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Calvarysky B, Dotan I, Shepshelovich D, Leader A, Cohen TD. Drug-Drug Interactions Between Glucagon-Like Peptide 1 Receptor Agonists and Oral Medications: A Systematic Review. Drug Saf 2024; 47:439-451. [PMID: 38273155 PMCID: PMC11018670 DOI: 10.1007/s40264-023-01392-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Glucagon-like peptide 1 receptor agonists (GLP1RAs) are used in the treatment of diabetes and obesity. Their slowing effect of gastric emptying might change oral drug absorption, potentially affecting pharmacokinetics, particularly in the case of medications with a narrow therapeutic index. PURPOSE The purpose of this systematic review is to summarize data on drug-drug interactions between GLP1RAs and oral drugs. DATA SOURCES The PubMed and EMBASE databases were searched up to November, 1st 2023. STUDY SELECTION We selected pharmacokinetic studies of any injectable GLP1RA given with an oral medication, and product prescribing sheets reporting data without access to the original study. DATA EXTRACTION Two authors independently extracted the data. DATA SYNTHESIS Twenty-two reports and six prescribing sheets were included. Treatment with GLP1RAs resulted in unaffected or reduced Cmax and delayed tmax of drugs with high solubility and permeability (warfarin, contraceptive pills, acetaminophen), drugs with high solubility and low permeability (angiotensin converting enzyme inhibitors), drugs with low solubility and high permeability (statins) and drugs with low solubility and permeability (digoxin). However, the use of GLP1RAs did not exert clinically significant changes in the AUC or differences in clinically relevant endpoints. LIMITATIONS The major limitations of the studies that are included in this systematic review are the enrollment of healthy subjects and insufficient data in conditions that might affect pharmacokinetics (e.g., kidney dysfunction). CONCLUSIONS To conclude, reduced Cmax and delayed tmax of drugs co-administered with GLP1RAs are consistent with the known delayed gastric output by the latter. Nevertheless, the overall drug exposure was not considered clinically significant. Dose adjustments are probably not required for simultaneous use of GLP1RAs with oral medications. Still, results should be carefully generalized to cases of background kidney dysfunction or when using drugs with narrow therapeutic index. The study is registered in PROSPERO: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022332339 .
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Affiliation(s)
- Bronya Calvarysky
- Pharmacy, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Idit Dotan
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Shepshelovich
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Internal medicine D, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Avi Leader
- Institute of Hematology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talia Diker Cohen
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Potere N, Mahé I, Angchaisuksiri P, Cesarman-Maus G, Tan CW, Rashid A, AlGahtani FH, Imbalzano E, van Es N, Leader A, Olayemi E, Porreca E, Ní Áinle F, Okoye HC, Candeloro M, Mayeur D, Valerio L, Clark RC, Castellucci LA, Barco S, Di Nisio M. Unmet needs and barriers in venous thromboembolism education and awareness among people living with cancer: a global survey. J Thromb Haemost 2024:S1538-7836(24)00177-6. [PMID: 38582384 DOI: 10.1016/j.jtha.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/02/2024] [Accepted: 03/21/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major preventable cause of morbidity, disability, and mortality in subjects with cancer. A global appraisal of cancer-associated VTE education and awareness is not available. OBJECTIVES To evaluate VTE-related education, awareness, and unmet needs from the perspective of people living with cancer using a quantitative and qualitative approach. METHODS This cross-sectional study used data from an online-based survey covering multidimensional domains of cancer-associated VTE. Data are presented descriptively. Potential differences across participant subgroups were explored. RESULTS Among 2262 patients with cancer from 42 countries worldwide, 55.3% received no VTE education throughout their cancer journey, and an additional 8.2% received education at the time of VTE diagnosis only, leading to 63.5% receiving no or inappropriately delayed education. When education was delivered, only 67.8% received instructions to seek medical attention in case of VTE suspicion, and 36.9% reported scarce understanding. One-third of participants (32.4%) felt psychologically distressed when becoming aware of the potential risks and implications connected with cancer-associated VTE. Most responders (78.8%) deemed VTE awareness highly relevant, but almost half expressed concerns about the quality of education received. While overall consistent, findings in selected survey domains appeared to numerically differ across age group, ethnicity, continent of residence, educational level, metastatic status, and VTE history. CONCLUSION This study involving a large and diverse population of individuals living with cancer identifies important unmet needs in VTE-related education, awareness, and support across healthcare systems globally. These findings unveil multilevel opportunities to expedite patient-centered care in cancer-associated VTE prevention and management.
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Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences, School of Medicine and Health Sciences, "G. D'Annunzio" University, Chieti, Italy.
| | - Isabelle Mahé
- Innovative Therapies in Haemostasis, INSERM UMR_S1140, INNOVTE-FRIN Université Paris Cité, Assistance Publique des Hôpitaux de Paris, Hôpital Louis Mourier, Paris, France
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Chee Wee Tan
- Department of Hematology, Royal Adelaide Hospital, University of Adelaide, Adelaide, South Australia, Australia
| | - Anila Rashid
- Section of Haematology, Department of Pathology & Laboratory Medicine/Oncology, Aga Khan University Hospital, Karachi, Pakistan
| | - Farjah H AlGahtani
- Division of Hematology-Oncology, Oncology Center, Department of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC - University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | | | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, School of Medicine and Health Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Fionnuala Ní Áinle
- Department of Hematology, Mater Misericordiae University Hospital and Rotunda Hospital, Dublin, Ireland; School of Medicine, University College, Dublin, Ireland
| | - Helen C Okoye
- Department of Hematology and Immunology, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, School of Medicine and Health Sciences, "G. D'Annunzio" University, Chieti, Italy
| | - Didier Mayeur
- Medical Oncology, Transversal Department of Supportive Care, Association Francophone des Soins Oncologiques de Support, Centre Georges-François Leclerc, Dijon, France
| | - Luca Valerio
- Centers for Thrombosis and Hemostasis and Cardiology, University Hospital Mainz, Mainz, Germany
| | - R Cary Clark
- Programs and Education, International Society on Thrombosis and Haemostasis, Carrboro, North Carolina, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Stefano Barco
- Centers for Thrombosis and Hemostasis and Cardiology, University Hospital Mainz, Mainz, Germany; Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, School of Medicine and Health Sciences, "G. D'Annunzio" University, Chieti, Italy
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Naftali J, Barnea R, Eliahou R, Pardo K, Tolkovsky A, Adi M, Hasminski V, Saliba W, Bloch S, Raphaeli G, Leader A, Auriel E. Lung cancer is associated with acute ongoing cerebral ischemia: A population-based study. Int J Stroke 2024; 19:406-413. [PMID: 37978833 DOI: 10.1177/17474930231217670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Cerebral microinfarcts (CMIs) are the most common type of brain ischemia; however, they are extremely rare in the general population. CMIs can be detected by magnetic resonance diffusion-weighted imaging (MRI-DWI) only for a very short period of approximately 2 weeks after their formation and are associated with an increased stroke risk and cognitive impairment. We aimed to examine CMI detection rate in patients with lung cancer (LC), which is strongly associated with ischemic stroke risk relative to other cancer types. METHODS We used the Clalit Health Services record (representing more than 5 million patients) to identify adults with LC and breast, pancreatic, or colon cancer (non-lung cancer, NLC) who underwent brain magnetic resonance diffusion (MRI) scan within 5 years following cancer diagnosis. All brain MRI scans were reviewed, and CMIs were documented, as well as cardiovascular risk factors. RESULTS Our cohort contained a total of 2056 MRI scans of LC patients and 1598 of NLC patients. A total of 143 CMI were found in 73/2056 (3.5%) MRI scans of LC group compared to a total of 29 CMI in 22/1598 (1.4%) MRI scans of NLC (p < 0.01). Cancer type (e.g. LC vs NLC) was the only associated factor with CMI incidence on multivariate analysis. After calculating accumulated risk, we found an incidence of 2.5 CMI per year in LC patients and 0.5 in NLC. DISCUSSION CMIs are common findings in cancer patients, especially in LC patients and therefore might serve as a marker for occult brain ischemia, cognitive decline, and cancer-related stroke (CRS) risk.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ruth Eliahou
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Keshet Pardo
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Assaf Tolkovsky
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Meital Adi
- Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Vadim Hasminski
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Walid Saliba
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Sivan Bloch
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Guy Raphaeli
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Avi Leader
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Cheong MA, Leader A. Cancer and arterial thrombosis: therapeutic options. Res Pract Thromb Haemost 2024; 8:102393. [PMID: 38660456 PMCID: PMC11039399 DOI: 10.1016/j.rpth.2024.102393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/21/2024] [Indexed: 04/26/2024] Open
Abstract
A State of the Art lecture titled "Cancer and Arterial Thrombosis: Therapeutic Options" was presented at the International Society on Thrombosis and Haemostasis Congress in 2023. This State of the Art review delves into the complex relationship between cancer and arterial thromboembolism (ATE), encompassing acute coronary syndrome, ischemic strokes, and peripheral arterial disease. The burden of cancer-associated ATE is not well defined, but studies indicate elevated risks, particularly in the 6 months after a cancer diagnosis. Incidence varies among cancer subtypes, with lung cancer displaying the highest rates. Additionally, the pathophysiology of cancer-associated ATE involves a multifaceted interplay of cancer-induced hypercoagulopathy, cancer therapy-related thrombosis, and personal risk factor contributors. ATEs are clinically heterogeneous and in the context of cancer have particular mechanistic differences compared with ATE patients without cancer. This requires modifications in approach and tailored management considerations. Specific etiologies contributing to ATE, such as coronary vasospasm and non-bacterial-thrombotic endocarditis, need to be considered. The diagnosis of cancer alone usually does not contraindicate patients to standard guideline-based therapies for the management of ATE, although nuances in treatment may need to be considered in light of the underlying cancer. Atrial fibrillation in cancer patients further complicates the thrombotic landscape. Cancer patients with atrial fibrillation are at a higher risk of ATE, necessitating careful consideration of anticoagulation therapy as clinical benefits and bleeding risks need to be weighed. ATE may also be a presenting sign of underlying malignancy, which requires increased awareness and focused clinical evaluation for cancer in selected cases. Finally, we summarize relevant new data on this topic presented during the 2023 International Society on Thrombosis and Haemostasis Congress.
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Affiliation(s)
- May Anne Cheong
- Department of Haematology, Singapore General Hospital, Singapore
| | - Avi Leader
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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Fredman D, McNeil R, Eldar O, Leader A, Gafter-Gvili A, Avni T. Efficacy and safety of rivaroxaban versus apixaban for venous thromboembolism: A systematic review and meta-analysis of observational studies. J Thromb Thrombolysis 2024; 57:453-465. [PMID: 38127261 DOI: 10.1007/s11239-023-02926-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) including rivaroxaban and apixaban are preferred over vitamin K antagonists for the treatment of venous thromboembolism (VTE). We conducted a systematic review and a meta-analysis to compare the efficacy and safety of rivaroxaban versus apixaban in the treatment of VTE. METHODS We conducted an electronic search for studies that directly compared treatment with rivaroxaban and apixaban in adult patients with VTE. The relative risks (RRs) and 95% confidence intervals (CIs) were estimated and pooled using a fixed-effect model unless significant heterogeneity was present (I2 > 40%), then random-effects model was used. The primary efficacy and safety outcomes were recurrent VTE (rVTE) and major bleeding events, respectively. RESULTS Nine observational studies were included in our meta-analysis, assessing 24,156 patients for apixaban and 38,847 for rivaroxaban. Pooling of data for our primary efficacy outcome showed a trend towards lower risk of rVTE with apixaban compared to rivaroxaban (RR 0.77, 95% CI 0.57-1.04, I2 = 53%). Analysis of our primary safety outcome showed a significantly lower risk of major bleeding with apixaban compared to rivaroxaban (RR 0.68, 95% CI 0.61-0.76, I2 = 0%). Apixaban was associated with significantly decreased risk of net clinical harm, clinically relevant non major bleeding (CRNMB) and any bleeding, compared to rivaroxaban (RR 0.75, 95% CI 0.61-0.92, I2 = 50%; RR 0.58, 95% CI 0.50-0.67, I2 = 7%; RR 0.64, 95% CI 0.59-0.70, I2 = 0%, respectively). CONCLUSIONS Apixaban is associated with a significantly lower risk of major bleeding compared to rivaroxaban for treatment of VTE. Given the limitations of the existing evidence, further interventional studies comparing the two drugs are needed.
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Affiliation(s)
- Danielle Fredman
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
| | - Rotem McNeil
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Ofir Eldar
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Institute of Haematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Anat Gafter-Gvili
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Institute of Haematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Tomer Avni
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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Drozdinsky G, Arad N, Spectre G, Livneh N, Poran I, Raanani P, Falanga A, Ten Cate H, Gafter-Gvili A, Leader A. Anticoagulation in cancer patients with atrial fibrillation and grade 3-4 thrombocytopenia. Thromb Res 2024; 235:92-97. [PMID: 38308884 DOI: 10.1016/j.thromres.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/03/2024] [Accepted: 01/17/2024] [Indexed: 02/05/2024]
Abstract
INTRODUCTION Atrial fibrillation or flutter (AF) is prevalent in cancer patients. Many of these patients have an indication for anticoagulation (AC) but are also at risk for developing chemotherapy-induced thrombocytopenia. There are scarce data regarding management of AC and risk of bleeding and thrombosis in cancer patients with AF and thrombocytopenia. AIM To assess anticoagulation management and incidence of bleeding and arterial thromboembolism (ATE) in cancer patients with AF and grade 3-4 thrombocytopenia (platelets <50 × 109/L). METHODS A retrospective cohort study included adults with active cancer, grade 3-4 thrombocytopenia and AF with CHA2DS2-VASc score ≥ 1. Patients were stratified according to AC discontinuation (No-AC) or continuation (Continue-AC) when platelets dropped below 50 × 109/L and followed for 30 days. The study outcomes were ATE (ischemic stroke, transient ischemic attack or systemic emboli) and major bleeding. Cox proportional hazards model was used to calculate hazard ratios (HR) with death as a competing risk (Fine and Gray model). RESULTS The cohort included 131 patients; 90 in the No-AC group and 41 in the Continue-AC group. Patient characteristics were balanced between the groups. The 30-day cumulative incidence of ATE was 2 % [95 % CI 0.4 %-7 %] in the No-AC group and 2 % [0.2 %-11 %] in the Continue-AC group (HR 0.92 [95 % CI 0.09-9.88]). The 30-day cumulative incidence of major bleeding was 7.8 % [95 % CI 3.40 %-14.52 %] and 2.44 % [95 % CI 0.18 %-11.22 %] in the No-AC and Continue-AC groups, respectively (HR 3.29 [95 % CI 0.42-26.04]). CONCLUSIONS The high rate of bleeding and low rate of ATE in thrombocytopenic cancer patients with AF suggests that holding AC during time-limited periods may be a reasonable approach.
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Affiliation(s)
- Genady Drozdinsky
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noam Arad
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Nir Livneh
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Otolaryngology Head and Neck Surgery, Sheba Medical Center, Tel Hashomer, Israel
| | - Itamar Poran
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Anna Falanga
- University of Milano-Bicocca, Department of Medicine, Milan, Italy; Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Center for Thrombosis and Hemostasis, Gutenberg University Medical Center, Mainz, Germany
| | - Anat Gafter-Gvili
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Department of Medicine A, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Hematology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, US; Weill Cornell Medical College, New York, NY, USA.
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Iyengar V, Agrawal S, Chiasakul T, Tehranchi K, Mcnichol M, Carney BJ, Leader A, Zwicker JI, Patell R. Comparison of direct oral anticoagulants versus low-molecular-weight heparin in primary and metastatic brain cancers: a meta-analysis and systematic review. J Thromb Haemost 2024; 22:423-429. [PMID: 37866517 DOI: 10.1016/j.jtha.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND The safety and efficacy of direct-acting oral anticoagulants (DOACs) for therapeutic anticoagulation in the setting of primary or metastatic brain cancer is not known. OBJECTIVES To conduct a meta-analysis and systematic review of studies that compare the risk of intracranial hemorrhage (ICH) in patients with brain cancer treated with DOACs vs low-molecular-weight heparin (LMWH). METHODS A literature search was conducted using PubMed, EMBASE, and Cochrane databases. Summary statistics were obtained by calculating the risk ratio (RR), and heterogeneity across studies was estimated using the I2 statistic. A total of 10 retrospective studies (n = 1638) met criteria for inclusion. The primary endpoint was the pooled RR for ICH in patients with brain tumors receiving anticoagulation with DOACs compared with those receiving LMWH. Secondary analyses included the risk of fatal ICH in each subgroup. RESULTS The pooled RR for ICH in patients receiving DOACs vs those receiving LMWH was 0.65 (95% CI, 0.36-1.17; P = .15; I2 = 50%). In studies evaluating primary brain cancer, there was a reduction in risk of ICH with DOACs (RR, 0.35; 95% CI, 0.18-0.69; P = .003; I2 = 0%). In patients with metastatic brain cancer, there was no difference in the risk of ICH with the type of anticoagulation (RR, 1.05; 95% CI, 0.71-1.56; P = .80; I2 = 0%). The overall risk of fatal ICH was not different between anticoagulants. CONCLUSION The risk of ICH in patients with brain cancer receiving therapeutic anticoagulation varies by anticoagulation agent and diagnosis of primary or metastatic disease.
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Affiliation(s)
- Varun Iyengar
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Shubham Agrawal
- Department of Internal Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania, USA
| | - Thita Chiasakul
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand; Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kian Tehranchi
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Megan Mcnichol
- Division of Knowledge Services, Department of Information Services, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Brian J Carney
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Avi Leader
- Institiute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey I Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Soff G, Leader A, Al-Samkari H, Falanga A, Maraveyas A, Sanfilippo K, Wang TF, Zwicker J. Management of chemotherapy-induced thrombocytopenia: guidance from the ISTH Subcommittee on Hemostasis and Malignancy. J Thromb Haemost 2024; 22:53-60. [PMID: 37827380 DOI: 10.1016/j.jtha.2023.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 10/14/2023]
Abstract
Thrombocytopenia is a common adverse effect of chemotherapy. The development of chemotherapy-induced thrombocytopenia (CIT) is influenced by cancer type and therapy, occurring in approximately one-third of patients with a solid tumor diagnosis and half of all patients with a hematologic malignancy. CIT may complicate the administration of chemotherapy, leading to therapeutic delays or dose reductions. This guidance document, presented by the International Society on Thrombosis and Haemostasis (ISTH) Subcommittee on Hemostasis and Malignancy, provides a comprehensive summary of the evidence and offers direction on the use of thrombopoietin receptor agonists (TPO-RAs) in various settings of CIT, including solid tumors, acute myeloid leukemia, stem cell transplant, and lymphoma. Studies have shown that TPO-RAs can improve platelet counts in CIT, but the clinical benefits of TPO-RA in terms of reducing bleeding, limiting platelet transfusion, avoiding chemotherapy delay, or dose reduction are uncertain. Further research is needed to optimize the selection of appropriate indications and study design to manage thrombocytopenia following chemotherapy.
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Affiliation(s)
- Gerald Soff
- Department of Medicine, University of Miami Health System/Sylvester Comprehensive Cancer Center, Miami, Florida, USA.
| | - Avi Leader
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Hanny Al-Samkari
- Classical Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anthony Maraveyas
- Faculty of Health Sciences, Joint Centre for Cancer Studies, The Hull York Medical School, Castle Hill Hospital, Hull, UK
| | - Kristen Sanfilippo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, USA. https://twitter.com/sanfilippomd
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. https://twitter.com/tzufeiwang
| | - Jeffrey Zwicker
- Section of Hematology, Memorial Sloan Kettering Cancer Center, New York, New York, USA. https://twitter.com/jzbos
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Shapiro M, Hamulyák EN, Leader A, Landau R, Middeldorp S, Gurevich-Shapiro A. Venous thromboembolism among physically active young adult females. Res Pract Thromb Haemost 2023; 7:102236. [PMID: 38193067 PMCID: PMC10772887 DOI: 10.1016/j.rpth.2023.102236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 10/06/2023] [Accepted: 10/10/2023] [Indexed: 01/10/2024] Open
Abstract
Background Young adult females are at risk of venous thromboembolism (VTE) due to various acquired and transient factors. In recent years, a growing number of females have engaged in strenuous physical activity, but its role as a risk factor for VTE is uncertain. Objectives To determine the incidence of VTE in young adult females engaged in strenuous physical activity. Methods A large national cohort of female individuals enlisted in the Israeli Defense Forces between 2012 and 2019 was analyzed. The study group consisted of participants undergoing strenuous physical training during their military service, while the control group maintained regular activity levels. We compared the incidence of VTE between the groups and adjusted for potential risk factors using a multivariate Cox analysis. Results The cohort included 160,718 female individuals aged 18 to 21years, of whom 11,745 engaged in strenuous physical activity and 148,973 served as controls. During a mean follow-up of 1.7 years, VTE occurred in 5 individuals (0.04%) in the strenuous activity group and 47 individuals (0.03%) in the control group. The incidence per 10,000 person-years was 2.41 (95% CI, 0.78-5.62) for the strenuous activity group and 1.82 (95% CI, 1.34-2.42) for the controls. Strenuous activity did not increase the risk for VTE in univariate or multivariate regression, with a hazard ratio (HR) of 1.27 (95% CI, 0.49-4.22). Use of oral contraceptives was the only significant risk factor, demonstrating dose effect; HR 1.95 (95% CI, 1.06-3.57) for low dose and HR 3.62 (95% CI, 1.40-9.37) for medium estrogen dose contraceptives. Conclusion Strenuous physical activity did not increase the risk for VTE among a large cohort of young adult female individuals.
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Affiliation(s)
- Michael Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Internal Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eva N. Hamulyák
- Department of Internal Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Avi Leader
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Regev Landau
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Endocrine Department, Shamir Medical Center, Be'er Ya'akov, Israel
- Medical Corps, Israel Defense Forces, Tzrifin, Israel
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anna Gurevich-Shapiro
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Department of Systems Immunology, Weizmann Institute of Science, Rehovot, Israel
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10
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Soule CA, Kunta C, Leader A, Dicker AP, Simone NL. Patient Advocate Presence Helps Poster Presenters Understand Clinical Significance of their Research and Increases Empathy. Int J Radiat Oncol Biol Phys 2023; 117:e59. [PMID: 37785784 DOI: 10.1016/j.ijrobp.2023.06.776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Patient advocates represent the voice of the patient community and bring a unique perspective to research. We hypothesized that including patient advocates in poster sessions allow trainees to communicate their science in lay language, have an increased understanding of the clinical impact of their work, and increase their empathy for patients. MATERIALS/METHODS A survey was designed to assess the impact invited patient advocates had on poster presenters at our Department of Radiation Oncology Research Symposium. The two advocates, one with primary breast and primary endometrial cancer, and one with metastatic breast cancer, visited each poster to discuss the project goals and outcomes with all 16 researchers (graduate/medical students, postdoctoral fellows including medical and physics residents, laboratory assistants, and faculty). The survey included demographics, and Likert scored questions about their ease in discussing research and use of lay language, the impact of the advocate on increasing the presenter's empathy and understanding the clinical significance of their work, and future role of advocates in complementing their research. RESULTS Following the poster session, 14 of 16 participants completed the survey. Respondents were 57.1% male, 57.1% younger than 30 years old, and 50% people of color. Poster presenters comprised: 35.7% Graduate/Medical Students, 42.9% Medical/Physics Residents or Postdoctoral Fellows, 14% Faculty, and 7% laboratory assistants. All respondents agreed/strongly agreed they were comfortable talking to advocates. Overall, 42.8% of participants strongly agreed that they could talk to the patient advocate in lay language. 85.7% agreed/strongly agreed that their empathy for patients increased by this interaction. Although 92.9% of poster presenters believed patient advocates were able to help them understand the clinical impact of their research and 71.4% believed advocates helped them think of ideas to complement their research, 57.1% did not believe advocates could help them identify novel research conclusions. Most respondents would like advocates at future poster presentations (92.9%), but were not as sure and they would like advocates participating in study design or data analysis. Women, people of color, and graduate/medical students were most comfortable communicating in lay language, believed advocates increased their empathy and understanding of the clinical significance of their work. CONCLUSION Patient advocates in poster sessions help trainees communicate their science, increase their empathy and understanding of the clinical impact of their research. Workshops should be considered to help young scientists communicate their science in lay language. Future radiation oncology training should consider including the patient advocate voice to improve the tangible connection between research and real-world impact.
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Affiliation(s)
- C A Soule
- Thomas Jefferson University, Philadelphia, PA
| | - C Kunta
- Thomas Jefferson University, Philadelphia, PA
| | - A Leader
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - A P Dicker
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - N L Simone
- Department of Radiation Oncology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
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11
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Kahn SR, Arnold DM, Casari C, Desch KC, Devreese KMJ, Favaloro EJ, Gaertner F, Gouw SC, Gresele P, Griffioen AW, Heger L, Kini RM, Kohli S, Leader A, Lisman T, Lordkipanidzé M, Mullins E, Okoye HC, Rosovsky RP, Salles-Crawley II, Selby R, Sholzberg M, Stegner D, Violi F, Weyand AC, Williams S, Zheng Z. Illustrated State-of-the-Art Capsules of the ISTH 2023 Congress. Res Pract Thromb Haemost 2023; 7:100193. [PMID: 37538494 PMCID: PMC10394567 DOI: 10.1016/j.rpth.2023.100193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023] Open
Abstract
This year's Congress of the International Society of Thrombosis and Haemostasis (ISTH) took place in person in Montréal, Canada, from June 24-28, 2023. The conference, held annually, highlighted cutting-edge advances in basic, translational, population and clinical sciences relevant to the Society. As for all ISTH congresses, we offered a special, congress-specific scientific theme; this year, the special theme was immunothrombosis. Certainly, over the last few years, COVID-19 infection and its related thrombotic and other complications have renewed interest in the concepts of thromboinflammation and immunothrombosis; namely, the relationship between inflammation, infection and clotting. Other main scientific themes of the Congress included Arterial Thromboembolism, Coagulation and Natural Anticoagulants, Diagnostics and Omics, Fibrinolysis and Proteolysis, Hemophilia and Rare Bleeding Disorders, Hemostatic System in Cancer, Inflammation and Immunity, Pediatrics, Platelet Disorders, von Willebrand Disease and Thrombotic Microangiopathies, Platelets and Megakaryocytes, Vascular Biology, Venous Thromboembolism and Women's Health. Among other sessions, the program included 28 State-of-the-Art (SOA) sessions with a total of 84 talks given by internationally recognized leaders in the field. SOA speakers were invited to prepare brief illustrated reviews of their talks that were peer reviewed and are included in this article. These illustrated capsules highlight the major scientific advances with potential to impact clinical practice. Readers are invited to take advantage of the excellent educational resource provided by these illustrated capsules. They are also encouraged to use the image in social media to draw attention to the high quality and impact of the science presented at the Congress.
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Affiliation(s)
- Susan R Kahn
- Medicine, Sir Mortimer B Davis Jewish General Hospital, McGill University, 3755 Cote Ste Catherine, Montreal, Quebec
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Caterina Casari
- Université Paris-Saclay, INSERM, Hémostase inflammation thrombose HITH U1176, 94276, Le Kremlin-Bicêtre, France
| | - Karl C Desch
- Cell and Molecular Biology Program, University of Michigan, Ann Arbor, USA
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Emmanuel J Favaloro
- Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW Australia
| | - Florian Gaertner
- Technische Universität München (TUM), Ismaninger Straße 22, München, Bayern 81675, Germany
| | - Samantha C Gouw
- Amsterdam UMC location University of Amsterdam, Department of Pediatric Hematology, Meibergdreef 9, Amsterdam, The Netherlands
| | - Paolo Gresele
- University of Perugia, Department of Medicine and Surgery, Head Section of Internal and Cardiovascular Medicine
| | - Arjan W Griffioen
- Angiogenesis Laboratory, Department of Medical Oncology, Amsterdam UMC, Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Lukas Heger
- Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA; Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, MA 02115, USA; Departement of Cardiology and Angiology, University Hospital Freiburg Bad Krozingen, 79106 Freiburg, Germany
- Program in Cellular and Molecular Medicine, Boston Children's Hospital, Boston, MA 02115, USA
- Departement of Cardiology and Angiology, University Hospital Freiburg Bad Krozingen, 79106 Freiburg, Germany
| | | | - Shrey Kohli
- Institute of Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, Universitätsklinikum Leipzig, Leipzig University, 04103 Leipzig, Germany
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Eric Mullins
- Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- University of Cincinnati - College of Medicine, Cincinnati, OH, USA
| | - Helen Chioma Okoye
- College of Medicine, University of Nigeria, Ituku Ozalla campus, Enugu Nigeria
| | | | | | - Rita Selby
- Departments of Laboratory Medicine & Pathobiology and Department of Medicine, University of Toronto
| | | | | | - Francesco Violi
- Department of Clinical, Internal Medicine, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Angela C Weyand
- Department of Pediatrics, University of Michigan Medical School
| | | | - Ze Zheng
- Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
- Versiti Blood Research Institute, Milwaukee, Wisconsin 53226, USA
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12
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Naftali J, Barnea R, Eliahou R, Tolkovsky A, Pardo K, Zukerman M, Soback N, Adi M, Leader A, Bloch S, Saliba W, Auriel E. Cerebral Microinfarcts Are Common in Undiagnosed Lung Cancer Patients: A Population-Based Study. Acta Neurol Scand 2023. [DOI: 10.1155/2023/9240247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Background. Cerebral microinfarcts (CMI) represent covert brain ischemia and were associated with stroke risk and cognitive impairment. Magnetic resonance imaging diffusion-weighted imaging (DWI) hyperintensities have been suggested to represent acute CMI. The relationship between malignancy and CMI is unknown. Aims. We aimed to examine whether CMI is more common in patients with undiagnosed lung cancer, and therefore might serve as a prediction marker for cognitive impairment or cancer-related stroke. Methods. We used the computerized database of Clalit Health Services (the largest healthcare provider in Israel) to identify adults diagnosed with lung cancer who had an MRI brain scan for any indication prior to cancer diagnosis. We analyzed DWI sequences, in order to evaluate CMI incidence in this population, and compared it to control groups of patients with other undiagnosed malignancies and patients without known cancer. Results. Altogether, we reviewed 1822 MRI brain scans, of which 497 scans were taken in patients with undiagnosed lung cancer, 543 scans of noncancer patients, and 793 scans of patients with other undiagnosed malignancies. In the lung cancer group, we found 24 CMI, compared with 4 in the noncancer group (
) and 8 in the other cancer group (
). Conclusions. CMI is common in undiagnosed lung cancer patients compare to other undiagnosed cancer types or noncancer patients. At the time of lung cancer diagnosis patients may be at risk for future stroke or cognitive decline.
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Affiliation(s)
- Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Ruth Eliahou
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Rabin Medical Center, Petach Tikva, Israel
| | - Assaf Tolkovsky
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Keshet Pardo
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
| | - Michal Zukerman
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Noa Soback
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Meital Adi
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Department of Radiology, Kaplan Medical Center, Rehovot, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Sivan Bloch
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Neurology, Lady Davis Carmel Medical Center, Israel
| | - Walid Saliba
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petach Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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13
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Icht O, Leader A, Batat E, Yosef L, Shochat T, Goldstein DA, Dudnik E, Spectre G, Raanani P, Hammerman A, Zer A. Arterial and Venous Thromboembolism in ALK-Rearrangement-Positive Non-small Cell Lung Cancer: A Population-Based Cohort Study. Oncologist 2023:7103524. [PMID: 37014824 DOI: 10.1093/oncolo/oyad061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 02/08/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION There is scarce data regarding the incidence of venous thromboembolism (VTE) and arterial thromboembolism (ATE) in the molecular subtypes of non-small cell lung cancer (NSCLC). We aimed to investigate the association between Anaplastic Lymphoma Kinase (ALK)-positive NSCLC and thromboembolic events. METHODS A retrospective population-based cohort study of the Clalit Health Services database, included patients with NSCLC diagnosed between 2012 and 2019. Patients exposed to ALK-tyrosine-kinase inhibitors (TKIs) were defined as ALK-positive. The outcome was VTE (at any site) or ATE (stroke or myocardial infarction) 6 months prior to the diagnosis of cancer, until 5 years post-diagnosis. The cumulative incidence of VTE and ATE and hazard-ratios (HR) with 95% CIs were calculated (at 6- 12- 24 and 60-months), using death as a competing risk. Cox proportional hazards multivariate regression was performed, with the Fine and Gray correction for competing risks. RESULTS The study included 4762 patients, of which 155 (3.2%) were ALK-positive. The overall 5-year VTE incidence was 15.7% (95% CI, 14.7-16.6%). ALK-positive patients had a higher VTE risk compared to ALK-negative patients (HR 1.87 [95% CI, 1.31-2.68]) and a 12-month VTE incidence of 17.7% (13.9-22.7%) compared to 9.9% (9.1-10.9%) in ALK-negative patients. The overall 5-year ATE incidence was 7.6% [6.8-8.6%]. ALK positivity was not associated with ATE incidence (HR 1.24 [0.62-2.47]). CONCLUSIONS In this study, we observed a higher VTE risk, but not ATE risk, in patients with ALK-rearranged NSCLC relative to those without ALK rearrangement. Prospective studies are warranted to evaluate thromboprophylaxis in ALK-positive NSCLC.
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Affiliation(s)
- Oded Icht
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Erez Batat
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Lilach Yosef
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Tzippy Shochat
- Statistical consulting unit, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel A Goldstein
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Elizabeth Dudnik
- Lung Cancer Service, Assuta Medical Centers, Tel Aviv, Israel
- Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ariel Hammerman
- The Community Medical Services Division, Clalit Health Services, Tel Aviv, Israel
| | - Alona Zer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Oncology Division, Rambam Health Care Campus, Haifa, Israel
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14
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Robinson R, Spectre G, Lishner M, Sharabi O, Robinson E, Hamburger Avnery O, Gafter-Gvili A, Raanani P, Leader A. Direct oral anticoagulants in patients with venous thromboembolism and hematological malignancies. J Thromb Thrombolysis 2023; 55:729-736. [PMID: 36943661 DOI: 10.1007/s11239-023-02791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/23/2023]
Abstract
Data are needed on direct oral anticoagulants (DOACs) for the treatment of venous thromboembolism (VTE) in hematological malignancies (HM). Retrospective studies to date lacked a control group and did not focus on patients with VTE. Out aim was to assess the incidence of VTE recurrence and bleeding in HM patients treated with low molecular weight heparin (LMWH) or DOACs for acute VTE. This is a retrospective cohort study including patients with active HM and newly-diagnosed VTE, indexed on the first day of anticoagulation and followed for 12 months. The outcome was a composite of recurrent VTE, major bleeding or clinically relevant non-major bleeding. Cumulative incidence [95% confidence interval (CI)] was calculated for each anticoagulation group (LMWH, DOAC) and hazard ratios (HR) were calculated using cox-proportional hazards model, with death as a competing risk. 143 HM patients treated with LMWH (96) or DOACs (47) for acute VTE were included. The most common HM types were lymphoma in 83 (58%) and plasma cell dyscrasia in 32 (22.3%). The 12-month cumulative incidence of the composite outcome was 24.2% (95% CI 15.9-33.5%; n = 22) in the LMWH group and 18.5% (8.5-31.5%; n = 8) in the DOAC group (HR 1.51 [0.695-3.297]). Two recurrent VTE occurred (both in the DOAC group while off-treatment). Nine (9.4%) LMWH-treated patients had major bleeding compared to 1 (2.1%) DOAC-treated patient (HR 4.85 [0.64-36.56]). This study generates the hypothesis that DOACs may be a safe and effective alternative to LMWH for VTE in patients with HM types represented in the study.
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Affiliation(s)
- Renana Robinson
- Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel.
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Lishner
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Meir Medical Center, Kfar Saba, Israel
- Research Institute, Meir Medical Center, Kfar Saba, Israel
| | - Ofek Sharabi
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Robinson
- Intensive Care Unit, Rabin Medical Centre, Petah Tikva, Israel
| | | | - Anat Gafter-Gvili
- Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine A, Rabin Medical Centre, Petah Tikva, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Leader A, Mendelson Cohen N, Afek S, Jaschek R, Frajman A, Itzhaki Ben Zadok O, Raanani P, Lishner M, Spectre G. Arterial Thromboembolism in Patients With Atrial Fibrillation and CHA2DS2-VASc Score 0 to 2 With and Without Cancer. JACC CardioOncol 2023; 5:174-185. [PMID: 37144112 PMCID: PMC10152191 DOI: 10.1016/j.jaccao.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 08/08/2022] [Accepted: 08/24/2022] [Indexed: 01/19/2023] Open
Abstract
Background It is unclear whether newly diagnosed cancer adds to the risk of arterial thromboembolism (ATE) in patients with atrial fibrillation/flutter (AF). This is especially relevant for AF patients with low to intermediate CHA2DS2-VASc scores in whom the risk-benefit ratios between ATE and bleeding are delicately balanced. Objectives The objectives were to evaluate the ATE risk in AF patients with a CHA2DS2-VASc score of 0 to 2 with and without cancer. Methods A population-based retrospective cohort study was performed. Patients with a CHA2DS2-VASc score of 0 to 2 not receiving anticoagulation at cancer diagnosis (or the matched index date) were included. Patients with embolic ATE or cancer before study index were excluded. AF patients were categorized into AF and cancer and AF and no cancer cohorts. Cohorts were matched for multinomial distribution of age, sex, index year, AF duration, CHA2DS2-VASc score, and low/high/undefined ATE risk cancer. Patients were followed from study index until the primary outcome or death. The primary outcome was acute ATE (ischemic stroke, transient ischemic attack, or systemic ATE) at 12 months using International Classification of Diseases-Ninth Revision codes from hospitalization. The Fine-Gray competing risk model was used to estimate the HR for ATE with death as a competing risk. Results The 12-month cumulative incidence of ATE was 2.13% (95% CI: 1.47-2.99) in 1,411 AF patients with cancer and 0.8% (95% CI: 0.56-1.10) in 4,233 AF patients without cancer (HR: 2.70; 95% CI: 1.65-4.41). The risk was highest in men with CHA2DS2-VASc = 1 and women with CHA2DS2-VASc = 2 (HR: 6.07; 95% CI: 2.45-15.01). Conclusions In AF patients with CHA2DS2-VASc scores of 0 to 2, newly diagnosed cancer is associated with an increased incidence of stroke, transient ischemic attack, or systemic ATE compared with matched controls without cancer.
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16
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Zeigler-Johnson C, Madsen R, Keith SW, Glanz K, Quinn AM, Giri VN, Bowen E, Sauls D, Leader A. Testing a Prostate Cancer Educational Intervention in High-Burden Neighborhoods. J Racial Ethn Health Disparities 2022; 9:2477-2484. [PMID: 34748171 PMCID: PMC9973384 DOI: 10.1007/s40615-021-01183-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/28/2021] [Accepted: 10/31/2021] [Indexed: 12/29/2022]
Abstract
To better capitalize on our enhanced understanding of prostate cancer (PCa) risk factors, it is important to better understand how knowledge and attitudes contribute to ethnic disparities in PCa outcomes. The goal of this study was to test the impact of a targeted PCa educational intervention vs. a healthy lifestyle educational control intervention on levels of knowledge, concern, and intention to screen for PCa.We recruited 239 men from neighborhoods with the highest PCa burden in Philadelphia. We assigned 118 men from two of the neighborhoods to the control group 121 men from 2 other neighborhoods to the intervention group. Repeated outcome assessment measures were obtained by administering the survey at baseline, post-session, 1 month post-session, and 4 months post-session.We conducted descriptive statistics to characterize the study sample and linear mixed effect regression models to analyze the intervention's effect on the outcomes. At baseline, we observed no differences in the outcomes between the PCa-targeted intervention and healthy lifestyle control groups.We found that knowledge of PCa and intention to screen increased significantly over time for both the control and intervention groups (p ≤ 0.01 at the 4-month follow-up). In contrast, change in the level of PCa concern was only significant for the intervention group immediately post-session and at 1-month follow-up (p = 0.04 and p = 0.01, respectively).This study showed that gathering at-risk men for discussions about PCa or other health concerns may increase their PCa knowledge and intention to talk to a doctor about PCa screening.
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Affiliation(s)
- C. Zeigler-Johnson
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - R. Madsen
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - S. W. Keith
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA
| | - K. Glanz
- Perelman School of Medicine and School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - A. M. Quinn
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA,Quinn Health Consulting, Philadelphia, PA
| | - V. N. Giri
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA,Departments of Cancer Biology and Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | - D. Sauls
- Delaware Prostate Cancer Coalition, Dover, DE
| | - A. Leader
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
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17
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Potere N, Barco S, Mahé I, Cesarman‐Maus G, Angchaisuksiri P, Leader A, Okoye HC, Olayemi E, Ay C, Carrier M, Connors JM, Farmakis IT, Fumagalli RM, Jing Z, Lee LH, McLintock C, Ní Ainle F, Giannakoulas G, Goto S, Guillermo Esposito MC, Jara‐Palomares L, Szlaszynska M, Tan CW, Van Es N, Wang T, Hunt BJ, Di Nisio M. Awareness of venous thromboembolism among patients with cancer: Preliminary findings from a global initiative for World Thrombosis Day. J Thromb Haemost 2022; 20:2964-2971. [PMID: 36201366 PMCID: PMC9828201 DOI: 10.1111/jth.15902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cancer-associated venous thromboembolism (CAT) has detrimental impact on patients' clinical outcomes and quality of life. Data on CAT education, communication, and awareness among the general cancer population are scanty. METHODS We present the preliminary results of an ongoing patient-centered survey including 27 items covering major spheres of CAT. The survey, available in 14 languages, was promoted and disseminated online through social networks, email newsletters, websites, and media. RESULTS As of September 20, 2022, 749 participants from 27 countries completed the survey. Overall, 61.8% (n = 460) of responders were not aware of their risk of CAT. Among those who received information on CAT, 26.2% (n = 56) were informed only at the time of CAT diagnosis. Over two thirds (69.1%, n = 501) of participants received no education on signs and symptoms of venous thromboembolism (VTE); among those who were educated about the possible clinical manifestations, 58.9% (n = 119) were given instructions to seek consultation in case of VTE suspicion. Two hundred twenty-four respondents (30.9%) had a chance to discuss the potential use of primary thromboprophylaxis with health-care providers. Just over half (58.7%, n = 309) were unaware of the risks of bleeding associated with anticoagulation, despite being involved in anticoagulant-related discussions or exposed to anticoagulants. Most responders (85%, n = 612) valued receiving CAT education as highly relevant; however, 51.7% (n = 375) expressed concerns about insufficient time spent and clarity of education received. CONCLUSIONS This ongoing survey involving cancer patients with diverse ethnic, cultural, and geographical backgrounds highlights important patient knowledge gaps. These findings warrant urgent interventions to improve education and awareness, and reduce CAT burden.
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Affiliation(s)
- Nicola Potere
- Department of Medicine and Ageing Sciences“G. D'Annunzio” UniversityChietiItaly
| | - Stefano Barco
- Department of AngiologyUniversity Hospital ZurichZurichSwitzerland
- Center for Thrombosis and HemostasisJohannes Gutenberg UniversityMainzGermany
| | - Isabelle Mahé
- Université Paris CitéHôpital Louis MourierParisFrance
- Innovative Therapies in HaemostasisINSERM UMR_S1140Saint‐EtienneFrance
| | | | | | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva; Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Helen C. Okoye
- Department of Haematology and Immunology, College of MedicineUniversity of NigeriaEnuguNigeria
| | | | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and HaemostaseologyMedical University ViennaViennaAustria
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa HospitalOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Jean Marie Connors
- Brigham and Women's Hospital, Hematology DivisionHarvard Medical SchoolBostonUSA
| | - Ioannis T. Farmakis
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, AHEPA University HospitalAristotle University of ThessalonikiThessalonikiGreece
| | | | - Zhi‐Cheng Jing
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College HospitalChinese Academy of Medical SciencesBeijingChina
| | - Lai Heng Lee
- Department of HaematologySingapore General HospitalSingapore
| | - Claire McLintock
- National Women's HealthAuckland City HospitalAucklandNew Zealand
| | | | - George Giannakoulas
- Department of Cardiology, AHEPA University HospitalAristotle University of ThessalonikiThessalonikiGreece
| | - Shinya Goto
- Department of MedicineTokai University School of MedicineIseharaJapan
| | | | - Luis Jara‐Palomares
- Unidad Médico‐Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES)Instituto de Salud Carlos IIIMadridSpain
| | | | - Chee Wee Tan
- Department of Haematology, Royal Adelaide Hospital, SA Pathology, Adelaide, South Australia, AustraliaUniversity of AdelaideSouth AustraliaAustralia
| | - Nick Van Es
- Amsterdam UMC location University of Amsterdam, Vascular Medicine, Amsterdam, Netherlands; Amsterdam Cardiovascular SciencesPulmonary Hypertension & ThrombosisAmsterdamthe Netherlands
| | - Tzu‐Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa HospitalOttawa Hospital Research InstituteOttawaOntarioCanada
| | - Beverley J. Hunt
- St Thomas' Hospital Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology GroupGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences“G. D'Annunzio” UniversityChietiItaly
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18
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Berger T, Shacham Abulafia A, Shimony S, Pasvolsky O, Vaxman I, Miron Y, Feldman S, Leader A, Raanani P. Prevalence and Clinical Characteristics of Paraproteinemia Associated with Chronic Myeloid Leukemia. Acta Haematol 2022; 145:619-626. [DOI: 10.1159/000526168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/14/2022] [Indexed: 11/19/2022]
Abstract
Introduction: Data regarding the prevalence of paraproteinemia in patients with chronic myeloid leukemia (CML) are lacking.
Methods: To evaluate for paraproteinemia prevalence we undertook this cross-sectional study among consecutive chronic-phase CML patients. Complete blood count, chemistry, immunoglobulins, serum-free light chains, serum-protein electrophoresis and immunofixation were collected. Further analyses evaluated whether various patient, disease and treatment-related variables are associated with paraproteinemia.
Results: One hundred patients, median age 63.5 (IQR 48.1-72) years were recruited. Median time from CML diagnosis to enrollment was 6.3 (IQR 2.3-11.3) years.
Monoclonal-protein was detected in eight patients (8%), diagnosed with: smoldering multiple myeloma (SMM, n=2) and low-risk monoclonal gammopathy of undetermined significance (MGUS, n=6). Six patients were on tyrosine kinase inhibitor treatment, two were in treatment-free-remission. The only covariate associated with paraproteinemia was the presence of anemia, albeit with borderline statistical significance in univariate analysis (p=0.053) and when adjusted for age (p=0.056).
Conclusions: In this largest study so far describing the prevalence of paraproteinemia among CML patients, we found MGUS prevalence to be higher than the 3.2% expected prevalence in the general-population above 50 years and a non-negligible prevalence of SMM (2%). Screening for paraproteinemia in CML patients, especially in the presence of anemia, should be considered.
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19
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Sharman Moser S, Spectre G, Raanani P, Friedman‐Mazursky O, Tirosh M, Chodick G, Leader A. Cancer‐associated venous thromboembolism in Israel: Incidence, risk factors, treatment, and health care utilization in a population based cohort study. Res Pract Thromb Haemost 2022; 6:e12653. [PMID: 35619639 PMCID: PMC9126988 DOI: 10.1002/rth2.12653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/18/2021] [Accepted: 12/28/2021] [Indexed: 11/07/2022] Open
Abstract
Background Recent international guidelines recommend thromboprophylaxis in patients with cancer at intermediate‐high venous thromboembolism (VTE) risk. Objectives We aimed to assess the current incidence, risk factors and management of cancer‐associated VTE and associated health care resource utilization in a 2.5‐million‐member state‐mandated health service in Israel. Methods Patients aged ≥18 years with newly diagnosed cancer, initiating systemic anticancer treatment from 2010 through 2018 were identified from the Israel National Cancer Registry. The index date was fixed as the first day of systemic anticancer treatment. The cumulative VTE incidence from the first day of systemic anticancer treatment and the respective hazard ratios for VTE risk factors were calculated at 12 months of follow‐up. Health care resource utilization (primary care physician, emergency room, and hospital visits) during the study period was compared between patients with and without VTE. Results A total of 15 388 patients were included, and 338 had VTE with a 12‐month cumulative incidence of 2.2% (95% confidence interval, 1.96%‐2.43%). In a multivariable model, older age, higher comorbidity index, intermediate‐high‐risk Khorana score, certain malignancy types, and chemotherapy were significantly associated with an increased VTE risk in the year after initiating anticancer treatment. Compared with matched controls, the VTE subcohort were more likely to be hospitalized (81.4% vs 35.2%), have longer hospital stays (20.1 days vs 13.1 days), have an emergency room visit (41.5% vs 19.3%), and have a larger number of primary care physician visits (17.6 vs 12.5). Conclusion Several risk factors, including the Khorana score, were associated with VTE incidence. VTE was associated with long‐term use of anticoagulation. Health care utilization was higher in patients with VTE.
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Affiliation(s)
- Sarah Sharman Moser
- Maccabitech Institute for Research and Innovation Maccabi Healthcare Services Tel Aviv Israel
| | - Galia Spectre
- Institute of Hematology Rabin Medical Center Petah Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Pia Raanani
- Institute of Hematology Rabin Medical Center Petah Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | | | - Matanya Tirosh
- Medical Affairs Pfizer Pharmaceuticals Israel Herzliya Israel
| | - Gabriel Chodick
- Maccabitech Institute for Research and Innovation Maccabi Healthcare Services Tel Aviv Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Avi Leader
- Institute of Hematology Rabin Medical Center Petah Tikva Israel
- Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
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20
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Aharoni M, Leader A, Shochat T, Raanani P, Spectre G. Exacerbation of immune thrombocytopenia following initial and booster vaccination with Pfizer-BioNTech COVID-19 vaccine. Platelets 2022; 33:781-786. [PMID: 35536172 DOI: 10.1080/09537104.2022.2071856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As the immune thrombocytopenia exacerbation rate after booster COVID-19 vaccines is unknown, we explore the rates after first, second and booster Pfizer-BioNTech COVID-19 vaccines. A retrospective study of adult ITP patients, receiving 1-3 vaccines was performed. The primary outcome was clinical ITP exacerbation defined as platelet count decrease requiring initiation/escalation of ITP treatment and/or new medical attention due to bleeding, within 3 months. Secondary outcome was any clinically relevant platelet decrease during the 3 months post-vaccination. The study included 93 ITP patients receiving 1 (n = 2), 2 (n = 22) or 3 (n = 69) vaccines. ITP exacerbation occurred in 2/93 (2.2%) patients following initial vaccination and in 3/69 (4.3%) following booster dose. Clinically relevant platelet decreases after initial doses occurred in 8/72 (11.1%) patients and in 8/39 (20.5%) after the booster. Clinical ITP exacerbation after booster doses did not follow clinical exacerbation after initial doses. Half of patients with clinically relevant platelet decreases after booster dose also had clinically relevant decreases following initial vaccination. We concluded that clinical ITP exacerbation is infrequent following Pfizer-BioNTech COVID-19 vaccine. Clinical exacerbation after booster doses was not preceded by clinical exacerbation after initial doses. Clinically relevant platelet decreases after booster doses occur frequently in patients with clinically relevant decreases after initial doses.
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Affiliation(s)
- Maayan Aharoni
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
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21
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Leader A, Dagan N, Barda N, Goldberg I, Raanani P, Spectre G, Balicer R, Gafter-Gvili A. Previously undiagnosed cancer in patients with arterial thrombotic events - A population-based cohort study. J Thromb Haemost 2022; 20:635-647. [PMID: 34818468 DOI: 10.1111/jth.15600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emerging data suggest increased arterial thrombosis risk in the months preceding a cancer diagnosis. OBJECTIVES To assess whether patients without documented vascular risk factors or pre-existing cardiovascular disease have a higher relative risk of cancer 12 months after arterial thrombotic events (ATE), compared to unselected patients. PATIENTS/METHODS A population-based cohort study of Clalit Health Services (CHS) database included CHS members ≥25 years without prior cancer or ATE (n = 2 804 584). An iterative matching process selected 10 potential controls chronologically for each consecutive exposed, age- and sex-matched (actual controls drawn 1:1 from a lot). Study exposure, ATE, was defined as ischemic stroke, transient ischemic attack, myocardial infarction or systemic arterial thromboembolism during hospitalization. The outcome was newly-diagnosed cancer within 12 months, based on Israeli national cancer registry. Cox proportional hazards multivariate regression calculated hazard ratio (HR) for outcomes, adjusted for cancer risk factors. Analysis also performed for three subgroups: age ≤50 years; no cardiovascular risk factors; no prior cardiovascular disease. RESULTS The full ATE and matched control cohorts included 43 108 patients. The 12-month cumulative incidence of cancer (95% confidence interval) was 0.020 (0.019-0.022) in the ATE cohort and 0.012 (0.011-0.013) in controls, corresponding to an adjusted HR of 1.665 (1.489-1.862). The relative risk of cancer was high in all subgroups up to a HR of 3.754 (1.912-7.372) in patients without cardiovascular risk factors. CONCLUSION There is an increased risk of previously undiagnosed cancer at 12 months after ATE, especially in patients without documented vascular risk factors or pre-existent cardiovascular disease.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Dagan
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Noam Barda
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Idan Goldberg
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Balicer
- Clalit Health Services, Clalit Research Institute, Tel Aviv, Israel
- Department of Public Health, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel
| | - Anat Gafter-Gvili
- Institute of Hematology, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine A, Rabin Medical Center, Petah Tikva, Israel
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22
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Cohen I, Goldvaser H, Kirgner I, Leader A, Raanani P, Isakov O, Shepshelovich D. Targeted therapies for immune thrombocytopenic purpura: a meta-analysis of randomized controlled trials. Ann Hematol 2021; 100:2879-2887. [PMID: 34613438 DOI: 10.1007/s00277-021-04669-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/17/2021] [Indexed: 12/01/2022]
Abstract
Several targeted therapies have been approved in recent years for second-line treatment of immune thrombocytopenic purpura (ITP), providing an alternative to rituximab and splenectomy. The extent to which these drugs reduce bleeding risk has not been well defined. Targeted therapies recently approved for the treatment of ITP in adults were identified through a search of recently published professional guidelines. Randomized controlled trials (RCTs) supporting regulatory approval were identified through a search of drug labels on FDA@gov. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were computed for pre-specified efficacy outcomes including platelet recovery to ≥ 50,000/µL, major and minor bleeding events, and survival. ORs for all adverse events were also computed. Four targeted therapies were identified, including three thrombopoietin receptor agonists and one tyrosine kinase inhibitor. Six RCTs, comprising 752 patients, were included in the meta-analysis. More patients treated with targeted therapies for ITP as compared to placebo achieved platelet counts over ≥ 50,000/µL (OR 8.29, 95% CI 5.59-12.29). Compared to placebo, targeted therapies for ITP were associated with significantly lower odds for major bleeding (OR 0.43, 95% CI 0.21-0.91), minor bleeding (OR 0.66, 95% CI 0.45-0.97), and with numerically lower mortality rates (OR 0.24, 95% CI 0.05-1.07). The odds for adverse events were comparable between the two arms (OR 1.43 95% CI 0.76-2.67). Compared to placebo, targeted therapies for ITP increase platelet counts, decrease bleeding events, and show a trend towards lower mortality, without increased toxicity. These findings support their use as a second-line ITP treatment.
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Affiliation(s)
- Inbar Cohen
- Medicine T, Tel Aviv Sourasky Medical Center, Weizmann 6, 6423906, Tel Aviv, Israel.
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - Hadar Goldvaser
- Department of Medical Oncology, Shaare Zedek Medical Center, and the Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Ilya Kirgner
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
- Hematology Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Avi Leader
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ofer Isakov
- Medicine T, Tel Aviv Sourasky Medical Center, Weizmann 6, 6423906, Tel Aviv, Israel
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Daniel Shepshelovich
- The Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Tel Aviv, Israel
- Medicine D, Tel Aviv Sourasky Medical, Weizmann 6, 6423906, Tel Aviv, Israel
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23
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Wang TF, Baumann Kreuziger L, Leader A, Spectre G, Lim MY, Gahagan A, Gangaraju R, Sanfilippo KM, Mallick R, Zwicker JI, Carrier M. Characteristics and outcomes of patients on concurrent direct oral anticoagulants and targeted anticancer therapies-TacDOAC registry: Communication from the ISTH SSC Subcommittee on Hemostasis and Malignancy. J Thromb Haemost 2021; 19:2068-2081. [PMID: 34327825 DOI: 10.1111/jth.15367] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cancer patients are increasingly prescribed direct oral anticoagulants (DOACs) and targeted anticancer therapies, but limited data are available on the outcomes during concurrent use. OBJECTIVES We conducted an international registry through the Scientific and Standardization Committee of the ISTH to evaluate the characteristics, bleeding, and thrombotic outcomes in patients receiving concurrent DOACs and targeted anticancer therapies. PATIENTS/METHODS Patients receiving concurrent DOACs for venous thromboembolism (VTE) or atrial fibrillation and selected targeted anticancer therapies were followed for 6 months after the start of concurrent use. Data including patient and cancer characteristics, major bleeding, non-major bleeding events, and venous or arterial thromboses were collected. RESULTS Two hundred and two patients were included from six institutions in the United States and Israel. The most common malignancies were hematologic (N = 57, 28.2%), followed by breast (N = 50, 24.8%) and lung (N = 44, 21.8%). The most common anticancer therapies were epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) inhibitors (N = 43, 21.3%), followed by Bruton's tyrosine kinase (BTK) inhibitors (N = 42, 20.8%) and palbociclib (N = 42, 20.8%). During follow-up, there were 9 major bleeding and 12 non-major bleeding events, corresponding to cumulative incidences of 4% (95% confidence interval [CI]: 2-8%) and 6% (95% CI: 3-10%), respectively. The cumulative incidence of major bleeding events was highest in BTK inhibitor users (10%). There were 3 VTE and 2 arterial thromboses, corresponding to cumulative incidences of 1.5% (95% CI: 0.4-4.0%) and 1.0% (95% CI: 0.2-3.3%), respectively. CONCLUSIONS In this cohort receiving concurrent DOACs and targeted anticancer therapies, the incidence of bleeding is higher compared to thrombosis, particularly with BTK inhibitors. Future larger prospective studies are needed.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, The Ottawa Hospital and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Baumann Kreuziger
- Department of Medicine, Medical College of Wisconsin, Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ming Y Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Gahagan
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Radhika Gangaraju
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristen M Sanfilippo
- Division of Hematology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeffrey I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital and Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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24
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Levi L, Spectre G, Nesichi O, Leader A, Raanani P, Reuven Y, Schindel H, Shpitzer T, Reifen E, Bachar G, Mizrachi A. Implementation of a Novel Protocol for Preventing Venous Thromboembolism in Otolaryngology Patients. Otolaryngol Head Neck Surg 2021; 166:297-304. [PMID: 34255600 DOI: 10.1177/01945998211024923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality. The Caprini risk assessment model (CRAM) is a validated tool for estimating the risk for postoperative VTE. Previous studies demonstrated a low risk of VTE among otorhinolaryngology-head and neck surgery (ORL-HNS). Hence, our objective was to modify the CRAM-based protocol to be applicable for otolaryngology patients and assess protocol efficacy and safety. STUDY DESIGN Observational pilot study conducted on ORL-HNS patients undergoing surgery. SETTING University-affiliated tertiary care center. METHODS We constructed a modified protocol based on the CRAM and previous reports in the ORL-HNS literature using a reduced postoperative anticoagulation regimen. Primary end point was symptomatic VTE up to 3 months after surgery. Main secondary outcome was postoperative bleeding. RESULTS A total of 508 patients were enrolled. Of them, 48% underwent head and neck surgery, 18% direct laryngoscopy and transoral robotic surgery, 15% endoscopic sinus surgery, and 11% otology surgery. Adherence to the protocol was 79%. Mean follow-up time was 115 days (range, 30-448 days). Only 1 patient developed deep vein thrombosis, and none developed pulmonary embolism. Two patients had major bleeding not related to the use of anticoagulation. CONCLUSIONS Our novel CRAM-based protocol appears to be efficacious and safe for VTE prevention in otolaryngology. A larger-scale study is required to validate these findings. LEVEL OF EVIDENCE Level 2b.
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Affiliation(s)
- Lirit Levi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Ofir Nesichi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Institute for Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Yonatan Reuven
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hilla Schindel
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Reifen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Icht O, Darzi N, Shimony S, Jacobi O, Reinhorn D, Landman Y, Mutai R, Averbuch I, Shochat T, Spectre G, Raanani P, Rotem O, Dudnik E, Peled N, Zer A, Leader A. Venous thromboembolism incidence and risk assessment in lung cancer patients treated with immune checkpoint inhibitors. J Thromb Haemost 2021; 19:1250-1258. [PMID: 33605020 DOI: 10.1111/jth.15272] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/06/2021] [Accepted: 02/12/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND There are scarce data on venous thromboembolism (VTE) rates among non-small cell lung cancer (NSCLC) patients treated with immune-checkpoint inhibitors (ICI). The Khorana Score (KS), used to guide thromboprophylaxis in cancer patients, was validated in patients receiving chemotherapy. OBJECTIVE To assess VTE rates and KS performance among NSCLC patients treated with ICI or chemotherapy. METHODS We performed a retrospective cohort study of NSCLC patients starting either ICI or platinum-based chemotherapy. The 6-month cumulative incidence of VTE in the ICI and chemotherapy cohorts and hazard ratios (HR) with 95% confidence intervals (CI) were calculated, using death as a competing risk. Subgroup analysis of low (0-1) and high (≥2) KS risk groups was performed. RESULTS The study included 345 NSCLC patients receiving single agent ICI (n = 176) or chemotherapy (n = 169). The 6-month cumulative incidence of VTE was 7.1% in the chemotherapy cohort and 4.5% in the ICI cohort (HR for chemotherapy = 1.6, 95% CI 0.66-3.9). Among chemotherapy treated patients, the high-risk KS group had a trend toward a higher VTE incidence, compared with patients with a low-risk KS (HR 3.04, 95% CI 0.82-11.22). Among ICI-treated patients, the high-risk KS group had a trend toward a lower VTE incidence compared with the low-risk group (HR 0.17, 95% CI 0.02-1.36). CONCLUSIONS VTE rates were higher among NSCLC patients treated with platinum-based chemotherapy than those treated with ICI alone, though the precision of the relative estimate is low. The KS did not identify high-risk ICI-treated patients, suggesting that an ICI-specific risk model is warranted.
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Affiliation(s)
- Oded Icht
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Naama Darzi
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Shai Shimony
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Oded Jacobi
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Daniel Reinhorn
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Yosef Landman
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Raz Mutai
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Itamar Averbuch
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Tzippy Shochat
- Statistical consulting unit, Rabin Medical Center, Petah Tikva, Israel
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Ofer Rotem
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elizabeth Dudnik
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nir Peled
- Soroka Cancer Institute, Soroka Medical Center, affiliated to Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alona Zer
- Institute of Oncology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
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Abstract
Disseminated intravascular coagulation (DIC) is characterized by the intravascular activation of coagulation with loss of localization arising from different causes, and is diagnosed using scoring systems which rely upon the presence of an underlying disorder compatible with DIC alongside hemostatic derangements such as low platelet count, prolonged prothrombin time, and elevated fibrinogen degradation products. DIC is common in patients with acute leukemia, with prevalence ranging from 17 to 100% in acute promyelocytic leukemia (APL) and 8.5 to 25% in acute lymphoblastic leukemia (ALL) and non-APL acute myeloid leukemia (AML). The pathophysiology is complex and varies between the leukemia subtypes, and is not fully reflected by the laboratory markers currently used to classify DIC. Similarly, the clinical consequence of DIC in acute leukemia also varies across the types of leukemia. DIC is primarily associated with bleeding in APL, while thrombosis is the dominant phenotype in ALL and non-APL AML. The cornerstone of managing DIC is the treatment of the underlying disease, as exemplified by the important role of early administration of all-trans retinoic acid in APL. Other aspects of management focus on supportive care aimed at minimizing the risk of bleeding, via transfusion of blood products. The use of blood products is more liberal in APL, due to the hemorrhagic phenotype and unacceptably high rates of early hemorrhagic death. This review will focus on the pathophysiology, risk factors, clinical implications, and the management of DIC in patients across the spectrum of acute leukemias.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands.,CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Avi Leader
- CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute, Rabin Medical Center, Petah Tikva, Israel
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27
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Leader A, Hamulyák E, Carney B, Avrahami M, Knip J, Rozenblatt S, Beenen L, Yust-Katz S, Coppens M, Raanani P, Middeldorp S, Büller H, Zwicker J, Spectre G. PO-94 Intracranial hemorrhage with direct oral anticoagulants in patients with primary or secondary brain tumors. Thromb Res 2021. [DOI: 10.1016/s0049-3848(21)00267-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Leader A, Hofstetter L, Spectre G. Challenges and Advances in Managing Thrombocytopenic Cancer Patients. J Clin Med 2021; 10:1169. [PMID: 33799591 PMCID: PMC8000983 DOI: 10.3390/jcm10061169] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022] Open
Abstract
Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands
| | - Liron Hofstetter
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 4941492, Israel; (L.H.); (G.S.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Livneh N, Braeken D, Drozdinsky G, Gafter-Gvili A, Seelig J, Rozovski U, Berger T, Raanani P, Falanga A, Ten Cate H, Spectre G, Leader A. Anticoagulation in patients with atrial fibrillation, thrombocytopenia and hematological malignancy. J Thromb Thrombolysis 2021; 52:590-596. [PMID: 33523384 DOI: 10.1007/s11239-021-02393-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 01/21/2023]
Abstract
Managing anticoagulation in hematological malignancy patients with atrial fibrillation and thrombocytopenia is a clinical challenge with limited data. We aimed to identify anticoagulation management strategies and evaluate bleeding and thrombosis rates associated with each approach. A retrospective cohort study in Israel and the Netherlands was conducted. Patients with hematological malignancy and atrial fibrillation were indexed when platelets were < 50 × 109/L and followed for 30 days. The cohort included 61 patients of whom 42 (69%) had anticoagulation held at index. On multivariate analysis, holding anticoagulation was associated with age < 65 years and atrial fibrillation diagnosed within 30 days prior index. Clinically relevant bleeding was diagnosed in 7 (16.7%) and 1 (5.3%) of patients who had anticoagulation held and continued respectively, while arterial thromboembolism occurred in 1 patient in each group (2.4% and 5.3%, respectively). All-cause mortality rate was high at 45%. Accordingly, the 30-day bleeding risk may outweigh the risk of arterial thromboembolism in hematological malignancy, platelets < 50 × 109/L and atrial fibrillation.
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Affiliation(s)
- Nir Livneh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dionne Braeken
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Anat Gafter-Gvili
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine A, Rabin Medical Center, Petah Tikva, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Jaap Seelig
- Department of Cardiology, Hospital Rijnstate, Arnhem, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Uri Rozovski
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Tamar Berger
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Pia Raanani
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Anna Falanga
- Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Galia Spectre
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel
| | - Avi Leader
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, 39 Jabotinsky, 4941492, Petah Tikva, Israel.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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Gutwein O, Lavi N, Barzilai M, Shacham-Abulafia A, Leader A, Chubar E, Dally N, Shapira S, Mishchenko E, Ellis M, Koren-Michowitz M. Management and Outcome of Venous Thrombosis in Patients with Myeloproliferative Neoplasms: Data from the Israeli MPN Working Group. Acta Haematol 2020; 144:438-445. [PMID: 33316809 DOI: 10.1159/000511426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/08/2020] [Indexed: 11/19/2022]
Abstract
The BCR-ABL-negative myeloproliferative neoplasms (MPN) are associated with high incidence of venous thrombosis and a significant rate of recurrent events, but there is no consensus regarding their management. In this retrospective study, we analyzed 96 patients with MPN-related venous thrombosis. The index venous thrombosis occurred at a median age of 58 years (IQR 37-71), with 58% of the events involving unusual sites. Patients who were on antiplatelet agents at the time of index thrombosis tended to be older than patients who were not receiving antiplatelets at the time of index thrombosis. The majority of index thromboses occurring after the diagnosis of MPN had uncontrolled blood counts at the time of event and were not receiving antithrombotic agents. Following the thrombotic episode, 75% of patients received long-term anticoagulation. At a median follow-up of 3.4 years, the recurrence rate was 14%. Thrombophilia was significantly more prevalent among patients with recurrent thrombosis compared to patients without recurrence (p < 0.01). Patients who developed a recurrent event early were more likely to have thrombophilia (either inherited or antiphospholipid antibodies), and controlled blood counts, and were likely to receive anticoagulation at the time of recurrence compared to patients with later recurrences. Thrombophilia may contribute to venous thrombosis recurrence, especially early after the index venous thrombosis. Suboptimal anticoagulation and blood count control are factors associated with late venous thrombosis recurrence.
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Affiliation(s)
- Odit Gutwein
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Noa Lavi
- Division of Hematology, Rambam Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Merav Barzilai
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Sourasky Medical Center, Tel Aviv, Israel
| | - Adi Shacham-Abulafia
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tiqva, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tiqva, Israel
| | - Evgeni Chubar
- Hematology Unit, HaEmek Medical Center, Afula, Israel
| | - Najib Dally
- Division of Hematology, Ziv Medical Center, Safed, Israel
- Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shirley Shapira
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Elena Mishchenko
- Institute of Hematology, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Martin Ellis
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Hematology Institute, Meir Medical Center, Kfar Saba, Israel
| | - Maya Koren-Michowitz
- Department of Hematology, Shamir Medical Center (Assaf Harofeh), Zerifin, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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31
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Taylor J, Ruggiero M, Maity A, Ko K, Greenberger B, Donofree D, Sherif K, Lazar M, Jaslow R, Richard S, Mitchell E, Anne P, Trabulsi E, Leader A, Simone N. Sexual Health Toxicity in Cancer Survivors: Is There a Gender Disparity in Physician Evaluation and Intervention? Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Shacham Abulafia A, Shemesh S, Rosenmann L, Berger T, Leader A, Sharf G, Raanani P, Rozovski U. Health-Related Quality of Life in Patients with Chronic Myeloid Leukemia Treated with First- Versus Second-Generation Tyrosine Kinase Inhibitors. J Clin Med 2020; 9:jcm9113417. [PMID: 33113857 PMCID: PMC7692789 DOI: 10.3390/jcm9113417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 01/08/2023] Open
Abstract
The life expectancy of patients with chronic myeloid leukemia (CML) approaches that of the age-matched population and quality of life (QOL) issues are becoming increasingly important. To describe patients’ characteristics and assess QOL, we delivered a 30-item core questionnaire, a 24-item CML-specific questionnaire, both from the European Organization for Research and Treatment of Cancer (EORTC), and additional health-related items to 350 patients. Among 193 patients who completed the questionnaires, 139 received either imatinib (n = 70, 33%), dasatinib (n = 45, 23%) or nilotinib (n = 24, 12%). Patients’ median age was 58 (range: 23 to 89) years and 86 (63%) were males. Stratifying patients by treatment, we recognized two distinct populations. In comparison to patients on dasatinib and nilotinib, patients on imatinib were two decades older, had a longer duration of disease and current treatment, experienced fewer limitations on daily activities (p = 0.02), less fatigue (p = 0.001), lower degree of impaired body image (p = 0.022) and less painful episodes (p = 0.014). Similarly, they had better emotional functioning, were less worried, stressed, depressed or nervous (p = 0.01) and were more satisfied with their treatment (p = 0.018). Not only does age associate with current treatments, but it also predicts how patients perceive QOL. Young patients express impaired QOL compared with elderly patients.
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Affiliation(s)
- Adi Shacham Abulafia
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Correspondence: ; Tel.: +972-(0)543040797
| | - Sivan Shemesh
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Lena Rosenmann
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
| | - Tamar Berger
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Giora Sharf
- Israeli CML Patients Organization, 5 Ehud Manor st., Netanya 4265952, Israel;
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva 49100, Israel; (L.R.); (T.B.); (A.L.); (P.R.); (U.R.)
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
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Leader A, Gurevich-Shapiro A, Spectre G. Anticoagulant and antiplatelet treatment in cancer patients with thrombocytopenia. Thromb Res 2020; 191 Suppl 1:S68-S73. [DOI: 10.1016/s0049-3848(20)30400-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 12/30/2022]
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Leader A, Ten Cate V, Ten Cate-Hoek AJ, Beckers EAM, Spectre G, Giaccherini C, Gurevich-Shapiro A, Krashin E, Raanani P, Schouten HC, Falanga A, Ten Cate H. Anticoagulation in thrombocytopenic patients with hematological malignancy: A multinational clinical vignette-based experiment. Eur J Intern Med 2020; 77:86-96. [PMID: 32173172 DOI: 10.1016/j.ejim.2020.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/03/2020] [Accepted: 03/05/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND Thrombocytopenia in cancer patients with an indication for anticoagulation poses a unique clinical challenge. There are guidelines for the setting of venous thromboembolism but not atrial fibrillation (AF). Evidence is lacking and current practice is unclear. OBJECTIVE To identify patient and physician characteristics associated with anticoagulation management in hematological malignancy and thrombocytopenia. METHODS A clinical vignette-based experiment was designed. Eleven hematologists were interviewed, identifying 5 relevant variable categories with 2-5 options each. Thirty hypothetical vignettes were generated. Each physician received 5 vignettes and selected a management strategy (hold anticoagulation; no change; transfuse platelets; modify type/dose). The survey was distributed to hematologists and thrombosis specialists in 3 countries. Poisson regression models with cluster robust variance estimates were used to calculate relative risks for using one management option over the other, for each variable in comparison to a reference variable. RESULTS 168 physicians answered 774 cases and reported continuing anticoagulation for venous thromboembolism or AF in 607 (78%) cases, usually with dose reduction or platelet transfusion support. Overall, management was affected by platelet count, anticoagulation indication, time since indication, type of hematological disease and treatment, and prior major bleeding, as well as physician demographics and practice setting. The CHA2DS2-VASc score and time since AF diagnosis affected anticoagulation management in AF. CONCLUSION This study indicates what the widely accepted management strategies are. These strategies, and possibly others, should be assessed prospectively to ascertain effectiveness. The decision process is intricate and compatible with current venous thromboembolism guidelines.
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Affiliation(s)
- Avi Leader
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Vincent Ten Cate
- Epidemiology Department, Maastricht University, Maastricht, the Netherlands
| | - Arina J Ten Cate-Hoek
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Erik A M Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cinzia Giaccherini
- Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Anna Gurevich-Shapiro
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Internal Medicine H, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Eilon Krashin
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Translational Hemato-Oncology Laboratory, Meir Medical Center, Kfar-Saba, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Harry C Schouten
- Department of Hematology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Anna Falanga
- Immunohematology and Transfusion Medicine Department, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, School of Medicine, Milan, Italy
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, the Netherlands
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d'Alessandro E, Becker C, Bergmeier W, Bode C, Bourne JH, Brown H, Buller HR, Ten Cate-Hoek AJ, Ten Cate V, van Cauteren YJM, Cheung YFH, Cleuren A, Coenen D, Crijns HJGM, de Simone I, Dolleman SC, Klein CE, Fernandez DI, Granneman L, van T Hof A, Henke P, Henskens YMC, Huang J, Jennings LK, Jooss N, Karel M, van den Kerkhof D, Klok FA, Kremers B, Lämmle B, Leader A, Lundstrom A, Mackman N, Mannucci PM, Maqsood Z, van der Meijden PEJ, van Moorsel M, Moran LA, Morser J, van Mourik M, Navarro S, Neagoe RAI, Olie RH, van Paridon P, Posma J, Provenzale I, Reitsma PH, Scaf B, Schurgers L, Seelig J, Siegbahn A, Siegerink B, Soehnlein O, Soriano EM, Sowa MA, Spronk HMH, Storey RF, Tantiwong C, Veninga A, Wang X, Watson SP, Weitz J, Zeerleder SS, Ten Cate H. Thrombo-Inflammation in Cardiovascular Disease: An Expert Consensus Document from the Third Maastricht Consensus Conference on Thrombosis. Thromb Haemost 2020; 120:538-564. [PMID: 32289858 DOI: 10.1055/s-0040-1708035] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Thrombo-inflammation describes the complex interplay between blood coagulation and inflammation that plays a critical role in cardiovascular diseases. The third Maastricht Consensus Conference on Thrombosis assembled basic, translational, and clinical scientists to discuss the origin and potential consequences of thrombo-inflammation in the etiology, diagnostics, and management of patients with cardiovascular disease, including myocardial infarction, stroke, and peripheral artery disease. This article presents a state-of-the-art reflection of expert opinions and consensus recommendations regarding the following topics: (1) challenges of the endothelial cell barrier; (2) circulating cells and thrombo-inflammation, focused on platelets, neutrophils, and neutrophil extracellular traps; (3) procoagulant mechanisms; (4) arterial vascular changes in atherogenesis; attenuating atherosclerosis and ischemia/reperfusion injury; (5) management of patients with arterial vascular disease; and (6) pathogenesis of venous thrombosis and late consequences of venous thromboembolism.
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Affiliation(s)
- Elisa d'Alessandro
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Christian Becker
- Department of Dermatology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Wolfgang Bergmeier
- Department of Biochemistry and Biophysics, McAllister Heart Institute, University of North Carolina, Chapel Hill, United States
| | - Christoph Bode
- Department of Cardiology and Angiology I, Medical Center - University of Freiburg, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Joshua H Bourne
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Helena Brown
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Harry R Buller
- Department of Vascular Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Arina J Ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Vincent Ten Cate
- Clinical Epidemiology and Systems Medicine, Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Yvonne J M van Cauteren
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Yam F H Cheung
- Leibniz-Institut für Analytische Wissenschaften - ISAS, Dortmund, Germany
| | - Audrey Cleuren
- Life Sciences Institute, University of Michigan, Ann Arbor, Michigan, United States
| | - Danielle Coenen
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Ilaria de Simone
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Sophie C Dolleman
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Experimental Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Christine Espinola Klein
- Center of Cardiology/Cardiology I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
| | - Delia I Fernandez
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Lianne Granneman
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Arnoud van T Hof
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Peter Henke
- Michigan Medicine Vascular Surgery Clinic, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Yvonne M C Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jingnan Huang
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Lisa K Jennings
- CirQuest Labs, LLC and the University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Natalie Jooss
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Mieke Karel
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Danique van den Kerkhof
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Frederik A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Bram Kremers
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Bernhard Lämmle
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Haemostasis Research Unit, University College London, London, United Kingdom
| | - Avi Leader
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Hematology, Rabin Medical Center, Petah Tikva, Israel
| | - Annika Lundstrom
- Division of Internal Medicine, Department of Clinical Sciences, Karolinska Institute, Danderyd Hospital, Stockholm, Sweden
| | - Nigel Mackman
- Department of Medicine, UNC McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, United States
| | - Pier M Mannucci
- Scientific Direction, IRCCS Ca' Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
| | - Zahra Maqsood
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Paola E J van der Meijden
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Marc van Moorsel
- Department of Clinical Chemistry and Haematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luis A Moran
- CiMUS, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - John Morser
- Division of Hematology, Stanford University School of Medicine and Palo Alto Veterans Administration Health Care System, California, United States
| | - Manouk van Mourik
- Department of Cardiology, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Stefano Navarro
- Rudolf-Virchov-Zentrum, DFG Forschungszentrum fur Experimentelle Biomedizin, Wurzburg, Germany
| | - Raluca A I Neagoe
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Renske H Olie
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Pauline van Paridon
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jens Posma
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Isabella Provenzale
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Pieter H Reitsma
- Department of Internal Medicine (Nephrology) and the Einthoven Laboratory for Experimental Vascular and Regenerative Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Billy Scaf
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Leon Schurgers
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Jaap Seelig
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands.,Department of Cardiology, Rijnstate ziekenhuis, Arnhem, The Netherlands
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry and Science for Life Laboratory, Uppsala University, Uppsala, Sweden
| | - Bob Siegerink
- Center for Stroke research Berlin, Charité Universitätamedizin, Berlin, Germany
| | - Oliver Soehnlein
- Institute for Cardiovascular Prevention, Ludwig Maximilian University Munich, Munich, Germany
| | - Eva Maria Soriano
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, University of Reading, Reading, United Kingdom
| | - Marcin A Sowa
- Institute for Cardiovascular and Metabolic Research, School of Biological Sciences, University of Reading, Reading, United Kingdom
| | - Henri M H Spronk
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Chukiat Tantiwong
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Alicia Veninga
- Department of Biochemistry, Maastricht University and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Xueqing Wang
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Steve P Watson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Jeff Weitz
- Division of Hematology and Thromboembolism, Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sacha S Zeerleder
- Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, University of Bern, and Department for BioMedical Research, University of Bern, Bern, Switzerland
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry and Internal Medicine and Thrombosis Expert Center, Maastricht University Medical Center and CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
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Marron T, Leader A, Lavin Y, Maier B, Casanova-Acebes M, Wolf A, Flores R, Beasley M, Rahman A, Kenigsberg E, Merad M. IA13 Targeting Myeloid Cells that Define the Tumor Immune Microenvironment in NSCLC. J Thorac Oncol 2020. [DOI: 10.1016/j.jtho.2019.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Leader A, Maier B, Grout J, Chang C, Walker L, Davila M, Lanksy A, Marron T, Flores R, Beasley M, Salmon H, Rahman A, Kenigsberg E, Merad M. P2.04-04 CITEseq Characterization in Early Stage NSCLC Patients Identifies Distinct Patterns of Immune Infiltrate. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.1510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Marron T, Wolf A, Flores R, Veluswamy R, Gomez J, Beasley M, Yankelevitz D, Leader A, Lowy I, Miller E, Thurston G, Jankovic V, Deering R, Brown B, Rahman A, Gnjatic S, Hirsch F, Bhardwaj N, Merad M. EP1.04-15 NSCLC Response Determinants to Chemoimmunotherapy: Deep Profiling of Tumors Following Neoadjuvant Cemiplimab and Chemotherapy. J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.2143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Zer A, Joseph L, Battat E, Shochat T, Leader A, Goldstein DA, Hammerman A. Venous thromboembolism (VTE) in patients with ALK-rearranged non-small cell lung cancer (ALK-LC): A population-based cohort. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6608 Background: Advanced NSCLC is associated with an increased risk for VTE, with a reported rate of 8-15%. Clinical observations suggest a higher rate of VTE in patients with ALK-rearranged NSCLC. Clalit Health Services (CHS) is both a healthcare payer and provider, covering over 50% of the population in Israel, with individual patient data recorded in a centralized electronic database. We aimed to determine the incidence of VTE in patients with ALK-LC using a population-based cohort. Methods: We identified all patients diagnosed with NSCLC between 01/2012-12/2017 within CHS. Clinical and demographic data (including VTE risk factors, i.e. components of the Khorana score) were extracted from the CHS registry for all patients. Patients with ALK-LC were identified according to crizotinib prescriptions (dispensed after an approved CHS' pre-authorization for an ALK-LC diagnosis). VTE was identified by ICD diagnosis codes 415.xx, 444.xx, 451.xx and 453.xx. VTE risk factors (Khorana score) were also extracted. Association between ALK-LC and VTE were analyzed using logistic regression, estimating univariate and multivariate Odds Ratios (OR). Results: Overall, 4327 patients with a diagnosis of NSCLC were identified. 149 (3%) had at least one prescription for crizotinib for advanced ALK-LC. The rate of VTE in these patients was 25% (38 of 149 patients), while in the non-ALK-LC the rate was 14% (596/4178), OR = 2.05, p = 0.0004. The association was significant also in a multivariate analysis adjusting for, age, smoking status, BMI, platelet count, hemoglobin and Charlson co-morbidity score (OR 1.66, p = 0.018). Conclusions: This pooled analysis of individual patient data confirms prior data from smaller retrospective studies, suggesting ALK-LC is associated with a high risk of VTE. Randomized trials with prophylactic anti-coagulation are unlikely to be performed in this rare subtype, thus increased awareness and consideration of VTE prophylaxis in high risk patients is warranted.
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Affiliation(s)
- Alona Zer
- Sarcoma Unit, Davidoff Cancer Institute, Rabin Medical Center, affiliated to the Sackler Faculty of Medicine, Petach Tiqwa, Israel
| | | | - Erez Battat
- Chief Physician's Office, Clalit Health Services Headquarters, Tel-Aviv, Israel
| | - Tzippy Shochat
- Statistical Consulting Unit, Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel
| | - Avi Leader
- Rabin Medical Center, Petach Tikva, Israel
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Pasvolsky O, Zoref-Lorenz A, Abadi U, Geiger KR, Hayman L, Vaxman I, Raanani P, Leader A. Hemophagocytic lymphohistiocytosis as a harbinger of aggressive lymphoma: a case series. Int J Hematol 2019; 109:553-562. [PMID: 30850926 DOI: 10.1007/s12185-019-02623-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 12/23/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory syndrome, which can manifest either secondary to a variety of underlying causes, or due to a primary genetic defect. Malignancy is the most common underlying disease in adults with HLH, with lymphomas being the most common malignancy. Lymphoma-associated hemophagocytic syndrome (LAHS) typically follows a rapidly progressive clinical course and is associated with poor prognosis. We herein present four patients with HLH associated with aggressive lymphoma. At initial presentation, the underlying etiology of the HLH was unclear. Two patients were eventually diagnosed with anaplastic large cell lymphoma, while the other two had diffuse large B cell lymphoma. Two of the patients experienced rapid clinical deterioration, one at diagnosis and the other at relapse, and both died prior to diagnosis of lymphoma despite HLH-directed therapy. These cases highlight the need for intensive management in adults with HLH without a clear etiology, especially in cases when lymphoma-associated HLH is suspected. We describe the current pitfalls in diagnosis and treatment of LAHS and discuss possible ways to improve patient management.
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Affiliation(s)
- Oren Pasvolsky
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Adi Zoref-Lorenz
- Department of Internal Medicine B, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Abadi
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karyn Revital Geiger
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lucille Hayman
- Department of Pathology, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iuliana Vaxman
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Leader
- Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Beilinson Hospital, 49100, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Leader A, Ten Cate V, Ten Cate-Hoek AJ, Spectre G, Beckers EAM, Raanani P, Giaccherini C, Pereg D, Schouten HC, Falanga A, Ten Cate H. Managing Anti-Platelet Therapy in Thrombocytopaenic Patients with Haematological Malignancy: A Multinational Clinical Vignette-Based Experiment. Thromb Haemost 2018; 119:163-174. [PMID: 30597510 DOI: 10.1055/s-0038-1676520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Data on anti-platelet therapy (APT) for prevention of atherothrombotic events in thrombocytopaenic cancer patients is lacking. We aimed to identify patient and physician characteristics associated with APT management in thrombocytopaenic patients with haematological malignancy. A clinical vignette-based experiment was designed. Eleven haematologists were interviewed, identifying five variable categories. Next, 18 hypothetical vignettes were generated. Each physician received three vignettes and chose to: hold all APT; continue APT without platelet transfusion support; or continue APT with platelet transfusion support. The survey was distributed to haematologists and thrombosis specialists in three countries. Multivariate cluster robust Poisson regression models were used to calculate relative risks (RRs) of using one management option (over the other) for each variable in comparison to a reference variable. A total of 145 physicians answered 434 cases. Clinicians were more likely to hold APT in case of 20,000/µL platelets (vs. 40,000/µL; RR for continuing: 0.82 [95% confidence interval: 0.75-0.91]), recent major gastrointestinal bleeding (vs. none; RR 0.81 [0.72-0.92]) and when the physician worked at a university-affiliated community hospital (vs. non-academic community hospital; RR 0.84 [0.72-0.98]). Clinicians were more likely to continue APT in ST elevation myocardial infarction with dual APT (vs. unstable angina with single APT; RR 1.31 [1.18-1.45]) and when there were institutional protocols guiding management (vs. none; RR 1.15 [1.03-1.27]). When APT was continued, increased platelet transfusion targets were used in 34%. In summary, the decision process is complex and affected by multiple patient and physician characteristics. Platelet transfusions were frequently chosen to support APT, although no evidence supports this practice.
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Affiliation(s)
- Avi Leader
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Vincent Ten Cate
- Department of Epidemiology, Maastricht University, Maastricht, The Netherlands
| | - Arina J Ten Cate-Hoek
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erik A M Beckers
- Department of Hematology, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Cinzia Giaccherini
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Harry C Schouten
- Department of Hematology, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Thrombosis Expert Center, Maastricht University Medical Center, Maastricht, The Netherlands
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Pasvolsky O, Leader A. Postpartum Hemophagocytic Lymphohystiocytosis: A New Entity Is Born. Acta Haematol 2018; 141:61-62. [PMID: 30537710 DOI: 10.1159/000495340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel,
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Leader A, Benyamini N, Gafter-Gvili A, Dreyer J, Calvarysky B, Amitai A, Yarchovsky-Dolberg O, Sharf G, Tousset E, Caspi O, Ellis M, Levi I, De Geest S, Raanani P. Effect of Adherence-enhancing Interventions on Adherence to Tyrosine Kinase Inhibitor Treatment in Chronic Myeloid Leukemia (TAKE-IT): A Quasi-experimental Pre–Post Intervention Multicenter Pilot Study. Clinical Lymphoma Myeloma and Leukemia 2018; 18:e449-e461. [DOI: 10.1016/j.clml.2018.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/08/2018] [Accepted: 06/19/2018] [Indexed: 01/28/2023]
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Leader A, Gafter-Gvili A, Benyamini N, Dreyer J, Calvarysky B, Amitai A, Yarchovsky-Dolberg O, Sharf G, Tousset E, Caspi O, Ellis M, Levi I, Raanani P, De Geest S. Identifying Tyrosine Kinase Inhibitor Nonadherence in Chronic Myeloid Leukemia: Subanalysis of TAKE-IT Pilot Study. Clin Lymphoma Myeloma Leuk 2018; 18:e351-e362. [PMID: 30122203 DOI: 10.1016/j.clml.2018.06.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 06/07/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND There are inconsistencies in reports on correlates for nonadherence (NA) to tyrosine kinase inhibitors (TKIs) in chronic myeloid leukemia (CML). The diagnostic accuracy of subjective adherence measures using electronic monitoring (EM) as the reference standard is yet to be determined. This study aimed to evaluate correlates of TKI NA using EM and test the diagnostic accuracy of subjective adherence measures. PATIENTS AND METHODS CML patients receiving a TKI for any duration were enrolled at 4 hematology institutes, and adherence was measured for 4 months. EM adherence was the reference adherence measure, expressed as the percentage of days with the drug taken as prescribed. Subjective adherence was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (BAASIS) self-report and clinician-reported visual analog scale (VAS) at 2 time points. Baseline theory-derived correlates of NA were identified using single and multiple regression analysis. The diagnostic accuracy of BAASIS and clinician-reported VAS was tested against an exploratory EM NA cutoff of < 95%. RESULTS The median EM adherence (n = 55) was 97.5% (range, 48-100%), while the 25th percentile was 92.1%. Lack of membership in a CML patient support group, living alone, and third-line treatment were associated with EM NA on multiple regression analysis. The BAASIS self-report (n = 94) had a sensitivity of 67% and a specificity of 71% for diagnosing NA, while clinician-reported VAS (n = 89) had a sensitivity of 78% and specificity of 42%. CONCLUSION A quarter of patients had potentially clinically meaningful NA. These NA correlates and the BAASIS provide a basis for identifying nonadherent patients who can be targeted by interventions.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel.
| | - Anat Gafter-Gvili
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel; Department of Medicine A, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Noam Benyamini
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Juliet Dreyer
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Bronya Calvarysky
- Department of Pharmacy, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel
| | - Alina Amitai
- Department of Pharmacy, Meir Medical Center, Kfar Saba, Israel
| | - Osnat Yarchovsky-Dolberg
- Sackler School of Medicine, Tel Aviv University, Israel; Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Giora Sharf
- Israeli CML Patients Organization, Netanya, Israel
| | | | - Opher Caspi
- Sackler School of Medicine, Tel Aviv University, Israel; Integrative medicine and Cancer Survivorship Program; Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Martin Ellis
- Sackler School of Medicine, Tel Aviv University, Israel; Integrative medicine and Cancer Survivorship Program; Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
| | - Itai Levi
- Hematology Institute, Soroka University Medical Center, Beer-Sheva, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Sabina De Geest
- Institute of Nursing Science, Department Public Health, University of Basel, Switzerland; Academic Center of Nursing and Midwifery, Department Public Health and Primary Care, KU Leuven, Belgium
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Gover-Proaktor A, Granot G, Pasmanik-Chor M, Pasvolsky O, Shapira S, Raz O, Raanani P, Leader A. Bosutinib, dasatinib, imatinib, nilotinib, and ponatinib differentially affect the vascular molecular pathways and functionality of human endothelial cells. Leuk Lymphoma 2018; 60:189-199. [PMID: 29741440 DOI: 10.1080/10428194.2018.1466294] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The tyrosine kinase inhibitors (TKIs), nilotinib, ponatinib, and dasatinib (but not bosutinib or imatinib), are associated with vascular adverse events (VAEs) in chronic myeloid leukemia (CML). Though the mechanism is inadequately understood, an effect on vascular cells has been suggested. We investigated the effect of imatinib, nilotinib, dasatinib, bosutinib, and ponatinib on tube formation, cell viability, and gene expression of human vascular endothelial cells (HUVECs). We found a distinct genetic profile in HUVECs treated with dasatinib, ponatinib, and nilotinib compared to bosutinib and imatinib, who resembled untreated samples. However, unique gene expression and molecular pathway alterations were detected between dasatinib, ponatinib, and nilotinib. Angiogenesis/blood vessel-related pathways and HUVEC function (tube formation/viability) were adversely affected by dasatinib, ponatinib, and nilotinib but not by imatinib or bosutinib. These results correspond to the differences in VAE profiles of these TKIs, support a direct effect on vascular cells, and provide direction for future research.
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Affiliation(s)
- Ayala Gover-Proaktor
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Galit Granot
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Metsada Pasmanik-Chor
- b Bioinformatics Unit, G.S.W. Faculty of Life Sciences , Tel Aviv University , Tel Aviv , Israel
| | - Oren Pasvolsky
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Saar Shapira
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Oshrat Raz
- a Felsenstein Medical Research Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Pia Raanani
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Avi Leader
- c Institute of Hematology, Davidoff Cancer Center , Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel.,d Sackler School of Medicine , Tel Aviv University , Tel Aviv , Israel
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Frenkel Rutenberg T, Velkes S, Vitenberg M, Leader A, Halavy Y, Raanani P, Yassin M, Spectre G. Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants. Thromb Res 2018; 166:106-112. [PMID: 29727737 DOI: 10.1016/j.thromres.2018.04.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/17/2018] [Accepted: 04/20/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Early surgical treatment is recommended to reduce morbidity and mortality in patients with fragility hip fractures. Anticoagulation treatment poses a surgical challenge. While the action of vitamin K antagonists (VKAs) can be reversed, for direct oral anticoagulants (DOACs) antidote is only available for dabigatran. We aimed to assess the outcomes of patients treated with VKAs or DOACs undergoing surgical treatment for fragility hip fractures. MATERIALS AND METHODS A retrospective study of patients presenting with proximal femoral fractures between January 2012 and June 2016. Patients with VKAs received vitamin-K. Primary outcomes were 1-year and in-hospital mortality. Secondary outcomes were time to surgery, in-hospital complications, need for blood transfusions and 1-year readmissions. RESULTS Seven-hundred seventy-nine patients (796 hips) were included; 103 received VKAs, 47 DOACs and 646 no-anticoagulation. No difference between the 3 groups was noted with respect to patients' demographics or surgery type. Charlson's comorbidity index was higher for the DOACs group. Patients under anticoagulation were delayed to theater (Surgery < 48 h in 51% DOACs and 59% VKAs patients vs. 92% of no-anticoagulation, p < 0.001). Neither in-hospital nor 1-year mortality differed between groups. No other outcome measures differed, except for more wound infections in VKAs patients. CONCLUSIONS While preoperative anticoagulation delays surgery following fragility hip fractures, this delay was not found to be related to increased morbidity or mortality. DOACs-treated patients did not have adverse outcomes compared to VKAs-treated patients despite the irreversibility of their treatment.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Department of Orthopedics, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
| | - Steven Velkes
- Department of Orthopedics, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Maria Vitenberg
- Department of Orthopedics, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
| | - Avi Leader
- Institution of Hematology, Coagulation Unit, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Yael Halavy
- Institution of Hematology, Coagulation Unit, Rabin Medical Center, Petah-Tikva, Israel
| | - Pia Raanani
- Institution of Hematology, Coagulation Unit, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Mustafa Yassin
- Department of Orthopedics, Hasharon Hospital, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Galia Spectre
- Institution of Hematology, Coagulation Unit, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
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Leader A, ten Cate V, ten Cate-Hoek A, Beckers E, Spectre G, Raanani P, Schouten H, Falanga A, ten Cate H. Anticoagulation in Thrombocytopenic Patients with Hematological Malignancy: A Multi-center, Multinational Decision Making Analysis. Thromb Res 2018. [DOI: 10.1016/j.thromres.2018.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Spronk HMH, Padro T, Siland JE, Prochaska JH, Winters J, van der Wal AC, Posthuma JJ, Lowe G, d'Alessandro E, Wenzel P, Coenen DM, Reitsma PH, Ruf W, van Gorp RH, Koenen RR, Vajen T, Alshaikh NA, Wolberg AS, Macrae FL, Asquith N, Heemskerk J, Heinzmann A, Moorlag M, Mackman N, van der Meijden P, Meijers JCM, Heestermans M, Renné T, Dólleman S, Chayouâ W, Ariëns RAS, Baaten CC, Nagy M, Kuliopulos A, Posma JJ, Harrison P, Vries MJ, Crijns HJGM, Dudink EAMP, Buller HR, Henskens YMC, Själander A, Zwaveling S, Erküner O, Eikelboom JW, Gulpen A, Peeters FECM, Douxfils J, Olie RH, Baglin T, Leader A, Schotten U, Scaf B, van Beusekom HMM, Mosnier LO, van der Vorm L, Declerck P, Visser M, Dippel DWJ, Strijbis VJ, Pertiwi K, Ten Cate-Hoek AJ, Ten Cate H. Atherothrombosis and Thromboembolism: Position Paper from the Second Maastricht Consensus Conference on Thrombosis. Thromb Haemost 2018; 118:229-250. [PMID: 29378352 DOI: 10.1160/th17-07-0492] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Atherothrombosis is a leading cause of cardiovascular mortality and long-term morbidity. Platelets and coagulation proteases, interacting with circulating cells and in different vascular beds, modify several complex pathologies including atherosclerosis. In the second Maastricht Consensus Conference on Thrombosis, this theme was addressed by diverse scientists from bench to bedside. All presentations were discussed with audience members and the results of these discussions were incorporated in the final document that presents a state-of-the-art reflection of expert opinions and consensus recommendations regarding the following five topics: 1. Risk factors, biomarkers and plaque instability: In atherothrombosis research, more focus on the contribution of specific risk factors like ectopic fat needs to be considered; definitions of atherothrombosis are important distinguishing different phases of disease, including plaque (in)stability; proteomic and metabolomics data are to be added to genetic information. 2. Circulating cells including platelets and atherothrombosis: Mechanisms of leukocyte and macrophage plasticity, migration, and transformation in murine atherosclerosis need to be considered; disease mechanism-based biomarkers need to be identified; experimental systems are needed that incorporate whole-blood flow to understand how red blood cells influence thrombus formation and stability; knowledge on platelet heterogeneity and priming conditions needs to be translated toward the in vivo situation. 3. Coagulation proteases, fibrin(ogen) and thrombus formation: The role of factor (F) XI in thrombosis including the lower margins of this factor related to safe and effective antithrombotic therapy needs to be established; FXI is a key regulator in linking platelets, thrombin generation, and inflammatory mechanisms in a renin-angiotensin dependent manner; however, the impact on thrombin-dependent PAR signaling needs further study; the fundamental mechanisms in FXIII biology and biochemistry and its impact on thrombus biophysical characteristics need to be explored; the interactions of red cells and fibrin formation and its consequences for thrombus formation and lysis need to be addressed. Platelet-fibrin interactions are pivotal determinants of clot formation and stability with potential therapeutic consequences. 4. Preventive and acute treatment of atherothrombosis and arterial embolism; novel ways and tailoring? The role of protease-activated receptor (PAR)-4 vis à vis PAR-1 as target for antithrombotic therapy merits study; ongoing trials on platelet function test-based antiplatelet therapy adjustment support development of practically feasible tests; risk scores for patients with atrial fibrillation need refinement, taking new biomarkers including coagulation into account; risk scores that consider organ system differences in bleeding may have added value; all forms of oral anticoagulant treatment require better organization, including education and emergency access; laboratory testing still needs rapidly available sensitive tests with short turnaround time. 5. Pleiotropy of coagulation proteases, thrombus resolution and ischaemia-reperfusion: Biobanks specifically for thrombus storage and analysis are needed; further studies on novel modified activated protein C-based agents are required including its cytoprotective properties; new avenues for optimizing treatment of patients with ischaemic stroke are needed, also including novel agents that modify fibrinolytic activity (aimed at plasminogen activator inhibitor-1 and thrombin activatable fibrinolysis inhibitor.
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Affiliation(s)
- H M H Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Padro
- Cardiovascular Research Center (ICCC), Hospital Sant Pau, Barcelona, Spain
| | - J E Siland
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - J H Prochaska
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - J Winters
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A C van der Wal
- Department of Pathology, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - J J Posthuma
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - G Lowe
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - E d'Alessandro
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.,Department of Pathology, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Wenzel
- Department of Cardiology, Universitätsmedizin Mainz, Mainz, Germany
| | - D M Coenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - P H Reitsma
- Einthoven Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - W Ruf
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - R H van Gorp
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R R Koenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - T Vajen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - N A Alshaikh
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, United States
| | - F L Macrae
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - N Asquith
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - J Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A Heinzmann
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Moorlag
- Synapse, Maastricht, The Netherlands
| | - N Mackman
- Department of Medicine, UNC McAllister Heart Institute, University of North Carolina, Chapel Hill, North Carolina, United States
| | - P van der Meijden
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J C M Meijers
- Department of Plasma Proteins, Sanquin, Amsterdam, The Netherlands
| | - M Heestermans
- Einthoven Laboratory, Leiden University Medical Center, Leiden, The Netherlands
| | - T Renné
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Dólleman
- Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - W Chayouâ
- Synapse, Maastricht, The Netherlands
| | - R A S Ariëns
- Thrombosis and Tissue Repair Group, Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - C C Baaten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A Kuliopulos
- Tufts University School of Graduate Biomedical Sciences, Biochemistry/Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, Massachusetts
| | - J J Posma
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - P Harrison
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - M J Vries
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - E A M P Dudink
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H R Buller
- Department of Vascular Medicine, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Y M C Henskens
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - S Zwaveling
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Synapse, Maastricht, The Netherlands
| | - O Erküner
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - J W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Gulpen
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - F E C M Peeters
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - J Douxfils
- Department of Pharmacy, Thrombosis and Hemostasis Center, Faculty of Medicine, Namur University, Namur, Belgium
| | - R H Olie
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - T Baglin
- Department of Haematology, Addenbrookes Hospital Cambridge, Cambridge, United Kingdom
| | - A Leader
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Davidoff Cancer Center, Rabin Medical Center, Institute of Hematology, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Tel Aviv, Israel
| | - U Schotten
- Center for Cardiology/Center for Thrombosis and Hemostasis/DZHK, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - B Scaf
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H M M van Beusekom
- Department of Experimental Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - L O Mosnier
- Department of Molecular and Experimental Medicine, The Scripps Research Institute, La Jolla, United States
| | | | - P Declerck
- Department of Pharmaceutical and Pharmacological Sciences, University of Leuven, Leuven, Belgium
| | | | - D W J Dippel
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands
| | | | - K Pertiwi
- Department of Cardiovascular Pathology, University of Amsterdam, Academic Medical Center, Amsterdam, The Netherlands
| | - A J Ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - H Ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
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Leader A, Raanani P. Switching-On Adherence in Chronic Myeloid Leukemia. Acta Haematol 2017; 138:138-139. [PMID: 28873366 DOI: 10.1159/000479484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 07/11/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
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50
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Leader A, Zelikson-Saporta R, Pereg D, Spectre G, Rozovski U, Raanani P, Hermoni D, Lishner M. The Effect of Combined Aspirin and Clopidogrel Treatment on Cancer Incidence. Am J Med 2017; 130:826-832. [PMID: 28213047 DOI: 10.1016/j.amjmed.2017.01.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/27/2016] [Accepted: 01/24/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Multiple studies have shown an association between aspirin treatment and a reduction in newly diagnosed cancer. Conversely, there are conflicting clinical and laboratory data on the effect of combined clopidogrel and aspirin therapy on cancer incidence, including analyses suggesting an increased cancer risk. No large-scale cohort study has been performed to address this issue in a heterogeneous real-world scenario. We investigated the effect of clopidogrel and aspirin on cancer incidence compared with aspirin alone and no antiplatelet therapy. METHODS A population-based historical cohort study of subjects aged ≥50 years covered by Clalit Health Services, an Israeli health maintenance organization, was performed. Patients treated with the newer antiplatelet drugs, prasugrel or ticagrelor, which, like clopidogrel, inhibit adenosine diphosphate receptors, and those with prior cancer were excluded. Prescription records of antiplatelet medication were retrieved. RESULTS The cohort included 183,912 subjects diagnosed with 21,974 cancer cases based upon the International Classification of Diseases, Ninth Revision. Dual aspirin and clopidogrel was prescribed in 9.6%, while 49% received aspirin alone and 41% used neither. Compared with nonusers, there was a lower risk of cancer in subjects exposed to aspirin with (hazard ratio [HR] 0.46; 95% confidence interval [CI], 0.44-0.49) or without clopidogrel (HR 0.54; 95% CI, 0.52-0.56), on long-term follow-up. Combined treatment was associated with a lower cancer risk than the aspirin-only group (HR 0.92; 95% CI, 0.86-0.97). CONCLUSIONS Dual clopidogrel and aspirin treatment is safe regarding the cancer risk. This study generates the hypothesis that clopidogrel may reduce cancer incidence.
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Affiliation(s)
- Avi Leader
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Ravit Zelikson-Saporta
- Sackler School of Medicine, Tel Aviv University, Israel; Department of Medicine A, Meir Medical Center, Kfar Saba, Israel
| | - David Pereg
- Sackler School of Medicine, Tel Aviv University, Israel; Department of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Galia Spectre
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Uri Rozovski
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel; Sackler School of Medicine, Tel Aviv University, Israel
| | - Doron Hermoni
- Sackler School of Medicine, Tel Aviv University, Israel; Department of Family Medicine, Sharon-Shomron District, Clalit Health Services, Netanya, Israel
| | - Michael Lishner
- Sackler School of Medicine, Tel Aviv University, Israel; Department of Medicine A, Meir Medical Center, Kfar Saba, Israel.
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