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Jee J, Brannon AR, Singh R, Derkach A, Fong C, Lee A, Gray L, Pichotta K, Luthra A, Diosdado M, Haque M, Guo J, Hernandez J, Garg K, Wilhelm C, Arcila ME, Pavlakis N, Clarke S, Shah SP, Razavi P, Reis-Filho JS, Ladanyi M, Schultz N, Zwicker J, Berger MF, Li BT, Mantha S. DNA liquid biopsy-based prediction of cancer-associated venous thromboembolism. Nat Med 2024:10.1038/s41591-024-03195-0. [PMID: 39147831 DOI: 10.1038/s41591-024-03195-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 07/15/2024] [Indexed: 08/17/2024]
Abstract
Cancer-associated venous thromboembolism (VTE) is a major source of oncologic cost, morbidity and mortality. Identifying high-risk patients for prophylactic anticoagulation is challenging and adds to clinician burden. Circulating tumor DNA (ctDNA) sequencing assays ('liquid biopsies') are widely implemented, but their utility for VTE prognostication is unknown. Here we analyzed three plasma sequencing cohorts: a pan-cancer discovery cohort of 4,141 patients with non-small cell lung cancer (NSCLC) or breast, pancreatic and other cancers; a prospective validation cohort consisting of 1,426 patients with the same cancer types; and an international generalizability cohort of 463 patients with advanced NSCLC. ctDNA detection was associated with VTE independent of clinical and radiographic features. A machine learning model trained on liquid biopsy data outperformed previous risk scores (discovery, validation and generalizability c-indices 0.74, 0.73 and 0.67, respectively, versus 0.57, 0.61 and 0.54 for the Khorana score). In real-world data, anticoagulation was associated with lower VTE rates if ctDNA was detected (n = 2,522, adjusted hazard ratio (HR) = 0.50, 95% confidence interval (CI): 0.30-0.81); ctDNA- patients (n = 1,619) did not benefit from anticoagulation (adjusted HR = 0.89, 95% CI: 0.40-2.0). These results provide preliminary evidence that liquid biopsies may improve VTE risk stratification in addition to clinical parameters. Interventional, randomized prospective studies are needed to confirm the clinical utility of liquid biopsies for guiding anticoagulation in patients with cancer.
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Affiliation(s)
- Justin Jee
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A Rose Brannon
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rohan Singh
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andriy Derkach
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Adrian Lee
- GenesisCare, University of Sydney, Sydney, New South Wales, Australia
| | - Lauren Gray
- GenesisCare, University of Sydney, Sydney, New South Wales, Australia
| | - Karl Pichotta
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anisha Luthra
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Mohammad Haque
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jiannan Guo
- Resolution Bioscience, Exact Sciences, Kirkland, WA, USA
| | | | - Kavita Garg
- Resolution Bioscience, Exact Sciences, Kirkland, WA, USA
| | - Clare Wilhelm
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria E Arcila
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Nick Pavlakis
- GenesisCare, University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Clarke
- GenesisCare, University of Sydney, Sydney, New South Wales, Australia
| | - Sohrab P Shah
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pedram Razavi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Jorge S Reis-Filho
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Marc Ladanyi
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | | | - Jeffrey Zwicker
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | | | - Bob T Li
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, Cornell University, New York, NY, USA
| | - Simon Mantha
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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2
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Sánchez Prieto I, Gutiérrez Jomarrón I, Martínez Vázquez C, Rodríguez Barquero P, Gili Herreros P, García-Suárez J. Comprehensive evaluation of genetic and acquired thrombophilia markers for an individualized prediction of clinical thrombosis in patients with lymphoma and multiple myeloma. J Thromb Thrombolysis 2024; 57:984-995. [PMID: 38676874 PMCID: PMC11315779 DOI: 10.1007/s11239-024-02977-0] [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: 04/02/2024] [Indexed: 04/29/2024]
Abstract
Patients diagnosed with lymphoma or multiple myeloma are at elevated risk of venous thromboembolism (VTE). Optimum risk stratification and effective thromboprophylaxis can only be achieved through the development of a multiple-specific risk score that successfully captures all aspects of the heterogeneous prothrombotic environment existing in these patients. Our aim was to identify risk factors for thrombosis and suggest an improved tool combining clinical data, thrombo-inflammatory biomarkers and genetic (Thrombo inCode® test) variables for predicting thrombotic risk in patients with lymphoma and multiple myeloma. A prospective longitudinal study was conducted on newly-diagnosed lymphoma and multiple myeloma patients who presented at our institution between February 2020 and January 2021. The study included 47 patients with lymphoma and 16 patients with multiple myeloma. We performed a follow-up of 1 year or until September 2021. The incidence of venous thrombosis and associated risk factors were analysed, including the genetic Thrombo inCode® test. Khorana and ThroLy scores for lymphoma patients and IMPEDE VTE score for myeloma patients were calculated. At a median follow-up of 9.1 months, VTE incidence was 9.5% (6/63), with 4 and 2 patients with lymphoma and myeloma who developed the events, respectively. Univariate analysis showed that the incidence of thrombosis was significantly higher in patients with ECOG ≥ 2 and prior immobility. Median factor VIII levels were significantly higher in patients with thrombosis (with increased values in all of them). Moreover, there was a trend in genetic variant rs5985 (factor XIII) as a protective factor, and a trend to higher thrombotic risk in patients with factor V Leiden, rs2232698 variant (serpinA10), low total protein S activity, elevated D-dimer, aggressive lymphoma and treatment with dexamethasone. The results of our study demonstrate promise for the potential use of widely accessible markers to increase precision in risk prediction for VTE in patients with lymphoma and multiple myeloma, particularly ECOG ≥ 2, immobility and higher factor VIII levels, as well as lymphoma aggressiveness, treatment with dexamethasone and the haemostatic biomarkers D-dimer and total protein S activity. Additionally, genetic variants factor V Leiden, serpinA10 rs2232698 and factor XIII-A Val34Leu warrant further investigation for use in the research setting.
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Affiliation(s)
- Irene Sánchez Prieto
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain.
| | - Isabel Gutiérrez Jomarrón
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Celia Martínez Vázquez
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Pedro Rodríguez Barquero
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Paula Gili Herreros
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Julio García-Suárez
- Hematology Department, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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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] [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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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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Xue-Xing W, Jie C, Chun-Mei C, Yuan H, Chun-Mei W. Analyzing venous thromboembolism risk in malignant tumors: thromboelastogram and coagulation factors study. Biomark Med 2024; 18:373-383. [PMID: 39041842 DOI: 10.1080/17520363.2024.2342239] [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: 08/30/2023] [Accepted: 03/26/2024] [Indexed: 07/24/2024] Open
Abstract
Aim: This retrospective clinical study was designed to examine the predictive value of thromboelastography (TEG) combined with coagulation function for venous thromboembolism (VTE) in hospitalized patients with cancer. Materials & methods: Among 215 patients admitted between May 2020 and January 2022, 39 (18.14%) were diagnosed with VTE during hospitalization. Results: Significant differences were found in D-dimer, ATIII and TEG parameters (maximum amplitude and coagulation index) between VTE-positive and VTE-negative patients (p < 0.05). Multivariate analysis revealed tumor node metastasis stage, concomitant infection, smoking history and D-dimer as independently associated with VTE. The constructed model and D-dimer areas under the curve were 0.809 and 0.764, respectively. Conclusion: TEG parameters were not significantly predictive indicators for VTE, with D-dimer remaining a key predictor.
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Affiliation(s)
- Wang Xue-Xing
- Department of Oncology, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
| | - Chu Jie
- Department of Oncology, Ziyang Hospital, West China Hospital, Sichuan University, Ziyang, 641300, China
| | - Chen Chun-Mei
- Department of Pharmacy, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
| | - He Yuan
- The Third Affiliated Hospital of Kunming Medical University, Kunming, 650000, China
| | - Wei Chun-Mei
- Department of Oncology, Anning First People's Hospital Affiliated to Kunming University of Science and Technology, Kunming, 650300, China
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6
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Patel JN, Singh J, Ghosh N. Bruton's tyrosine kinase inhibitor-related cardiotoxicity: The quest for predictive biomarkers and improved risk stratification. Oncotarget 2024; 15:355-359. [PMID: 38829647 PMCID: PMC11146632 DOI: 10.18632/oncotarget.28589] [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: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
Ibrutinib was the first Bruton's tyrosine kinase (BTK) inhibitor approved for the treatment of patients with chronic lymphocytic leukemia (CLL). While producing durable responses and prolonging survival, roughly 20-25% of patients experience dose limiting side effects, mostly consisting of cardiovascular toxicities like severe hypertension and atrial fibrillation. While clinical predictors of BTK inhibitor-related cardiotoxicity have been proposed and may aid in risk stratification, there is no routine risk model used in clinical practice today to identify patients at highest risk. A recent study investigating genetic predictors of ibrutinib-related cardiotoxicity found that single nucleotide polymorphisms in KCNQ1 and GATA4 were significantly associated with cardiotoxic events. If replicated in larger studies, these biomarkers may improve risk stratification in combination with clinical factors. A clinicogenomic risk model may aid in identifying patients at highest risk of developing BTK inhibitor-related cardiotoxicity in which further risk mitigation strategies may be explored.
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Affiliation(s)
- Jai N. Patel
- Department of Cancer Pharmacology and Pharmacogenomics, Atrium Health Levine Cancer Institute, Charlotte, NC 28204, USA
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC 27157, USA
| | - Jai Singh
- Sanger Heart and Vascular Institute, Atrium Health, Charlotte, NC 28204, USA
| | - Nilanjan Ghosh
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC 27157, USA
- Department of Hematologic Malignancies and Blood Disorders, Atrium Health Levine Cancer Institute, Charlotte, NC 28204, USA
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7
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Brown LC, Robinson M, McCormack M, Steuerwald N, Symanowski J, Sha W, Bose R, Neelands B, Akinyelu T, Livasy C, Li W, Haynes N, Hamilton A, Smith M, Clark PE, Patel J, Burgess EF. Thrombosis Rates and Genetic Thrombophilia Risk Among Patients With Advanced Germ Cell Tumors Treated With Chemotherapy. Clin Genitourin Cancer 2024; 22:102086. [PMID: 38697880 DOI: 10.1016/j.clgc.2024.102086] [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: 02/09/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 05/05/2024]
Abstract
INTRODUCTION Men with advanced germ cell tumors (GCT) treated with chemotherapy are at high risk of venous thromboembolism (VTE). Predictors of VTE may identify patients who would benefit from prophylactic anticoagulation. PATIENTS AND METHODS Men with advanced GCT (Stage IS, II, III) treated with chemotherapy were identified at 2 centers. High genomic risk was defined from a 5 single nucleotide polymorphism (SNP) germline panel. Logistic regression was used to evaluate the impact of genomic risk on VTE within 6 months of chemotherapy initiation. Orthogonal Projection to Latent Structures Discriminant Analysis (OPLS-DA) was used to build models to predict VTE based on clinical variables and an 86 SNP panel. RESULTS This 123-patient cohort experienced a VTE rate of 26% with an incidence of high genomic risk of 21%. Men with high genomic risk did not have a significantly higher VTE rate (31%, 8/26) than men with low genomic risk (25%, 24/97), unadjusted OR 1.4 (95% CI 0.5-3.5, P = .54). Incorporation of clinical variables (Khorana score, N3 status and elevated LDH) resulted in adjusted OR 2.1 (95% CI 0.7-6.5, P = .18). A combined model using clinical variables and 86 SNPs performed similarly (AUC 0.77) compared to clinical variables alone (AUC 0.72). CONCLUSIONS A previously established 5-SNP panel was not associated with VTE among patients with GCT receiving chemotherapy. However, multivariable models based on clinical variables alone warrant further validation to inform prophylactic anticoagulation strategies.
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Affiliation(s)
- Landon C Brown
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC.
| | - Myra Robinson
- Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Michael McCormack
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC
| | - Nury Steuerwald
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - James Symanowski
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Wei Sha
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Rupali Bose
- Atrium Health, Levine Cancer Institute, Charlotte, NC
| | | | - Tobi Akinyelu
- Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Chad Livasy
- Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Wencheng Li
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC
| | | | | | - Mathew Smith
- Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Peter E Clark
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Jai Patel
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
| | - Earle F Burgess
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC; Atrium Health, Levine Cancer Institute, Charlotte, NC
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Falanga A, Lorusso D, Colombo N, Cormio G, Cosmi B, Scandurra G, Zanagnolo V, Marietta M. Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention. Cancers (Basel) 2024; 16:1769. [PMID: 38730721 PMCID: PMC11083004 DOI: 10.3390/cancers16091769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University “A. Moro”, 70124 Bari, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppa Scandurra
- Unità Operativa Oncologia Medica, Ospedale Cannizzaro di Catania, 95126 Catania, Italy;
| | | | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy;
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9
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Kawano T, Mackman N. Cancer patients and ischemic stroke. Thromb Res 2024; 237:155-162. [PMID: 38603819 DOI: 10.1016/j.thromres.2024.03.019] [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: 12/26/2023] [Revised: 02/26/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
Patients with cancer have an increased risk of ischemic stroke compared to the general population. Additionally, these patients have a worse prognosis compared to stroke patients without cancer. Activation of coagulation appears to play a key role in the pathophysiology of ischemic stroke in patients with cancer. However, the underlying mechanisms remain unknown. Moreover, we do not have a way to identify cancer patients with a high risk of stroke and cannot develop prevention strategies. Therefore, there is an urgent need for neurologists and oncologists to develop screening and prevention strategies for stroke in patients with cancer. In this review, we summarize the characteristics of cancer patients at a high risk of stroke, the predictors for the development of stroke and survival in cancer patients, and possible treatments.
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Affiliation(s)
- Tomohiro Kawano
- Department of Neurology, Kano general hospital, Osaka, Japan
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Seki Y. Clinical guidelines for prevention and treatment of CAT in Japan and other countries. Int J Hematol 2024; 119:505-515. [PMID: 38558108 DOI: 10.1007/s12185-024-03736-w] [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: 11/01/2023] [Revised: 02/18/2024] [Accepted: 02/19/2024] [Indexed: 04/04/2024]
Abstract
Cancer-associated thrombosis (CAT) is an important prognostic factor for an increasing number of cancer patients. Understanding of CAT among cancer care providers has grown in recent years, and guidelines for the prevention and treatment of CAT have been published in Japan and around the world. In this article, we introduce these major guidelines and discuss differences we identified between the Japanese guidelines and those of other countries, with a focus on problems and issues. Insurance coverage of low-molecular-weight heparin and indications for primary prevention with direct oral anticoagulants in particular require urgent consideration.
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Affiliation(s)
- Yoshinobu Seki
- Department of Hematology, Niigata University Medical and Dental Hospital, Chuoku Asahimachi-Dori 1, Niigata, 951-8520, Japan.
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11
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Roy DC, Wang TF, Lun R, Zahrai A, Mallick R, Burger D, Zitikyte G, Hawken S, Wells P. Inherited thrombophilia gene mutations and risk of venous thromboembolism in patients with cancer: A systematic review and meta-analysis. Am J Hematol 2024; 99:577-585. [PMID: 38291601 DOI: 10.1002/ajh.27222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/06/2023] [Accepted: 01/08/2024] [Indexed: 02/01/2024]
Abstract
In the general population, individuals with an inherited thrombophilia have a higher risk of thrombosis, but the effect of inherited thrombophilia on the risk of cancer-associated venous thromboembolism (VTE) remains controversial. Our objective was to determine the risk of VTE in cancer patients with inherited thrombophilia. We conducted a systematic review and meta-analysis of studies reporting on VTE after a cancer diagnosis in adult patients who were tested for inherited thrombophilia. In September 2022, we searched Medline, EMBASE, and Cochrane Central. Two reviewers screened the abstracts/full texts and assessed study quality using the Quality in Prognostic Studies tool. We used Mantel-Haenszel random-effects models to estimate pooled odds ratios (OR) of VTE and 95% confidence intervals (95%CI). We included 37 and 28 studies in the systematic review and meta-analysis, respectively. Most studies focused on specific cancer types and hematologic malignancies were rare. The risk of VTE was significantly higher in cancer patients with non-O (compared with O) blood types (OR: 1.56 [95% CI: 1.28-1.90]), Factor V Leiden, and Prothrombin Factor II G20210A mutations compared with wild types (OR: 2.28 [95% CI: 1.51-3.48] and 2.14 [95% CI: 1.14-4.03], respectively). Additionally, heterozygous and homozygous methylenetetrahydrofolate reductase C677T had ORs of 1.50 (95% CI: 1.00-2.24) and 1.38 (95% CI: 0.87-2.22), respectively. Among those with Plasminogen-Activator Inhibitor-1 4G/5G, Vascular Endothelial Growth Factor (VEGF) A C634G, and VEGF C2578A mutations, there was no significant association with VTE. In conclusion, this meta-analysis provided evidence that non-O blood types, Factor V Leiden, and Prothrombin Factor II G20210A mutations are important genetic risk factors for VTE in cancer patients.
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Affiliation(s)
- Danielle Carole Roy
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Tzu-Fei Wang
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ronda Lun
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Vascular Neurology, Stanford Healthcare, Palo Alto, California, United States
| | - Amin Zahrai
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Dylan Burger
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gabriele Zitikyte
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Steven Hawken
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Philip Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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12
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González Caraballo I, Martín Lozano R, Jiménez Rodríguez R, Soto Alsar J, Ortega Morán L, Martín Jiménez M, Muñoz Martín AJ. Chronological pattern of venous thromboembolism (VTE) occurrence impacts in survival of pancreatic ductal adenocarcinoma (PDAC). Clin Transl Oncol 2024:10.1007/s12094-024-03467-8. [PMID: 38558283 DOI: 10.1007/s12094-024-03467-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Limited data exist on the prognostic significance of the chronology of VTE in patients with PDAC. METHODS Medical data and survival characteristics of patients treated for PDAC from 2019 to 2021 were retrospectively reviewed. Early VTE was defined as occurring within the three months of PDAC diagnosis. RESULTS 197 patients were included, 54 (27.4%) developed a VTE. Early appearance of VTE was associated with worse prognosis: median overall survival (mOS) VTE < 3 months 8.5 months (HR 1.65, 95% CI 1.11-2.46; p = 0.014), mOS VTE > 3 months 12.8 months (HR 0.78, 95% CI 0.39-1.54; p = 0.5) and mOS patients without VTE 11.4 months (95% CI 10.1-15.4). There was no significant association between the patient's VTE risk according to the Khorana risk score (KRS) (chi2 test p-value = 0.9). CONCLUSION Early VTE is a prognostic factor in PDAC, which may identify a more aggressive subtype.
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Affiliation(s)
| | - Rocío Martín Lozano
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Javier Soto Alsar
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Laura Ortega Morán
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Miguel Martín Jiménez
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Andrés J Muñoz Martín
- Medical Oncology Service, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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13
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Drăgan A, Drăgan AŞ. Novel Insights in Venous Thromboembolism Risk Assessment Methods in Ambulatory Cancer Patients: From the Guidelines to Clinical Practice. Cancers (Basel) 2024; 16:458. [PMID: 38275899 PMCID: PMC10813930 DOI: 10.3390/cancers16020458] [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: 12/07/2023] [Revised: 01/07/2024] [Accepted: 01/19/2024] [Indexed: 01/27/2024] Open
Abstract
Many cancer patients will experience venous thromboembolism (VTE) at some stage, with the highest rate in the initial period following diagnosis. Novel cancer therapies may further enhance the risk. VTE in a cancer setting is associated with poor prognostic, a decreased quality of life, and high healthcare costs. If thromboprophylaxis in hospitalized cancer patients and perioperative settings is widely accepted in clinical practice and supported by the guidelines, it is not the same situation in ambulatory cancer patient settings. The guidelines do not recommend primary thromboprophylaxis, except in high-risk cases. However, nowadays, risk stratification is still challenging, although many tools have been developed. The Khrorana score remains the most used method, but it has many limits. This narrative review aims to present the current relevant knowledge of VTE risk assessment in ambulatory cancer patients, starting from the guideline recommendations and continuing with the specific risk assessment methods and machine learning models approaches. Biomarkers, genetic, and clinical features were tested alone or in groups. Old and new models used in VTE risk assessment are exposed, underlining their clinical utility. Imaging and biomolecular approaches to VTE screening of outpatients with cancer are also presented, which could help clinical decisions.
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Affiliation(s)
- Anca Drăgan
- Department of Cardiovascular Anaesthesiology and Intensive Care, Emergency Institute for Cardiovascular Diseases “Prof. Dr. C C Iliescu”, 258 Fundeni Road, 022328 Bucharest, Romania
| | - Adrian Ştefan Drăgan
- Faculty of General Medicine, Carol Davila University of Medicine and Pharmacy, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania;
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14
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Muñoz A, Salas E, Soria JM. Reply to F.I. Mulder et al. J Clin Oncol 2023; 41:5595. [PMID: 37816210 DOI: 10.1200/jco.23.00817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Andrés Muñoz
- Andrés Muñoz, MD, PhD, Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Eduardo Salas, MD, PhD, Transfer Technology Office, Fundació Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain; and José Manuel Soria, PhD, BSc, Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - Eduardo Salas
- Andrés Muñoz, MD, PhD, Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Eduardo Salas, MD, PhD, Transfer Technology Office, Fundació Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain; and José Manuel Soria, PhD, BSc, Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
| | - José Manuel Soria
- Andrés Muñoz, MD, PhD, Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Eduardo Salas, MD, PhD, Transfer Technology Office, Fundació Institut de Bioenginyeria de Catalunya (IBEC), Barcelona, Spain; and José Manuel Soria, PhD, BSc, Genomics of Complex Diseases Unit, Biomedical Research Institute Sant Pau (IIB-Sant Pau), Barcelona, Spain
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15
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Mulder FI, Guman NAM, Buller HR, Van Es N. Disclosure of Prediction Model. J Clin Oncol 2023; 41:5594. [PMID: 37816207 DOI: 10.1200/jco.23.00449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/26/2023] [Indexed: 10/12/2023] Open
Affiliation(s)
- Frits I Mulder
- Frits I. Mulder, MD and Noori A.M. Guman, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; Harry R. Buller, MD, PhD, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; and Nick Van Es, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Noori A M Guman
- Frits I. Mulder, MD and Noori A.M. Guman, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; Harry R. Buller, MD, PhD, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; and Nick Van Es, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Harry R Buller
- Frits I. Mulder, MD and Noori A.M. Guman, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; Harry R. Buller, MD, PhD, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; and Nick Van Es, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nick Van Es
- Frits I. Mulder, MD and Noori A.M. Guman, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; Harry R. Buller, MD, PhD, Department of Internal Medicine, Tergooi MC, Hilversum, the Netherlands; and Nick Van Es, MD, Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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16
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Guman NAM, Mulder FI, Ferwerda B, Zwinderman AH, Kamphuisen PW, Büller HR, van Es N. Polygenic risk scores for prediction of cancer-associated venous thromboembolism in the UK Biobank cohort study. J Thromb Haemost 2023; 21:3175-3183. [PMID: 37481074 DOI: 10.1016/j.jtha.2023.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Guidelines recommend thromboprophylaxis for patients with cancer at high risk of venous thromboembolism (VTE). Polygenic risk scores may improve VTE prediction but have not yet been evaluated in patients with cancer. OBJECTIVES We assessed the performance of the 5-, 37-, 297-, extended 297- (additionally including factor V Leiden and prothrombin G20210A), and 100-single-nucleotide polymorphism (SNP) scores in predicting cancer-associated VTE in the UK Biobank, a population-based, prospective cohort study. METHODS The primary outcome was VTE during 12 months after cancer diagnosis. Cancer and VTE diagnosis were based on ICD-10 codes. Discrimination was evaluated by c-indices and subdistribution hazard ratios in the upper vs 3 lower quartiles of the scores in a competing risk model. As a comparison, the c-index was calculated for the Khorana cancer type risk classification. RESULTS Of 36 150 patients with cancer (median age, 66 years; 48.7% females), 1018 (2.8%) developed VTE. C-indices at 12 months ranged from 0.56 (95% CI, 0.54-0.58) for the 5-SNP to 0.60 (95% CI, 0.58-0.62) for the extended 297-SNP scores. The subdistribution hazard ratios ranged from 1.36 (95% CI, 1.19-1.56) for the 5-SNP to 1.90 (95% CI, 1.68-2.16) for the extended 297-SNP scores and were consistent after adjusting for cancer type. For the Khorana cancer type classification, the c-index was 0.60 (95% CI, 0.58-0.61), which increased to 0.65 (95% CI, 0.63-0.67, +0.05; 95% CI, 0.04-0.07) when combined with the extended 297-SNP score. CONCLUSION These findings demonstrate that polygenic VTE risk scores can identify patients with cancer with a 1.9-fold higher VTE risk independent of cancer type. Combined clinical-genetic scores to improve cancer-associated VTE prediction should be evaluated further.
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Affiliation(s)
- Noori A M Guman
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands; Department of Internal Medicine, Tergooi Medical Center, Hilversum, The Netherlands.
| | - Frits I Mulder
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands; Department of Internal Medicine, Tergooi Medical Center, Hilversum, The Netherlands
| | - Bart Ferwerda
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Pieter W Kamphuisen
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands; Department of Internal Medicine, Tergooi Medical Center, Hilversum, The Netherlands
| | - Harry R Büller
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Nick van Es
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
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17
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Bolek H, Ürün Y. Cancer-associated thrombosis and drug-drug interactions of antithrombotic and antineoplastic agents. Cancer 2023; 129:3216-3229. [PMID: 37401828 DOI: 10.1002/cncr.34937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 07/05/2023]
Abstract
Venous thromboembolism (VTE) is often associated with malignant diseases and notably contributes to morbidity and mortality in patients with cancer. Cancer-associated thrombosis (CAT) brings additional costs to health expenditures and has a negative impact on oncological outcomes. Either the recurrence rate of VTE or bleeding complications are also higher in patients with cancer. Prophylactic anticoagulation has been recommended in peri-surgical periods, inpatient settings, and high-risk ambulatory patients. Although various risk stratification scores are used, none are ideal for identifying patients who can benefit from anticoagulant prophylaxis. New risk scoring systems or biomarkers are needed to identify patients who are more likely to benefit from prophylaxis with low bleeding risk. The questions about the patients who will be given prophylaxis and those who develop thromboembolism, with which drug, and how long they will be treated are still not fully answered. Anticoagulation is the cornerstone of the treatment, but management of CAT remains complex. Low molecular weight heparins and direct oral anticoagulants are effective and safe options for the treatment of CAT. Recognizing adverse effects, drug-drug interactions, and accompanying conditions that cause dose adjustment is crucial. Prevention and treatment of VTE in patients with cancer require a multidisciplinary and patient-based approach. PLAIN LANGUAGE SUMMARY: Cancer-associated thrombosis is a significant cause of mortality and morbidity in patients with cancer. Chemotherapy, surgery, and/or use of central venous access remarkably increase the risk of thrombosis. Prophylactic anticoagulation should be considered not only in inpatient follow-up and during peri-surgical period but also ambulatory patients with a high risk of thrombosis. Many parameters, such as drug-drug interactions, primary side of cancer, and comorbidities of patients should be considered when selecting anticoagulant drugs. More accurate risk stratification scores or biomarkers are still an unmet need.
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Affiliation(s)
- Hatice Bolek
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
| | - Yüksel Ürün
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
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18
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Franco-Moreno A, Madroñal-Cerezo E, Muñoz-Rivas N, Torres-Macho J, Ruiz-Giardín JM, Ancos-Aracil CL. Prediction of Venous Thromboembolism in Patients With Cancer Using Machine Learning Approaches: A Systematic Review and Meta-Analysis. JCO Clin Cancer Inform 2023; 7:e2300060. [PMID: 37616550 DOI: 10.1200/cci.23.00060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/02/2023] [Accepted: 07/10/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE Recent studies have suggested that machine learning (ML) could be used to predict venous thromboembolism (VTE) in cancer patients with high accuracy. METHODS We aimed to evaluate the performance of ML in predicting VTE events in patients with cancer. PubMed, Web of Science, and EMBASE to identify studies were searched. RESULTS Seven studies involving 12,249 patients with cancer were included. The combined results of the different ML models demonstrated good accuracy in the prediction of VTE. In the training set, the global pooled sensitivity was 0.87, the global pooled specificity was 0.87, and the AUC was 0.91, and in the test set 0.65, 0.84, and 0.80, respectively. CONCLUSION The prediction ML models showed good performance to predict VTE. External validation to determine the result's reproducibility is necessary.
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Affiliation(s)
- Anabel Franco-Moreno
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
| | - Elena Madroñal-Cerezo
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
- Medicine Department, Complutense University, Madrid, Spain
| | - Juan Torres-Macho
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario Infanta Leonor-Virgen de la Torre, Madrid, Spain
- Medicine Department, Complutense University, Madrid, Spain
| | - José Manuel Ruiz-Giardín
- Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
- CIBERINFEC, Madrid, Spain
| | - Cristina L Ancos-Aracil
- Thromboembolism Unit, Internal Medicine Department, Hospital Universitario de Fuenlabrada, Madrid, Spain
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19
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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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20
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Affiliation(s)
- Isabelle Mahé
- Université Paris Cité, Paris, France
- Assistance Publique des Hôpitaux de Paris, Hôpital Louis Mourier, Médecine Interne, Colombes, France
- Innovative Therapies in Haemostasis, INSERM UMR_S1140, Paris, France
- INNOVTE, FCRIN, France
- Address for correspondence: Dr Isabelle Mahé, Université Paris Cité, APHP, Hôpital Louis Mourier, Service de Médecine Interne, Inserm UMR_S1140, Innovations thérapeutiques en hémostase, 178 rue des Renouillers, 92700 Colombes, France. @isabellemahe1
| | - Florian Scotté
- Gustave Roussy, Patient Pathway Department, Villejuif, France
| | - Ismail Elalamy
- INNOVTE, FCRIN, France
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l’Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group “Cancer, Vessel Biology and Therapeutics,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
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21
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Muñoz AJ, Ortega L, Gutiérrez A, Gallardo E, Rubio-Rodríguez D, Rubio-Terrés C, Morón B, García-Alfonso P, Soria JM. Cost-effectiveness of apixaban and rivaroxaban in thromboprophylaxis of cancer patients treated with chemotherapy in Spain. J Med Econ 2023; 26:1145-1154. [PMID: 37602646 DOI: 10.1080/13696998.2023.2248839] [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: 12/07/2022] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Apixaban and rivaroxaban are two direct-acting oral anticoagulants (DOACs) recommended for thromboprophylaxis in cancer patients treated with chemotherapy in an ambulatory setting. We aimed to assess the cost-utility of thromboprophylaxis with apixaban and rivaroxaban vs no thromboprophylaxis in ambulatory cancer patients starting chemotherapy with an intermediate-to-high risk of venous thromboembolism (VTE), Khorana score ≥ 2 points. METHODS A cost-effectiveness analysis was performed from the perspective of Spain's National Health System (NHS) using an analytical decision model in the short-term (180 days) and a Markov model in the long-term (5 years). Transition probabilities were obtained from randomized, double-blind, placebo-controlled clinical trials of apixaban and rivaroxaban in adult ambulatory patients with cancer at risk for VTE, treated with chemotherapy (AVERT and CASSINI trials). The costs (€2,021) were taken from Spanish sources. The utilities of the model were obtained through the EQ-5D questionnaire. Deterministic (base case) and probabilistic (second-order Monte Carlo simulation) analyses were conducted. RESULTS In the probabilistic sensitivity analysis, apixaban generated a cost per patient of €1,082 ± 187, with a 95% confidence interval (CI) of €713-1,442, while no prophylaxis produced a cost per patient of €1,146 ± 218, with a 95% CI of €700-1,491, with a saving of €64 per patient and a gain of 0.008 QALYs. Likewise, rivaroxaban provided a cost per patient of €993 ± 133, with a 95% CI of €748-1,310, while no prophylaxis produced a cost per patient of €872 ± 152, with a 95% CI of €602-1,250, with an additional expense of €121 per patient and a gain of 0.008 QALYs. CONCLUSIONS In thromboprophylaxis of cancer patients, the use of apixaban and rivaroxaban generated similar costs compared to non-prophylaxis, without the difference found being statistically significant, with a clinically insignificant QALY gain.
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Affiliation(s)
- Andrés J Muñoz
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Laura Ortega
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Ana Gutiérrez
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Enrique Gallardo
- Medical Oncology Service, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona. Sabadell, Spain
| | | | | | - Blanca Morón
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Pilar García-Alfonso
- Medical Oncology Service, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - José Manuel Soria
- Institut de Recerca, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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