1
|
Rutjes AW, Porreca E, Candeloro M, Valeriani E, Di Nisio M. Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Cochrane Database Syst Rev 2020; 12:CD008500. [PMID: 33337539 PMCID: PMC8829903 DOI: 10.1002/14651858.cd008500.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) often complicates the clinical course of cancer. The risk is further increased by chemotherapy, but the trade-off between safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. This is the third update of a review first published in February 2012. OBJECTIVES To assess the efficacy and safety of primary thromboprophylaxis for VTE in ambulatory cancer patients receiving chemotherapy compared with placebo or no thromboprophylaxis, or an active control intervention. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Cochrane Vascular, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 3 August 2020. We also searched the reference lists of identified studies and contacted content experts and trialists for relevant references. SELECTION CRITERIA Randomised controlled trials comparing any oral or parenteral anticoagulant or mechanical intervention to no thromboprophylaxis or placebo, or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS We extracted data on risk of bias, participant characteristics, interventions, and outcomes including symptomatic VTE and major bleeding as the primary effectiveness and safety outcomes, respectively. We applied GRADE to assess the certainty of evidence. MAIN RESULTS We identified six additional randomised controlled trials (3326 participants) for this update, bringing the included study total to 32 (15,678 participants), all evaluating pharmacological interventions and performed mainly in people with locally advanced or metastatic cancer. The certainty of the evidence ranged from high to very low across the different outcomes and comparisons. The main limiting factors were imprecision and risk of bias. Thromboprophylaxis with direct oral anticoagulants (direct factor Xa inhibitors apixaban and rivaroxaban) may decrease the incidence of symptomatic VTE (risk ratio (RR) 0.43, 95% confidence interval (CI) 0.18 to 1.06; 3 studies, 1526 participants; low-certainty evidence); and probably increases the risk of major bleeding compared with placebo (RR 1.74, 95% CI 0.82 to 3.68; 3 studies, 1494 participants; moderate-certainty evidence). When compared with no thromboprophylaxis, low-molecular-weight heparin (LMWH) reduced the incidence of symptomatic VTE (RR 0.62, 95% CI 0.46 to 0.83; 11 studies, 3931 participants; high-certainty evidence); and probably increased the risk of major bleeding events (RR 1.63, 95% CI 1.12 to 2.35; 15 studies, 7282 participants; moderate-certainty evidence). In participants with multiple myeloma, LMWH resulted in lower symptomatic VTE compared with the vitamin K antagonist warfarin (RR 0.33, 95% CI 0.14 to 0.83; 1 study, 439 participants; high-certainty evidence), while LMWH probably lowers symptomatic VTE more than aspirin (RR 0.51, 95% CI 0.22 to 1.17; 2 studies, 781 participants; moderate-certainty evidence). Major bleeding was observed in none of the participants with multiple myeloma treated with LMWH or warfarin and in less than 1% of those treated with aspirin. Only one study evaluated unfractionated heparin against no thromboprophylaxis, but did not report on VTE or major bleeding. When compared with placebo or no thromboprophylaxis, warfarin may importantly reduce symptomatic VTE (RR 0.15, 95% CI 0.02 to 1.20; 1 study, 311 participants; low-certainty evidence) and may result in a large increase in major bleeding (RR 3.82, 95% CI 0.97 to 15.04; 4 studies, 994 participants; low-certainty evidence). One study evaluated antithrombin versus no antithrombin in children. This study did not report on symptomatic VTE but did report any VTE (symptomatic and incidental VTE). The effect of antithrombin on any VTE and major bleeding is uncertain (any VTE: RR 0.84, 95% CI 0.41 to 1.73; major bleeding: RR 0.78, 95% CI 0.03 to 18.57; 1 study, 85 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS In ambulatory cancer patients, primary thromboprophylaxis with direct factor Xa inhibitors may reduce the incidence of symptomatic VTE (low-certainty evidence) and probably increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo. LMWH decreases the incidence of symptomatic VTE (high-certainty evidence), but increases the risk of major bleeding (moderate-certainty evidence) when compared with placebo or no thromboprophylaxis. Evidence for the use of thromboprophylaxis with anticoagulants other than direct factor Xa inhibitors and LMWH is limited. More studies are warranted to evaluate the efficacy and safety of primary prophylaxis in specific types of chemotherapeutic agents and types of cancer, such as gastrointestinal or genitourinary cancer.
Collapse
Affiliation(s)
- Anne Ws Rutjes
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Emanuele Valeriani
- Internal Medicine Unit, "University G. D'Annunzio" Foundation, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, University "G. D'Annunzio" of Chieti-Pescara, Chieti Scalo, Italy
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, Netherlands
| |
Collapse
|
2
|
Akl EA, Kahale LA, Hakoum MB, Matar CF, Sperati F, Barba M, Yosuico VED, Terrenato I, Synnot A, Schünemann H. Parenteral anticoagulation in ambulatory patients with cancer. Cochrane Database Syst Rev 2017; 9:CD006652. [PMID: 28892556 PMCID: PMC6419241 DOI: 10.1002/14651858.cd006652.pub5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Anticoagulation may improve survival in patients with cancer through a speculated anti-tumour effect, in addition to the antithrombotic effect, although may increase the risk of bleeding. OBJECTIVES To evaluate the efficacy and safety of parenteral anticoagulants in ambulatory patients with cancer who, typically, are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. SEARCH METHODS A comprehensive search included (1) a major electronic search (February 2016) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 1), MEDLINE (1946 to February 2016; accessed via OVID) and Embase (1980 to February 2016; accessed via OVID); (2) handsearching of conference proceedings; (3) checking of references of included studies; (4) use of the 'related citation' feature in PubMed and (5) a search for ongoing studies in trial registries. As part of the living systematic review approach, we are running searches continually and we will incorporate new evidence rapidly after it is identified. This update of the systematic review is based on the findings of a literature search conducted on 14 August, 2017. SELECTION CRITERIA Randomized controlled trials (RCTs) assessing the benefits and harms of parenteral anticoagulation in ambulatory patients with cancer. Typically, these patients are undergoing chemotherapy, hormonal therapy, immunotherapy or radiotherapy, but otherwise have no standard therapeutic or prophylactic indication for anticoagulation. DATA COLLECTION AND ANALYSIS Using a standardized form we extracted data in duplicate on study design, participants, interventions outcomes of interest, and risk of bias. Outcomes of interested included all-cause mortality, symptomatic venous thromboembolism (VTE), symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, minor bleeding, and quality of life. We assessed the certainty of evidence for each outcome using the GRADE approach (GRADE handbook). MAIN RESULTS Of 6947 identified citations, 18 RCTs fulfilled the eligibility criteria. These trials enrolled 9575 participants. Trial registries' searches identified nine registered but unpublished trials, two of which were labeled as 'ongoing trials'. In all included RCTs, the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin appears to have no effect on mortality at 12 months (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.93 to 1.03; risk difference (RD) 10 fewer per 1000; 95% CI 35 fewer to 15 more; moderate certainty of evidence) and mortality at 24 months (RR 0.99; 95% CI 0.96 to 1.01; RD 8 fewer per 1000; 95% CI 31 fewer to 8 more; moderate certainty of evidence). Heparin therapy reduces the risk of symptomatic VTE (RR 0.56; 95% CI 0.47 to 0.68; RD 30 fewer per 1000; 95% CI 36 fewer to 22 fewer; high certainty of evidence), while it increases in the risks of major bleeding (RR 1.30; 95% 0.94 to 1.79; RD 4 more per 1000; 95% CI 1 fewer to 11 more; moderate certainty of evidence) and minor bleeding (RR 1.70; 95% 1.13 to 2.55; RD 17 more per 1000; 95% CI 3 more to 37 more; high certainty of evidence). Results failed to confirm or to exclude a beneficial or detrimental effect of heparin on thrombocytopenia (RR 0.69; 95% CI 0.37 to 1.27; RD 33 fewer per 1000; 95% CI 66 fewer to 28 more; moderate certainty of evidence); quality of life (moderate certainty of evidence). AUTHORS' CONCLUSIONS Heparin appears to have no effect on mortality at 12 months and 24 months. It reduces symptomatic VTE and likely increases major and minor bleeding. Future research should further investigate the survival benefit of different types of anticoagulants in patients with different types and stages of cancer. The decision for a patient with cancer to start heparin therapy should balance the benefits and downsides, and should integrate the patient's values and preferences.Editorial note:This is a living systematic review. Living systematic reviews offer a new approach to review updating in which the review is continually updated, incorporating relevant new evidence, as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
Collapse
Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut Medical Center, Riad El Solh St, Beirut, Lebanon
| | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Lyman GH, Eckert L, Wang Y, Wang H, Cohen A. Venous thromboembolism risk in patients with cancer receiving chemotherapy: a real-world analysis. Oncologist 2013; 18:1321-9. [PMID: 24212499 DOI: 10.1634/theoncologist.2013-0226] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
UNLABELLED The occurrence of malignant disease increases the risk for venous thromboembolism (VTE). Here we evaluate the risk for VTE in a large unselected cohort of patients with cancer receiving chemotherapy. METHODS The United States IMPACT health care claims database was retrospectively analyzed to identify patients with a range of solid tumors who started chemotherapy from January 2005 through December 2008. International Classification of Diseases, 9th revision, Clinical Modification Codes were used to identify cancer location, presence of VTE 3.5 months and 12 months after starting chemotherapy, and incidence of major bleeding complications. Health care costs were assessed one year before initiation of chemotherapy and one year after initiation of chemotherapy. RESULTS The overall incidence of VTE 3.5 months after starting chemotherapy was 7.3% (range 4.6%-11.6% across cancer locations) rising to 13.5% at 12 months (range 9.8%-21.3%). The highest VTE risk was identified in patients with pancreatic, stomach, and lung cancer. Patients in whom VTE developed had a higher risk for major bleeding at 3.5 months and at 12 months (11.0% and 19.8% vs. 3.8% and 9.6%, respectively). Health care costs were significantly higher in patients in whom VTE developed. CONCLUSION Those undergoing chemotherapy as outpatients are at increased risk for VTE and for major bleeding complications. Thromboprophylaxis may be considered for such patients after carefully assessing the risks and benefits of treatment.
Collapse
Affiliation(s)
- Gary H Lyman
- Duke University School of Medicine and the Duke Cancer Institute, Durham, North Carolina, USA
| | | | | | | | | |
Collapse
|
4
|
Yhim HY, Jang MJ, Kwak JY, Yim CY, Choi WI, Lee YC, Lee JO, Lee KW, Bang SM, Kim SH, Kim YK, Chang HJ, Oh D. The incidence, risk factors, and prognosis of recurrent venous thromboembolism (VTE) in patients with advanced solid cancers receiving anticoagulation therapy after the diagnosis of index VTE. Thromb Res 2013; 131:e133-40. [PMID: 23399441 DOI: 10.1016/j.thromres.2013.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Revised: 01/08/2013] [Accepted: 01/21/2013] [Indexed: 12/21/2022]
Abstract
UNLABELLED Patients with cancer have been associated with increased risk of recurrent venous thromboembolism (VTE). However, data on recurrent VTE in Asian patients with advanced solid cancers are limited. METHODS This study was conducted using data from the Korean VTE registry, which is an ongoing, prospective database. Patients were eligible if they had diagnosed with recurrent/metastatic solid cancers and initiated anticoagulation therapy following index VTE diagnosis. A total of 449 patients were included in this analysis. The 6-month and 12-month cumulative incidences of recurrent VTE were 20.6% and 27.0%, respectively. Isolated pulmonary embolism (PE) (51%) was the most predominant recurrence type. Pancreas as the primary tumor site, poor Eastern Cooperative Oncology Group performance status at the time of index VTE diagnosis, and initial presentation with PE were independent risk factors for developing recurrent VTE. With a median follow-up of 29.1months (range, 1.0-91.2), the median overall survival (OS) was 11.9months. Patients with recurrent VTE had a significantly worse OS than those without recurrent VTE (median, 8.4 vs. 13.0months, respectively; P=0.001). In conclusion, the incidence of recurrent VTE in Korean patients with advanced solid cancers is comparable with Caucasian patients. Pancreas as the primary tumor site, poor performance status, and initial presentation with PE are independent recurrent VTE risk factors in advanced cancer VTE patients. Additionally, OS is adversely affected by recurrent VTE.
Collapse
Affiliation(s)
- Ho-Young Yhim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Falanga A, Marchetti M, Vignoli A. Coagulation and cancer: biological and clinical aspects. J Thromb Haemost 2013; 11:223-33. [PMID: 23279708 DOI: 10.1111/jth.12075] [Citation(s) in RCA: 306] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Malignancy affects the hemostatic system and the hemostatic system affects malignancy. In cancer patients there are a number of coagulation abnormalities which provide the background for an increased tendency of these patients to both thrombosis and hemorrhage. The causes of this coagulation impairment rely on general risk factors which are common to other categories of patients, and other factors which are specific to cancer, such as tumor type and disease stage. In addition, data from basic research indicate that the hemostatic components and the cancer biology are interconnected in multiple ways. Notably, while cancer cells are able to activate the coagulation system, the hemostatic factors play a role in tumor progression. This opens the way to the development of bifunctional therapeutic approaches that are both capable of attacking the malignant process and resolving the coagulation impairment. On the other hand, the management of thrombosis and hemorrhages in cancer patients can be different. To approach these problems, some guidelines have been released by prominent international scientific societies. Also actively investigated is the issue of identifying new biomarkers to classify the subjects at a higher risk, thus improving the prevention of thrombohemorrhagic events in these patients. Finally, novel prophylactic and therapeutic approaches are currently under development. This review provides an overview of the hemostatic complications in cancer, together with new insights into the interaction between hemostasis and cancer biology. We also review the assessment of the risk of thrombohemorrhagic events in cancer patients, and the prophylaxis and treatment of such manifestations.
Collapse
Affiliation(s)
- A Falanga
- Division of Immunohematology and Transfusion Medicine, Ospedali Riuniti, Bergamo, Italy.
| | | | | |
Collapse
|
6
|
Elit LM, Lee AY, Parpia S, Swystun LL, Liaw PC, Hoskins P, Julian DH, Julian JA, Levine MN. Dalteparin Low Molecular Weight Heparin (LMWH) in ovarian cancer: A phase II randomized study. Thromb Res 2012; 130:894-900. [DOI: 10.1016/j.thromres.2012.09.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 09/13/2012] [Accepted: 09/14/2012] [Indexed: 01/28/2023]
|
7
|
|
8
|
Falanga A, Marchetti M. Anticancer treatment and thrombosis. Thromb Res 2012; 129:353-9. [DOI: 10.1016/j.thromres.2011.10.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 10/21/2011] [Accepted: 10/24/2011] [Indexed: 12/21/2022]
|
9
|
[Chemotherapy of metastatic pancreatic adenocarcinoma: challenges and encouraging results]. Bull Cancer 2012; 98:1439-46. [PMID: 22133915 DOI: 10.1684/bdc.2011.1494] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The outcome for patients with metastatic pancreatic ductal adenocarcinoma is dismal. In this article, we will review current first-line treatments for metastatic pancreatic adenocarcinoma focusing on phase III randomized studies. Single-agent gemcitabine, the reference treatment since 1995, offers only slight benefit. Numerous trials using gemcitabine in combination with different cytotoxic agents have resulted in no major improvement compared to gemcitabine alone. Only the gemcitabine-erlotinib combination has shown a small, but statistically improvement in survival. In selected patients with good performance status ECOG 0-1, no cardiac ischemia and almost normal bilirubin level, the Folfirinox regimen, when compared to gemcitabine as single agent, was associated with more toxicities, but also with significant increased survival and delay in the degradation of quality of life. So, Folfirinox is a new more toxic and more efficient regimen that may be considered in patients with good performance status.
Collapse
|
10
|
Ferroni P, Martini F, Portarena I, Grenga I, Riondino S, La Farina F, Laudisi A, Guadagni F, Roselli M. Early changes of a novel APC-dependent thrombin generation assay during chemotherapy independently predict venous thromboembolism in cancer patients—a pilot study. Support Care Cancer 2012; 20:2713-20. [DOI: 10.1007/s00520-012-1391-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 01/25/2012] [Indexed: 01/05/2023]
|
11
|
Haas SK, Freund M, Heigener D, Heilmann L, Kemkes-Matthes B, von Tempelhoff GF, Melzer N, Kakkar AK. Low-molecular-weight heparin versus placebo for the prevention of venous thromboembolism in metastatic breast cancer or stage III/IV lung cancer. Clin Appl Thromb Hemost 2012; 18:159-65. [PMID: 22275397 DOI: 10.1177/1076029611433769] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
In 2 double-blind studies, ambulatory patients with objectively proven, disseminated metastatic breast carcinoma (TOPIC-1) or stage III/IV non-small-cell lung carcinoma (TOPIC-2) were randomized to certoparin 3000 IU or placebo subcutaneously once daily, for 6 months. Primary efficacy outcome was objectively confirmed symptomatic or asymptomatic venous thromboembolism (VTE). Safety outcomes included bleeding (major and minor), and thrombocytopenia. TOPIC-1 was halted after an interim analysis. Venous thromboembolism occurrence was not different between treatment groups in TOPIC-1 (4% treated with certoparin, 7 of 174 vs 4% receiving placebo, 7 of 177, odds ratio [OR] 1.02; 95% confidence interval [CI] 0.30-3.48) and in TOPIC-2 (4.5%, 12 of 268) vs 8.3%, 22 of 264, respectively, OR 0.52; CI 0.23-1.12). Mortality was not different between groups. A post hoc analysis showed certoparin significantly reduced VTE in stage IV lung carcinoma (3.5% vs 10.2%; P = .032) without increased bleeding. In conclusion, thrombosis risk and prophylactic benefit was highest in stage IV lung carcinoma patients.
Collapse
Affiliation(s)
- Sylvia K Haas
- Institut für Experimentelle Onkologie und Therapieforschung, Technische Universität München, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Mandalà M, Falanga A, Roila F. Management of venous thromboembolism (VTE) in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2011; 22 Suppl 6:vi85-92. [PMID: 21908511 DOI: 10.1093/annonc/mdr392] [Citation(s) in RCA: 358] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- M Mandalà
- Unit of Medical Oncology, Haemostasis and Thrombosis Center, Department of Oncology and Haematology, Ospedali Riuniti, Bergamo, Italy
| | | | | | | |
Collapse
|
13
|
Epstein AS, O'Reilly EM. Targeting thrombosis in exocrine pancreas cancer: a continued need for improved therapies. Expert Rev Anticancer Ther 2011; 11:1783-5. [PMID: 22117145 DOI: 10.1586/era.11.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
14
|
Maraveyas A, Waters J, Roy R, Fyfe D, Propper D, Lofts F, Sgouros J, Gardiner E, Wedgwood K, Ettelaie C, Bozas G. Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer. Eur J Cancer 2011; 48:1283-92. [PMID: 22100906 DOI: 10.1016/j.ejca.2011.10.017] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/11/2011] [Accepted: 10/16/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Annualised figures show an up to 7-fold higher incidence of vascular thromboembolism (VTE) in patients with advanced pancreatic cancer (APC) compared to other common malignancies. Concurrent VTE has been shown to confer a worse overall prognosis in APC. METHODS One hundred and twenty three APC patients were randomised to receive either gemcitabine 1000 mg/m(2) or the same with weight-adjusted dalteparin (WAD) for 12 weeks. Primary end-point was the reduction of all-type VTE during the study period. NCT00462852, ISRCTN: 76464767. FINDINGS The incidence of all-type VTE during the WAD treatment period (<100 days from randomisation) was reduced from 23% to 3.4% (p = 0.002), with a risk ratio (RR)of 0.145, 95% confidence interval (CI) (0.035-0.612) and an 85% risk reduction. All-type VTE throughout the whole follow-up period was reduced from 28% to 12% (p = 0.039), RR = 0.419, 95% CI (0.187-0.935) and a 58% risk reduction. Lethal VTE <100 days was seen only in the control arm, 8.3% compared to 0% (p = 0.057), RR = 0.092, 95% CI (0.005-1.635). INTERPRETATION Weight adjusted dalteparin used as primary prophylaxis for 12 weeks is safe and produces a highly significant reduction of all-type VTE during the prophylaxis period. The benefit is maintained after dalteparin withdrawal although decreases with time.
Collapse
Affiliation(s)
- A Maraveyas
- Queen's Centre for Oncology and Haematology, Castle Hill Hospital, Cottingham, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Epstein AS, Soff GA, Capanu M, Crosbie C, Shah MA, Kelsen DP, Denton B, Gardos S, O'Reilly EM. Analysis of incidence and clinical outcomes in patients with thromboembolic events and invasive exocrine pancreatic cancer. Cancer 2011; 118:3053-61. [PMID: 21989534 DOI: 10.1002/cncr.26600] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Revised: 06/16/2011] [Accepted: 06/23/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Pancreatic adenocarcinoma is among the most common malignancies associated with thromboembolic events (TEs); however, reported incidence figures vary significantly and contain small patient cohorts. Pancreatic cancer-specific thrombosis studies examining the correlation between clinical variables, including thrombosis timing and the impact of thrombosis on survival, have not been reported. METHODS Survival analyses were performed relating to the development and timing of a TE in 1915 patients administered chemotherapy at Memorial Sloan-Kettering Cancer Center with invasive exocrine pancreatic cancer from January 1, 2000 to December 31, 2009. TE timing, relative to clinical parameters including laboratory data, erythropoietin-stimulating agent use, and body mass index (BMI), were also analyzed. RESULTS A thrombosis was identified in 690 (36%) patients. After adjusting for patients with pancreatic surgery and thrombosis (n = 127), developing a TE significantly increased the risk of death (hazard ratio [HR], 2.6; 95% confidence interval [CI], 2.3-2.8; P < .01). Patients with an early TE (within 1.5 months from pancreatic cancer diagnosis) had a significantly higher risk of death (HR, 2.1; 95% CI, 1.7-2.5; P < .01) compared with patients with late TE or no TE. Erythropoietin-stimulating agent use and an elevated international normalized ratio were associated with significantly shorter time to thrombosis. Low BMI was associated with significantly longer time to thrombosis. CONCLUSIONS TEs are common in exocrine pancreatic cancer, with coagulopathy, erythropoietin-stimulating agent use, and underweight BMI influencing thrombosis timing. TEs, particularly early ones, confer a significantly worse prognosis, suggesting a biological significance, underscoring the relevance of ongoing prophylaxis trials, and raising the question of whether early TEs should be considered a stratification factor for clinical trials.
Collapse
Affiliation(s)
- Andrew S Epstein
- Department of Medicine, Division of Gastrointestinal Medical Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Falanga A, Russo L. Epidemiology, risk and outcomes of venous thromboembolism in cancer. Hamostaseologie 2011; 32:115-25. [PMID: 21971578 DOI: 10.5482/ha-1170] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 07/11/2011] [Indexed: 12/16/2022] Open
Abstract
Cancer is associated with a fourfold increased risk of venous thromboembolism (VTE). The risk of VTE varies according to the type of malignancy (i. e. pancreatic cancer, brain cancer, lymphoma) and its disease stage and individual factors (i. e. sex, race, age, previous VTE history, immobilization, obesity). Preventing cancer-associated VTE is important because it represents a significant cause of morbidity and mortality. In order to identify cancer patient at particularly high risk, who need thromboprophylaxis, risk prediction models have become available and are under validation. These models include clinical risk factors, but also begin to incorporate biological markers. The major American and European scientific societies have issued their recommendations to guide the management of VTE in patients with cancer. In this review the principal aspects of epidemiology, risk factors and outcome of cancer-associated VTE are summarized.
Collapse
Affiliation(s)
- A Falanga
- Division of Immunohematology and Transfusion Medicine, Department Oncology-Hematology, Ospedali Riuniti, Bergamo, Italy.
| | | |
Collapse
|
17
|
Moore RA, Adel N, Riedel E, Bhutani M, Feldman DR, Tabbara NE, Soff G, Parameswaran R, Hassoun H. High incidence of thromboembolic events in patients treated with cisplatin-based chemotherapy: a large retrospective analysis. J Clin Oncol 2011; 29:3466-73. [PMID: 21810688 PMCID: PMC6815979 DOI: 10.1200/jco.2011.35.5669] [Citation(s) in RCA: 285] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 06/14/2011] [Indexed: 12/21/2022] Open
Abstract
PURPOSE This study was designed to determine the incidence of venous and arterial thromboembolic events (TEEs) in patients treated with cisplatin-based chemotherapy and to analyze the prognostic value of patients' baseline and treatment characteristics in predicting TEE occurrence. PATIENTS AND METHODS We performed a large retrospective analysis of all patients treated with cisplatin-based chemotherapy for any type of malignancy at Memorial Sloan-Kettering Cancer Center in 2008. A TEE was cisplatin-associated if it occurred between the time of the first dose of cisplatin and 4 weeks after the last dose. RESULTS Among 932 patients, 169 (18.1%) experienced a TEE during treatment or within 4 weeks of the last dose. TEEs included deep vein thrombosis (DVT) alone in 49.7%, pulmonary embolus (PE) alone in 25.4%, DVT plus PE in 13.6%, arterial TEE alone in 8.3%, or DVT plus arterial TEE in 3.0%. TEEs occurred within 100 days of initiation of treatment in 88% of patients. By univariate analysis, sex, age, race, Karnofsky performance status (KPS), exposure to erythropoiesis-stimulating agents, presence of central venous catheter (CVC), site of cancer, stage of cancer, leukocyte and hemoglobin levels, and Khorana score were all identified as risk factors. However, by multivariate analysis, only age, KPS, presence of CVC, and Khorana score retained significance. CONCLUSION This large retrospective analysis confirms the unacceptable incidence of TEEs in patients receiving cisplatin-based chemotherapy. In view of the controversy associated with prophylactic anticoagulation in patients with cancer treated with chemotherapy, randomized studies are urgently needed in this specific cancer population treated with cisplatin-based regimens.
Collapse
Affiliation(s)
- Russell A. Moore
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Nelly Adel
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Elyn Riedel
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Manisha Bhutani
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Darren R. Feldman
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Nour Elise Tabbara
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Gerald Soff
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Rekha Parameswaran
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| | - Hani Hassoun
- Russell A. Moore, Nelly Adel, Elyn Riedel, Darren R. Feldman, Nour Elise Tabbara, Gerald Soff, Rekha Parameswaran, and Hani Hassoun, Memorial Sloan-Kettering Cancer Center, New York, NY; and Manisha Bhutani, Michigan State University, East Lansing, MI
| |
Collapse
|
18
|
Mandalà M, Tondini C. The impact of thromboprophylaxis on cancer survival: focus on pancreatic cancer. Expert Rev Anticancer Ther 2011; 11:579-88. [PMID: 21504325 DOI: 10.1586/era.10.184] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pancreatic cancer is still a clinical challenge due to its predominantly late diagnosis and the chemoresistance to cytotoxic and target drugs. One of the major complications of pancreatic cancer is venous thromboembolism (VTE). Both ambulatory and hospitalized pancreatic cancer patients are at higher risk of developing VTE. Among patients with unresectable pancreatic cancer, the occurrence of VTE may be associated with a poor prognosis. Furthermore, emerging clinical data strongly suggest that anticoagulant treatment may improve patient survival by decreasing thromboembolic complications as well as by anticancer activity. Given the clinical relevance for both physicians and basic scientists, this article focuses on the experimental and clinical evidence supporting the relation between the coagulation cascade and the invasive and metastatic potential of pancreatic cancer, and suggests that anticoagulant therapy may represent a useful strategy to improve the prognosis of pancreatic cancer patients.
Collapse
Affiliation(s)
- Mario Mandalà
- Unit of Medical Oncology, Department of Oncology and Haematology, Ospedali Riuniti, Largo Barozzi 1, Bergamo 24126, Italy.
| | | |
Collapse
|
19
|
Lyman GH. Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis. Cancer 2010; 117:1334-49. [PMID: 21425133 DOI: 10.1002/cncr.25714] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 08/29/2010] [Accepted: 09/09/2010] [Indexed: 12/25/2022]
Abstract
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with cancer. The risk of VTE varies over the natural history of cancer, with the highest risk occurring during hospitalization and after disease recurrence. Patient and disease characteristics are associated with further increased risk of VTE in this setting. Specific factors include cancer type (eg, pancreatic cancer, brain cancer, lymphoma) and the presence of metastatic disease at the time of diagnosis. VTE is a significant predictor of increased mortality during the first year among all types and stages of cancer, with metastatic disease reported to be the strongest predictor of mortality. VTE is also associated with early death in ambulatory patients with cancer. These data highlight the need for close monitoring, prompt treatment, and appropriate preventive strategies for VTE in patients with cancer. The American Society of Clinical Oncology and the National Comprehensive Cancer Network have issued guidelines regarding the prophylaxis and treatment of patients with cancer. This review summarizes the impact of VTE on patients with cancer, the effects of VTE on clinical outcomes, the importance of thromboprophylaxis in this population, relevant ongoing clinical trials examining the prevention of VTE, and new pharmacologic treatment options.
Collapse
Affiliation(s)
- Gary H Lyman
- Comparative Effectiveness and Outcomes Research Program, Duke University and the Duke Comprehensive Cancer Center, Durham, North Carolina 27705, USA.
| |
Collapse
|
20
|
|
21
|
Lee AYY. Thrombosis in cancer: an update on prevention, treatment, and survival benefits of anticoagulants. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2010; 2010:144-149. [PMID: 21239784 DOI: 10.1182/asheducation-2010.1.144] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Thromboembolism is a common, complex, and costly complication in patients with cancer. Management has changed significantly in the past decade, but remains firmly dependent on the use of anticoagulants. Low-molecular-weight heparin is the preferred anticoagulant for prevention and treatment, although its limitations open opportunities for newer oral antithrombotic agents to further simplify therapy. Multiple clinical questions remain, and research is focusing on identifying high-risk patients who might benefit from primary thromboprophylaxis, treatment options for those with established or recurrent thrombosis, and the potential antineoplastic effects of anticoagulants. Risk-assessment models, targeted prophylaxis, anticoagulant dose escalation for treatment, and ongoing research studying the interaction of coagulation activation in malignancy may offer improved outcomes for oncology patients.
Collapse
Affiliation(s)
- Agnes Y Y Lee
- Thrombosis Program, Vancouver Coastal Health Vancouver General Hospital, and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|