 34335052 PMCID: PMC8318782 DOI: 10.2147/ijgm.s320492] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of death in cancer patients receiving outpatient chemotherapy. The latest guidelines emphasize stratifying the patients in terms of CAT risks periodically. Multiple risk assessment models (RAMs) were developed to classify patients and guide thromboprophylaxis to high-risk patients. This study aimed to discuss and highlight different RAMs across various malignancy types with their related advantages and disadvantages. A scoping review was conducted using predefined search terms in three scientific databases, including Google Scholar, Science Direct, and PubMed. The search for studies was restricted to original research articles that reported risk assessment models published in the last thirteen years (between 2008 and 2021) to cover the most recently published evidence following the development of the principal risk assessment score in 2008. Data charting of the relevant trials, scores, advantages, and disadvantages were done iteratively considering the malignancy type. Of the initially identified 1115 studies, 39 studies with over 67,680 patients were included in the review. In solid organ malignancy, nine risk assessment scores were generated. The first and most known Khorana risk score still offers the best available risk assessment model when used for high-risk populations with a threshold of 2 and above. However, KRS has a limitation of failure to stratify low-risk patients. The COMPASS-CAT score showed the best performance in the lung carcinoma patients who have a higher prevalence of thrombosis than other malignancy subtypes. In testicular germ cell tumours, Bezan et al RAM is a validated good discriminatory RAM for this malignancy subtype. CAT in haematological malignancy seems to be under-investigated and has multiple disease-related, and treatment-related confounding factors. AL-Ani et al score performed efficiently in acute leukemia. In multiple myeloma, both SAVED and IMPEDED VTE scores showed good performance. Despite the availability of different disease-specific scores in lymphoma-related thrombosis, the standard of care needs to be redefined.
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Affiliation(s)
- Manar Mosaad
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Mohamed Hassan Elnaem
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Ejaz Cheema
- School of Pharmacy, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ismail Ibrahim
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Jamalludin Ab Rahman
- Department of Community Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
| | - Ahlam Naila Kori
- Haematology Unit, Tengku Ampuan Afzan Hospital, Kuantan, Pahang, Malaysia
| | - How Soon Hin
- Department of Internal Medicine, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Pahang, Malaysia
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What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients? Biomedicines 2021; 9:biomedicines9080864. [PMID: 34440068 PMCID: PMC8389559 DOI: 10.3390/biomedicines9080864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.
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Nishimura A, Ikeda Y. [Predicting the Incidence of Venous Thromboembolism Using the Khorana Score: A Literature Review]. YAKUGAKU ZASSHI 2021; 141:611-622. [PMID: 33790126 DOI: 10.1248/yakushi.20-00228] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Venous thromboembolism (VTE) is the second most common cause of cancer-related deaths globally. The Khorana score, a VTE prediction model, is calculated using the site of cancer, white blood cell count, hemoglobin level, platelet count, and body mass index. This study aimed to investigate the usefulness of the Khorana score, using data available in the literature. On July 28, 2020, we collected papers using the following keywords: "cancer", "venous thromboembolism", "deep vein thrombosis", "pulmonary embolism", and "Khorana score" on PubMed. Papers published after 2016 were eligible. The selection criteria were as follows: "English or Japanese", "original paper", "abstract and full text", and "comply with the clinical question". There were 131 papers that matched the keywords, and 15 of them complied with the selection criteria. In 15 papers, Khorana score was calculated in 8047 patients. In the low- and intermediate-risk groups, 532 of 6812 patients developed VTE [7.8%, 95%confidence intervals (CI) 7.2-8.5], whereas in the high-risk group, 127 of 1235 patients developed VTE (10.3%, 95% CI 8.7-12.1) [odds ratio (OR) 1.3, 95% CI 1.0-1.6] (I2=0%, τ2=0, p=0.50). Venous thromboembolism prediction using the Khorana score might be useful. However, most of the number of VTE patients are in the low- and intermediate-risk groups. Therefore, a comprehensive evaluation according to clinical conditions is required, regardless of the risk classification using the Khorana score.
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Affiliation(s)
| | - Yoshiaki Ikeda
- Faculty of Pharmaceutical Sciences, Kinjo Gakuin University
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