1
|
Mai AS, Matetić A, Elgendy IY, Lopez-Mattei J, Kotronias RA, Sun LY, Yong JH, Bagur R, Van Spall HGC, Mamas MA. The association between cancer diagnosis, care, and outcomes in 1 million patients hospitalized for acute pulmonary embolism. Int J Cardiol 2023; 371:354-362. [PMID: 36167220 DOI: 10.1016/j.ijcard.2022.09.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/24/2022] [Accepted: 09/20/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate the clinical care provided to cancer patients hospitalized for acute pulmonary embolism (PE), as well as the association between type of cancer, in-hospital care, and clinical outcomes. METHODS This study examined the in-hospital care (systemic thrombolysis, catheter-directed thrombolysis, and surgical thrombectomy/embolectomy) and clinical outcomes (mortality, major bleeding, and hemorrhagic stroke) among adults hospitalized due to acute PE between October 2015 to December 2018 using the National Inpatient Sample (NIS). Multivariable logistic regression analysis was used to determine adjusted odds ratios (aOR) with 95% confidence interval (95% CI). RESULTS Of 1,090,130 hospital records included in the analysis, 216,825 (19.9%) had current cancer diagnoses, including lung (4.7%), hematological (2.5%), colorectal (1.6%), breast (1.3%), prostate (0.8%), and 'other' cancer (9.0%). Cancer patients had lower adjusted odds of receiving systemic thrombolysis, catheter-directed therapy, and surgical thrombectomy/embolectomy compared with their non-cancer counterparts (P < 0.001), except for systemic thrombolysis (aOR 0.96, 95% CI 0.85-1.09, P = 0.553) and catheter-directed therapy (aOR 0.82, 95% CI 0.67-1.00, P = 0.053) for prostate cancer. Cancer patients had greater odds of mortality (P < 0.05). Lung cancer patients had the highest odds of mortality (aOR 2.68, 95% CI 2.61-2.76, P < 0.001) and hemorrhagic stroke (aOR 1.75, 95% CI 1.61-1.90, P < 0.001), while colorectal cancer patients had the greatest odds of bleeding (aOR 2.04, 95% CI 1.94-2.15, P < 0.001). CONCLUSION Among those hospitalized for PE, cancer diagnoses were associated with lower odds of invasive management and poorer in-hospital outcomes, with metastatic status being an especially important determinant. Appropriateness of care could not be assessed in this study.
Collapse
Affiliation(s)
- Aaron Shengting Mai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrija Matetić
- Department of Cardiology, University Hospital of Split, Split, Croatia; Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Islam Y Elgendy
- Deparment of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Juan Lopez-Mattei
- Heart and Vascular Institute, Lee Health System, Fort Myers, Florida, USA
| | | | - Louise Y Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jung Hahn Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Rodrigo Bagur
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK
| | - Harriette G C Van Spall
- Research Institute of St. Joe's, Hamilton, and Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute for Primary Care and Health Sciences, Keele University, UK.
| |
Collapse
|
2
|
Kakkos SK, Arnaoutoglou E, Tsolakis IA, Giannoukas A, Papadimitriou CA, Kentepozidis N, Boukovinas I, Kalofonos HP, Labropoulos N, Matsagkas M. Frequency and predictors of chemotherapy-associated venous thromboembolism: the prospective PREVENT study. INT ANGIOL 2020; 39:112-117. [PMID: 32057213 DOI: 10.23736/s0392-9590.20.04272-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Our knowledge on the burden of symptomatic and asymptomatic venous thromboembolism (VTE) in patients with cancer undergoing chemotherapy is limited. The aim of our study was to prospectively investigate the frequency of symptomatic VTE and asymptomatic deep vein thrombosis of the lower limbs among cancer patients undergoing chemotherapy. METHODS We studied 231 patients (164 men) with pancreatic (N.=36), lung (N.=136), ovarian (N.=32) or prostate (N.=27) cancer receiving first line (N.=192, 83.1%) or adjuvant chemotherapy, followed-up for 3-6 months. RESULTS Some 17 patients were diagnosed with VTE, either asymptomatic detected on leg ultrasound (N.=7) or symptomatic (N.=10). The total frequency of VTE was 10.3% (17/165 with follow-up). Pancreatic cancer had the highest frequency of VTE (4/25, 16%) followed by ovarian (3/26, 11.5%) and lung cancer (10/94, 10.6%). There was no statistically significant difference in VTE rates among cancer types (P=0.36). VTE occurred more frequently in the presence of metastases (13/85, 15.3% vs. 4/80, 5.0%, for the remainder, P=0.03, OR 3.4). In the subgroup of patients receiving first line treatment, VTE occurred more frequently in patients with metastases (13/84, 15.5% vs. 2/53, 3.8%, for the remainder, P=0.033). In patients with pancreatic, lung or ovarian cancer receiving first line treatment, VTE occurred more frequently in patients with metastatic disease (19.1% vs. 4.0%, for the remainder, P=0.015). CONCLUSIONS VTE occurrence in this real-world patient cohort was high, reaching almost 20% in certain groups, like those with disseminated pancreatic, lung or ovarian cancer receiving first-line chemotherapy. Furthermore, VTE occurs mostly as a symptomatic event, being likely a result of the prothrombotic state of malignancy.
Collapse
Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, University of Thessaly, Larissa, Greece.,Department of Anesthesiology, University of Ioannina, Ioannina, Greece
| | - Ioannis A Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | | | - Christos A Papadimitriou
- Unit of Oncology, Second Department of Surgery, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Nicos Labropoulos
- Division of Oncology, Department of Medicine, University of Patras Medical School, Patras, Greece
| | | |
Collapse
|
3
|
Wu MY, Hou YT, Ke JY, Yiang GT. Case of internal jugular vein thrombosis and fever: Lemierre's syndrome or Trousseau's syndrome? Tzu Chi Med J 2019; 32:91-95. [PMID: 32110528 PMCID: PMC7015004 DOI: 10.4103/tcmj.tcmj_34_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/12/2019] [Accepted: 02/01/2019] [Indexed: 12/21/2022] Open
Abstract
Internal jugular vein thrombosis is a rare critical cardiovascular emergency, which has potential catastrophic clinical outcomes by resulting in stroke and pulmonary embolism. Several etiologies have been reported; however, there are limited data on Lemierre's and Trousseau's syndromes, which are both rare conditions with advanced disease progression and poor clinical outcomes. Lemierre's syndrome may present with typical progressively infectious symptoms and signs, including sore throat, neck mass, and fever, whereas Trousseau's syndrome may present with thrombophlebitis and painful edema. Without antibiotic agents controlling the infection, the condition of patients with Lemierre's syndrome may progress to sepsis or septic shock. The infection pattern plays an important role for differential diagnosis. Herein, we describe the case of a 46-year-old woman presenting with atypical symptoms of Trousseau's syndrome mimicking Lemierre's syndrome. Laboratory analysis including protein C, protein S, rheumatoid factor, and antinuclear antibody ruled out hypercoagulopathy and autoimmune vasculitis. Abdominal computed tomography and panendoscopy revealed ulcerative tumor at the antrum. Pathological examination confirmed the presence of signet-ring cell adenocarcinoma. We highlight the clinical features and etiologies of internal jugular vein thrombosis, especially in Lemierre's syndrome and Trousseau's syndrome, to aid physicians in making an early diagnosis and providing timely management.
Collapse
Affiliation(s)
- Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yueh-Tseng Hou
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jian-Yu Ke
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien, Taiwan
| |
Collapse
|
4
|
Hutchinson A, Rees S, Young A, Maraveyas A, Date K, Johnson MJ. Oral anticoagulation is preferable to injected, but only if it is safe and effective: An interview study of patient and carer experience of oral and injected anticoagulant therapy for cancer-associated thrombosis in the select-d trial. Palliat Med 2019; 33:510-517. [PMID: 30488789 PMCID: PMC6506899 DOI: 10.1177/0269216318815377] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cancer patients have a four- to fivefold greater risk of thrombosis than the general population. Recommended treatment for cancer-associated thrombosis is 3-6 months of low-molecular-weight heparin. The 'select-d' trial is an open-label, randomised, multi-centre pilot trial in patients with cancer-associated thrombosis, utilising dalteparin (low-molecular-weight heparin) versus rivaroxaban (a direct oral anticoagulant), to assess effectiveness and safety. AIM To explore patient and informal carers' experiences of cancer-associated thrombosis and their experience and understanding of the risk-benefit of thrombosis treatment. DESIGN Qualitative substudy of the select-d trial, using semi-structured interviews. Interviews were audio-recorded and transcribed. Data were analysed using Framework Analysis. PARTICIPANTS Participants were purposively sampled ( n = 37 patients; 46% male; age 40-89; 9 with carer present). RESULTS Three themes were found: experience of cancer-associated thrombosis, experience of anticoagulation and risk-benefit balance of the two modes of administration. Some were shocked by their thrombosis diagnosis (most were unaware of their risk), but others found it insignificant compared with cancer. Most patients found tablets more convenient, but injections were acceptable in the context of having cancer. While most were happy to follow medical advice, others weighed preference on the basis of effectiveness. CONCLUSION Lack of awareness of thrombosis risk is concerning; cancer patients must be informed to enable prompt help-seeking. Tablets could provide a welcome choice for patients if there is equivalent risk-benefit to injected anticoagulants. Patients trust their clinicians to tailor their treatment. Future research could explore the effect of routine information giving about the risk of thrombosis.
Collapse
|
5
|
Aggarwal A, Geer AVD, Faselis C, Büller HR, Di Nisio M, Rickles FR, Kamphuisen P, Kleinjan A. A worldwide survey to assess the current approach to the treatment of patients with cancer and venous thromboembolism. Thromb Haemost 2017; 110:959-65. [DOI: 10.1160/th13-05-0414] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/09/2013] [Indexed: 11/05/2022]
Abstract
SummaryLow-molecular-weight heparin (LWMH) is recommended as the preferred anticoagulant treatment over vitamin K antagonists (VKA) for venous thromboembolism (VTE) in patients with cancer. However, there is uncertainty about the duration and dose of LMWH treatment. Therefore, we designed this multinational survey to assess the current approach to the treatment of patients with cancer and VTE. An electronic survey tool was used to disseminate a survey containing 49 questions on different aspects of the treatment of patients with cancer and VTE, among both thrombosis and non-thrombosis specialists. A total of 229 invitations were sent, and 141 completed the survey (60% of the total). Fifty-eight percent of the respondents were from Europe, 35% from the US and the remaining 7% from other countries. Respondent’s specialties included haematology (23%), oncology (18%), pulmonology (15%) and general internal medicine (15%). LMWH was indicated as the first choice for the long-term treatment by 82% of the respondents, of whom 60% used full therapeutic doses and 40% chose a dose reduction. When continuing anticoagulants after the long-term treatment period, 44% of respondents preferred LMWH, 10% VKA, while the remaining 45% chose per individual patient for either LMWH or VKA. In conclusion, we observed a relatively high observance rate of the guidelines with respect to the use of LMWH for the long-term treatment of VTE in cancer. In contrast, the dose of LMWH and the type of anticoagulant chosen after the initial 3–12 months varied substantially, probably reflecting the limited available evidence.
Collapse
|
6
|
Shiroyama T, Hayama M, Satoh S, Nasu S, Tanaka A, Morita S, Morishita N, Suzuki H, Okamoto N, Hirashima T. Successful retreatment with osimertinib after osimertinib-induced acute pulmonary embolism in a patient with lung adenocarcinoma: A case report. Respir Med Case Rep 2016; 20:25-27. [PMID: 27896061 PMCID: PMC5121160 DOI: 10.1016/j.rmcr.2016.11.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 10/31/2016] [Accepted: 11/04/2016] [Indexed: 11/16/2022] Open
Abstract
Pulmonary embolism (PE) can be life-threatening, and it is challenging to diagnose because of its nonspecific signs and symptoms. PE is also an important potential risk of osimertinib treatment, however, clinical courses regarding retreatment after osimertinib-induced acute pulmonary embolism remain unclear. We described a 77-year-old woman with postoperative recurrent lung adenocarcinoma who developed osimertinib-induced acute PE. She received apixaban and was later successfully retreated with osimertinib. This case suggests that retreatment with osimertinib after osimertinib-induced acute PE may be a treatment option when alternative therapeutic options are limited.
Collapse
Affiliation(s)
- Takayuki Shiroyama
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Manabu Hayama
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Shingo Satoh
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Shingo Nasu
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Ayako Tanaka
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Satomu Morita
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Naoko Morishita
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Hidekazu Suzuki
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Norio Okamoto
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| | - Tomonori Hirashima
- Department of Thoracic Malignancy, Osaka Prefectural Medical Center for Respiratory and Allergic Diseases, Osaka, Japan
| |
Collapse
|
7
|
Low rates of symptomatic venous thromboembolism in patients with gastrointestinal cancer: an Iranian study. Blood Coagul Fibrinolysis 2016; 28:351-355. [PMID: 27661390 DOI: 10.1097/mbc.0000000000000601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
: Venous thromboembolism (VTE), which mostly includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is associated with considerable morbidity and mortality in patients with cancer. As little is known about VTE associated with gastrointestinal cancers among the populations in the Middle East. This study aimed to determine the relative frequency of symptomatic VTE in patients with gastrointestinal malignancies in Iran. The charts of patients with gastrointestinal cancers in our institute from April 2010 to March 2015 were investigated for symptomatic VTE in a retrospective study. In this study, all of the patients received chemotherapy. The data included the site of cancer, time of therapies initiation, patient's characteristics, type of VTE, the time of developing symptomatic VTE of patients with gastrointestinal cancer and the stage which VTE occurred. All of DVTs and pulmonary embolism were confirmed by Doppler ultrasonography and computed tomography angiography. A total of 614 consecutive patients with gastrointestinal cancer were included in study. In total, 22 patients (3.6%) were found to have experienced symptomatic VTE (confidence interval 95%: 2.1-5.1%) which included: 19 patients who suffered from DVT and three of them detected pulmonary embolism, and other types of VTE were not reported. Out of 22 patients with VTE, 17 of them have been occurred after chemotherapy (77%) within 6.17 ± 5.17 (range, 1-19) month after starting chemotherapy. The distribution of frequency of stage in which the VTE occurred, was more in stage III and IV. The rate of symptomatic VTE in patients with gastrointestinal cancer in Iran is relatively lower than other studies done in the west. Therefore, it seems the rate of VTE differs in different ethnic groups.
Collapse
|
8
|
When are breast cancer patients at highest risk of venous thromboembolism? A cohort study using English health care data. Blood 2015; 127:849-57; quiz 953. [PMID: 26574606 DOI: 10.1182/blood-2015-01-625582] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 11/03/2015] [Indexed: 01/27/2023] Open
Abstract
Patients with breast cancer are at increased risk of venous thromboembolism (VTE), particularly in the peridiagnosis period. However, no previous epidemiologic studies have investigated the relative impact of breast cancer treatments in a time-dependent manner. We aimed to determine the impact of breast cancer stage, biology, and treatment on the absolute and relative risks of VTE by using several recently linked data sources from England. Our cohort comprised 13,202 patients with breast cancer from the Clinical Practice Research Datalink (linked to Hospital Episode Statistics and Cancer Registry data) diagnosed between 1997 and 2006 with follow-up continuing to the end of 2010. Cox regression analysis was performed to determine which demographic, treatment-related, and biological factors independently affected VTE risk. Women had an annual VTE incidence of 6% while receiving chemotherapy which was 10.8-fold higher (95% confidence interval [CI], 8.2-14.4; absolute rate [AR], 59.6 per 1000 person-years) than that in women who did not receive chemotherapy. After surgery, the risk was significantly increased in the first month (hazard ratio [HR], 2.2; 95% CI, 1.4-3.4; AR, 23.5; reference group, no surgery), but the risk was not increased after the first month. Risk of VTE was noticeably higher in the 3 months after initiation of tamoxifen compared with the risk before therapy (HR, 5.5; 95% CI, 2.3-12.7; AR, 24.1); however, initiating therapy with aromatase inhibitors was not associated with VTE (HR, 0.8; 95% CI, 0.5-1.4; AR, 28.3). In conclusion, women receiving chemotherapy for breast cancer have a clinically important risk of VTE, whereas an increased risk of VTE immediately after endocrine therapy is restricted to tamoxifen.
Collapse
|
9
|
The humanistic and economic burden of venous thromboembolism in cancer patients: a systematic review. Blood Coagul Fibrinolysis 2015; 26:13-31. [PMID: 25202884 DOI: 10.1097/mbc.0000000000000193] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to present evidence on the epidemiology, health outcomes and economic burden of cancer-related venous thromboembolism (VTE). Medline, Cochrane Central Register of Controlled Trials, Econlit, Science Direct, JSTOR, Oxford Journals and Cambridge Journals were searched. The systematic literature search was limited to manuscripts published from January 2000 to December 2012. On the basis of the literature, cancer patients experience between two-fold and 20-fold higher risk of developing VTE than noncancer patients. They are more likely to experience a VTE event during the first 3-6 months after cancer diagnosis. In addition, an increased risk of VTE in patients with distant metastases and certain types of cancer (i.e. pancreatic or lung) was revealed. VTE was found to be a leading cause of mortality in cancer patients. The annual average total cost for cancer patients with VTE was found to be almost 50% higher than that of cancer patients without VTE. Inpatient care costs accounted for more than 60% of total cost. The existing evidence assessed in the present review demonstrated the significant health and economic consequences of cancer-related VTE, which make a strong case for the importance of its proper and efficient prevention and management.
Collapse
|
10
|
Investigation of Proposed Mechanisms of Chemotherapy-Induced Venous Thromboembolism. Clin Appl Thromb Hemost 2015; 21:420-7. [DOI: 10.1177/1076029615575071] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Venous thromboembolism (VTE) during chemotherapy is common, with 7% mortality in metastatic breast cancer (MBC). In a prospective cohort study of patients with breast cancer, we investigated whether vascular endothelial cell activation (VECA), and whether apoptosis, is the cause of chemotherapy-induced VTE. Methods: Serum markers of VECA, E-selectin (E-sel), vascular cell adhesion molecule 1 (VCAM-1) and d-dimer (fibrin degradation and hypercoagulability marker) were measured prechemotherapy and at 1, 4, and 8 days following chemotherapy. Clinical deep vein thrombosis (DVT) or pulmonary embolism and occult DVT detected by duplex ultrasound imaging were recorded as VTE-positive (VTE+). In patients with MBC, hypercoagulable response to chemotherapy was compared between patients with and without cancer progression. Development of VTE and cancer progression was assessed 3 months following starting chemotherapy. Results: Of the 134 patients, 10 (7.5%) developed VTE (6 [17%] of 36 MBC receiving palliation, 0 of 11 receiving neoadjuvant to downsize tumor, and 4 [5%] of 87 early breast cancer receiving adjuvant chemotherapy, P = .06). Levels of E-sel and VCAM-1 decreased in response to chemotherapy ( P < .001) in both VTE+ and patients not developing VTE (VTE−). However, decrease in VECA markers was similar in VTE+ and VTE− patients, implying this is not the cause of VTE. In patients with MBC following chemotherapy, d-dimer (geometric mean) increased by 36% in the 21 patients with MBC responding to chemotherapy but steadily decreased by 11% in the 15 who progressed (day 4, P < .01), implying patients with tumor response (apoptosis) had an early hypercoagulable response. Conclusions: During chemotherapy for breast cancer, VECA is induced; however, this is not the primary mechanism for VTE. Chemotherapy-induced apoptosis may enhance hypercoagulability and initiate VTE.
Collapse
|
11
|
|
12
|
Honecker F, Koychev D, Luhmann AD, Langer F, Dieckmann KP, Bokemeyer C, Oechsle K. Venous thromboembolic events in germ cell cancer patients undergoing platinum-based chemotherapy. ACTA ACUST UNITED AC 2013; 36:663-8. [PMID: 24192771 DOI: 10.1159/000355652] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Germ cell tumor (GCT) patients are at risk of venous thromboembolic events (VTEEs). A higher incidence of VTEEs has been reported in GCT patients undergoing cisplatin-based chemotherapy. PATIENTS AND METHODS A retrospective analysis of the incidence of and risk factors for VTEEs in 193 GCT patients receiving platinum-based chemotherapy in Hamburg, Germany, between 2000 and 2009 was performed. RESULTS VTEEs occurred in 22 patients (11%). In only 4 patients, the VTEEs occurred during cisplatin-based chemotherapy, while 18 patients (81%) experienced VTEEs prior to initiation of chemotherapy. Pure seminoma, 'intermediate risk' (International Germ Cell Cancer Collaborative Group (IGCCCG)), retroperitoneal or supraclavicular lymph node metastases, elevated lactate dehydrogenase (LDH) levels, a central venous catheter (CVC), arterial hypertension, application of granulocyte colony-stimulating factor (G-CSF) and of ≥ 3 cycles of cisplatin-based chemotherapy could be identified as risk factors. 2 risk groups could be described: (i) VTEEs manifesting before chemotherapy in patients with seminoma, retroperitoneal tumor masses, and elevated LDH levels, and (ii) VTEEs occurring during chemotherapy applied via CVC in patients with supraclavicular lymph node metastases. CONCLUSIONS The incidence of VTEEs in GCT patients was 11%, but in the majority of patients, the VTEEs occurred before the initiation of platinum-based chemotherapy. Supraclavicular lymph node metastases and use of a CVC are risk factors for VTEEs during chemotherapy.
Collapse
Affiliation(s)
- Friedemann Honecker
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | | |
Collapse
|
13
|
Rahme E, Feugère G, Sirois C, Weicker S, Ramos E. Anticoagulant use in patients with cancer associated venous thromboembolism: A retrospective cohort study. Thromb Res 2013; 131:210-7. [DOI: 10.1016/j.thromres.2012.12.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 11/16/2012] [Accepted: 12/07/2012] [Indexed: 12/01/2022]
|
14
|
Abstract
Cancer patients are at high risk for venous thromboembolism (VTE), which results in substantial morbidity and mortality. In this narrative review, we present evidence for the use of anticoagulants in the treatment and prevention of VTE in cancer patients. The benefit of perioperative anticoagulant prophylaxis following cancer surgery is well established. However, the risk-benefit trade-offs in non-surgical hospitalized cancer patients and among outpatients receiving chemotherapy are more complex. Emerging evidence suggests that the use of low molecular weight heparin (LMWH) may confer a small survival benefit in cancer patients without VTE. However, specific patient populations that may derive the most benefit have yet to be defined. Guidelines endorse LMWH as the preferred treatment for acute VTE, on the basis of high-quality clinical trial data, but the optimal duration of treatment remains unclear, and practical issues may limit its use outside the clinical trial setting. Novel oral anticoagulants may provide additional treatment and prophylaxis options, but their efficacy and safety in this population have not been established. Despite the significant impact of VTE on the lives of cancer patients and the large body of existing literature regarding treatment and prevention, important unanswered clinical questions remain, emphasizing the need for additional high-quality clinical trial data.
Collapse
Affiliation(s)
- D M Siegal
- Division of Hematology and Thromboembolism, McMaster University, Hamilton, Canada Division of Hematology/Oncology, University of New Mexico, Albuquerque, NM, USA
| | | |
Collapse
|
15
|
The Hemostasis Apparatus in Pancreatic Cancer and Its Importance beyond Thrombosis. Cancers (Basel) 2011; 3:267-84. [PMID: 24212618 PMCID: PMC3756361 DOI: 10.3390/cancers3010267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 12/05/2010] [Accepted: 01/10/2011] [Indexed: 12/21/2022] Open
Abstract
Laboratory evidence of aberrant coagulation is found in the majority of patients with advanced pancreatic cancer and a clinical consequence of this is the high incidence and prevalence of vascular thromboembolic events. Other sequelae are hypothesized to be the facilitation and acceleration of mechanisms that define the malignant phenotype, such as invasion, trafficking and anchoring, establishing the metastatic niche and inducing angiogenesis. We review the in vitro and preclinical evidence that supports the role of the coagulation apparatus in the metastatic process of pancreatic cancer, with a particular emphasis on interaction of this pathway with clinically-targeted growth factor receptor pathways. Links between hemostasis, angiogenesis and epidermal growth factor pathways and their significance as therapeutic targets are considered.
Collapse
|
16
|
Khalili H, Dashti-Khavidaki S, Talasaz AHH, Najmedin F, Hosseinpoor R. Anticoagulant Utilization Evaluation in a Teaching Hospital. J Pharm Pract 2010; 23:579-84. [DOI: 10.1177/0897190010372808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background and goal: Due to the importance of anticoagulation use along with the complications that deep vein thrombosis (DVT) and pulmonary embolism (PE) may bring about for the patients, in this study we decided to carry out a drug utilization evaluation on anticoagulants that are routinely administered in a tertiary teaching hospital. Method: Anticoagulants utilization was evaluated in 400 patients from 4 wards (infectious disease, cardiology, nephrology, and cardiac care unit) of a tertiary teaching hospital in a cross-sectional, prospective study. Results: According to the risk stratification, 220 (55%) of the evaluated patients have indication to receive anticoagulants as deep venous thrombosis prophylaxis. With definite diagnosis of DVT or PE, 169 (42.3%) patients have received anticoagulant therapy. In 11 (2.8%) cases, anticoagulants has been ordered inappropriately. In assessment of the anticoagulants regimens that were used as DVT prophylaxis doses of heparin and enoxaparin were appropriate in 75% and 79% of patients, respectively. Conclusion: Despite the existence of comprehensive guidelines for the prevention and treatment of DVT and PE, it is not performed accurately.
Collapse
Affiliation(s)
- Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Simin Dashti-Khavidaki
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Azita Haj-Hossein Talasaz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Najmedin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Hosseinpoor
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
17
|
Abstract
Venous thromboembolism (VTE) is a common complication in patients with malignant disease. First recognised by Bouillard in 1823 and later described by Trousseau in 1844, multiple studies have since provided considerable evidence for a clinical association between VTE and cancer. Across all cancers, the risk for VTE is elevated 7-fold; in certain malignancies, the risk for VTE may be increased up to 28-fold. Venous thromboembolism is the second leading cause of death in patients with cancer; among survivors, complications commonly include recurrent VTE and post-thrombotic syndrome, and (more rarely) chronic thromboembolic pulmonary hypertension, which are costly, and have a profound impact on the patient's quality of life. Tumour cells can activate blood coagulation through multiple mechanisms, including production of procoagulant, fibrinolytic, and proaggregating activities, release of proinflammatory and proangiogenic cytokines, and interacting directly with host vascular and blood cells (e.g., endothelial cells, leukocytes, and platelets) through adhesion molecules. Increasing evidence suggests that elements of the haemostatic system also have a direct role in eliciting or enhancing angiogenesis, cell survival, and metastasis. Despite the problem posed by VTE in the setting of cancer, it is evident that a significant number of oncologists do not recognise the link between cancer, its treatment, and thrombogenesis. On 22 May 2009, a group of UK-based physicians met in London, UK, to evaluate recent data on cancer thrombosis. This article (1 of 4) briefly reviews key data on the epidemiology and pathophysiology of VTE as a context for a discussion and consensus statement developed by meeting attendees, on the implications of this information for UK clinical practice.
Collapse
|
18
|
Kirwan CC, Byrne GJ, Kumar S, McDowell G. Platelet release of Vascular Endothelial Growth Factor (VEGF) in patients undergoing chemotherapy for breast cancer. JOURNAL OF ANGIOGENESIS RESEARCH 2009; 1:7. [PMID: 20016693 PMCID: PMC2794853 DOI: 10.1186/2040-2384-1-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2009] [Accepted: 10/24/2009] [Indexed: 01/02/2023]
Abstract
Background Venous thromboembolism (VTE) following breast cancer chemotherapy is common. Chemotherapy-induced alterations in markers of haemostasis occur during chemotherapy. In this study we investigated the changes in serum and plasma VEGF, together with platelet release of VEGF and related these to the development of VTE at 3 months. Methods Serum and plasma VEGF, together with platelet release of VEGF were measured prior to chemotherapy and at 24 hours; four-, eight days and three months following commencement of chemotherapy in early and advanced breast cancer patients and in age and sex matched controls. Duplex ultrasound imaging was performed after one month or if symptomatic. Results Of 123 patients 9.8% developed VTE within three months. Serum and plasma VEGF were increased in advanced breast cancer as was platelet release of VEGF. Prior to chemotherapy a 100 μg/ml increase in serum VEGF was associated with a 40% increased risk of VTE, while a 10 μg/ml increase in plasma VEGF was associated with a 20% increased risk of VTE. Serum VEGF showed a different response to chemotherapy in those who developed VTE. Conclusion A group of patients at risk of VTE could be identified, allowing targeted thrombopropylaxis. Whether or not the response in VEGF during chemotherapy has any angiogenic significance remains to be elucidated.
Collapse
Affiliation(s)
- Cliona C Kirwan
- Department of Academic Surgery, South Manchester University Hospitals NHS Trust, Wythenshawe Hospital, Southmoor Road, Manchester M239LT, UK.
| | | | | | | |
Collapse
|
19
|
Griffiths GO, Burns S, Noble SI, Macbeth FR, Cohen D, Maughan TS. FRAGMATIC: a randomised phase III clinical trial investigating the effect of fragmin added to standard therapy in patients with lung cancer. BMC Cancer 2009; 9:355. [PMID: 19807917 PMCID: PMC2761945 DOI: 10.1186/1471-2407-9-355] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 10/06/2009] [Indexed: 11/26/2022] Open
Abstract
Background Venous thromboembolism (VTE) occurs when blood clots in the leg, pelvic or other deep vein (deep vein thrombosis) with or without transport of the thrombus into the pulmonary arterial circulation (pulmonary embolus). VTE is common in patients with cancer and is increased by surgery, chemotherapy, radiotherapy and disease progression. Low molecular weight heparin (LMWH) is routinely used to treat VTE and some evidence suggests that LMWH may also have an anticancer effect, by reduction in the incidence of metastases. The FRAGMATIC trial will assess the effect of adding dalteparin (FRAGMIN), a type of LMWH, to standard treatment for patients with lung cancer. Methods/Design The study design is a randomised multicentre phase III trial comparing standard treatment and standard treatment plus daily LMWH for 24 weeks in patients with lung cancer. Patients eligible for this study must have histopathological or cytological diagnosis of primary bronchial carcinoma (small cell or non-small cell) within 6 weeks of randomisation, be 18 or older, and must be willing and able to self-administer 5000 IU dalteparin by daily subcutaneous injection or have it administered to themselves or by a carer for 24 weeks. A total of 2200 patients will be recruited from all over the UK over a 3 year period and followed up for a minimum of 1 year after randomisation. Patients will be randomised to one of the two treatment groups in a 1:1 ratio, standard treatment or standard treatment plus dalteparin. The primary outcome measure of the trial is overall survival. The secondary outcome measures include venous thrombotic event (VTE) free survival, serious adverse events (SAEs), metastasis-free survival, toxicity, quality of life (QoL), levels of breathlessness, anxiety and depression, cost effectiveness and cost utility. Trial registration Current Controlled Trials ISRCTN80812769
Collapse
Affiliation(s)
- Gareth O Griffiths
- Wales Cancer Trials Unit, School of Medicine, Cardiff University, Cardiff, UK.
| | | | | | | | | | | |
Collapse
|
20
|
Francis CW. Prevention of venous thromboembolism in hospitalized patients with cancer. J Clin Oncol 2009; 27:4874-80. [PMID: 19704060 DOI: 10.1200/jco.2009.22.3644] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This is a literature review of the frequency of venous thromboembolism in hospitalized patients with cancer and of the available evidence supporting the use of thromboprophylaxis. Patients with cancer are at particularly high risk of venous thromboembolism and account for almost 20% of patients in the population. Hospitalization is an important risk factor in patients with cancer, with rates reported between 0.6% and 7.8%. The incidence has been increasing over the past decade. Three randomized controlled trials and meta-analyses indicate that prophylaxis with low molecular weight heparin, heparin, or fondaparinux significantly reduces the rate of venous thromboembolism in hospitalized medical patients who are at high risk. Patients with cancer were included in these studies, but prospective trials specifically focused on patients with cancer are not available. Evidence indicates that appropriate thromboprophylaxis is provided to a minority of hospitalized patients with cancer and that targeted educational efforts and computerized prompt systems can increase appropriate use. Guidelines developed by both oncology and thrombosis organizations support the use of thromboprophylaxis in hospitalized patients with cancer. In conclusion, most patients hospitalized with cancer are at high risk of venous thromboembolism, and thromboprophylaxis should be provided in the absence of active bleeding or a high bleeding risk.
Collapse
Affiliation(s)
- Charles W Francis
- Department of Medicine, University of Rochester, Rochester, NY, USA.
| |
Collapse
|
21
|
Abstract
The association between venous thromboembolism and cancer has been recognized for over 140 years. This article reviews current prevention, diagnosis and treatment of cancer-related venous thromboembolism, and highlights emerging anticoagulants and the possible anticancer effects of anticoagulants such as low molecular weight heparins.
Collapse
Affiliation(s)
- Simon Noble
- Cardiff University and Royal Gwent Hospital, Wales NP20 2UB and
| | | |
Collapse
|
22
|
López-Gómez M, Gómez-Raposo C, Sereno Moyano M, Casado-Sáenz E, Feliú Batlle J, Ortega Ruipérez C, González Barón M. Idiopathic and recurrent thromboembolic phenomena in cancer patients. Clin Transl Oncol 2008; 10:665-9. [DOI: 10.1007/s12094-008-0268-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
23
|
Prandoni P. Prevention and treatment of venous thromboembolism with low-molecular-weight heparins: Clinical implications of the recent European guidelines. Thromb J 2008; 6:13. [PMID: 18782432 PMCID: PMC2546366 DOI: 10.1186/1477-9560-6-13] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Accepted: 09/09/2008] [Indexed: 11/10/2022] Open
Abstract
Venous thromboembolism (VTE) is an important cause of avoidable morbidity and mortality. However, routine prophylaxis for at-risk patients is underused. Recent guidelines issued by an international consensus group, including the International Union of Angiology (IUA), recommend use of low-molecular-weight heparins (LMWHs) for the treatment of acute VTE and prevention of recurrence, and for prophylaxis in surgical and medical patients. This review highlights current inadequacies in the provision of thromboprophylaxis, and considers the clinical implications of the European guidelines on the prevention and treatment of VTE.
Collapse
Affiliation(s)
- Paolo Prandoni
- Department of Cardiothoracic and Vascular Sciences, Thromboembolism Unit, University of Padua, Italy.
| |
Collapse
|
24
|
Kirwan CC, McDowell G, McCollum CN, Kumar S, Byrne GJ. Early changes in the haemostatic and procoagulant systems after chemotherapy for breast cancer. Br J Cancer 2008; 99:1000-6. [PMID: 18766191 PMCID: PMC2567096 DOI: 10.1038/sj.bjc.6604620] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Venous thromboembolism (VTE) following breast cancer chemotherapy is common. Chemotherapy-induced alterations in markers of haemostasis occur during chemotherapy. It is unclear how rapidly this occurs, whether this is upregulated in patients developing VTE and whether changes predict for VTE. Markers of haemostasis, functional clotting assays and vascular endothelial growth factor were measured before chemotherapy and at 24 h, 4 days, 8 days and 3 months following commencement of chemotherapy in early and advanced breast cancer patients and in age- and sex-matched controls. Duplex ultrasound imaging was performed after 1 month or if symptomatic. Of 123 patients, 9.8% developed VTE within 3 months. Activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer, fibrinogen, platelet count, VEGF and fibrinogen were increased in cancer. Fibrinogen, D-dimer, VEGF and tissue factor were increased, at baseline, in patients subsequently developing VTE. D-dimer of less than 500 ng ml−1 has a negative predictive value of 97%. Activated partial thromboplastin time, PT and thrombin–antithrombin showed significantly different trends, as early as within 24 h, in response to chemotherapy in patients subsequently developing VTE. Markers of coagulation and procoagulants are increased, before chemotherapy, in patients who subsequently develop VTE. A group of patients at minimal risk of VTE can be identified, allowing targeted thrombopropylaxis to the higher risk group.
Collapse
Affiliation(s)
- C C Kirwan
- Department of Surgery, South Manchester University Hospitals Trust, Wythenshawe Hospital, Southmoor Road, Manchester M23 9LT, UK
| | | | | | | | | |
Collapse
|
25
|
Abstract
Recent literature has highlighted the unique challenges facing professionals involved with the management of venous thromboembolism (VTE) in cancer patients. Although research favours the use of low molecular weight heparin (LMWH) rather than warfarin, no studies have been conducted exclusively in the palliative care population. Likewise, active treatment may not always be appropriate in the advanced cancer patient. This paper highlights the issues to be considered when facing a palliative care patient and suspected VTE. In particular, consideration must be given to the practicalities and acceptability of investigating suspected VTE, the dose and length of anticoagulation, and management of the patient nearing death. An understanding of the current evidence must be applied to the individual patient, taking into account their needs and wishes.
Collapse
|
26
|
Korte W. Cancer and thrombosis: an increasingly important association. Support Care Cancer 2008; 16:223-8. [PMID: 18197438 DOI: 10.1007/s00520-007-0376-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 12/06/2007] [Indexed: 01/20/2023]
Affiliation(s)
- Wolfgang Korte
- Institut für Klinische Chemie und Hämatologie, Kantonsspital, St Gallen, Switzerland.
| |
Collapse
|
27
|
Noble S. The challenges of managing cancer related venous thromboembolism in the palliative care setting. Postgrad Med J 2007; 83:671-4. [PMID: 17989265 DOI: 10.1136/pgmj.2007.061622] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cancer patients with venous thromboembolism (VTE) pose particular management challenges since they have an increased risk of bleeding and recurrent thrombosis compared to the non-cancer population. Also, as the disease progresses so do the hazards of anticoagulation, and patients in the palliative stages of their cancer could be viewed as a separate disease group with respect to diagnosis and management. As the focus from curative treatment moves towards symptom control, physicians face several challenges in providing the most appropriate care. Palliative care patients have rarely been included in research on VTE and the supporting evidence needs to be extrapolated cautiously. Quality of life aspects of VTE and their management may be a more appropriate outcome measure in this stage of disease than radiological end points. This paper looks at the challenges facing professionals in the management of VTE in the advanced cancer patient.
Collapse
Affiliation(s)
- S Noble
- Department of Palliative Medicine, Ward B6N, Royal Gwent Hospital, Cardiff Rd, Newport, NP20 2UB, UK.
| |
Collapse
|
28
|
Dolan S, Fitch M. The management of venous thromboembolism in cancer patients. ACTA ACUST UNITED AC 2007; 16:1308-12. [DOI: 10.12968/bjon.2007.16.21.27715] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Margaret Fitch
- President of International Society of Nurses in Cancer Care, Ontario, Canada
| |
Collapse
|
29
|
Affiliation(s)
- Charles W Francis
- Department of Hematology and Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA.
| |
Collapse
|
30
|
Balibrea J, Altimiras J, Larruzea I, Gómez-Outes A, Martínez-González J, Rocha E. Optimal dosing of bemiparin as prophylaxis against venous thromboembolism in surgery for cancer: An audit of practice. Int J Surg 2007; 5:114-9. [DOI: 10.1016/j.ijsu.2006.07.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Revised: 07/07/2006] [Accepted: 07/07/2006] [Indexed: 10/23/2022]
|
31
|
Bergqvist D, Caprini JA, Dotsenko O, Kakkar AK, Mishra RG, Wakefield TW. Venous Thromboembolism and Cancer. Curr Probl Surg 2007; 44:157-216. [PMID: 17437761 DOI: 10.1067/j.cpsurg.2007.01.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- David Bergqvist
- Uppsala University Hospital, Department of Surgical Sciences, Uppsala, Sweden
| | | | | | | | | | | |
Collapse
|
32
|
Abstract
Venous thromboembolic disease is a common cause of mortality and morbidity in patients with cancer. Patients have a 5-6-fold increase in the risk for a venous thromboembolism (VTE) compared with the general population, increasing to 6-7-fold for some cancers. Prophylaxis for VTE should be considered whenever additional risk factors intervene. About 10% of patients with an idiopathic VTE will harbour an occult cancer. Half of these can probably be detected after a focused history, examination, routine blood tests and a chest x ray. The remaining cases may be diagnosed with an intensive screening protocol. About 60% of patients diagnosed on screening will have early disease, but we do not know whether screening improves the outcome. Evidence suggests that patients with cancer and a VTE should be treated with low-molecular-weight heparin, and treatment continued until the cancer is cured.
Collapse
Affiliation(s)
- A Fennerty
- Harrogate District Foundation Trust, Lancaster Park Road, Harrogate HG2 7SX, UK.
| |
Collapse
|
33
|
Labarere J, Bosson JL, Sevestre MA, Delmas AS, Dupas S, Thenault MH, Legagneux A, Boge G, Terriat B, Pernod G. Brief report: graduated compression stocking thromboprophylaxis for elderly inpatients: a propensity analysis. J Gen Intern Med 2006; 21:1282-7. [PMID: 16995891 PMCID: PMC1924758 DOI: 10.1111/j.1525-1497.2006.00623.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Graduated compression stockings (GCS) are often used for deep vein thrombosis prophylaxis in nonsurgical patients, although evidence on their effectiveness is lacking in this setting. OBJECTIVE To determine whether prophylaxis with GCS is associated with a decrease in the rate of deep vein thrombosis in nonsurgical elderly patients. METHODS Using original data from 2 multicenter nonrandomized studies, we performed multivariable and propensity score analyses to determine whether prophylaxis with GCS reduced the rate of deep vein thrombosis among 1,310 postacute care patients 65 years or older. The primary outcome was proximal deep vein thrombosis detected by routine compression ultrasonography performed by registered vascular physicians. RESULTS Proximal deep vein thrombosis was found in 5.7% (21/371) of the GCS users and in 5.2% (49/939) of the GCS nonusers (odds ratio [OR], 1.09; 95% confidence interval [CI], 0.64-1.84). Although adjusting for propensity score eliminated all differences in baseline characteristics between users and nonusers, the OR for proximal deep vein thrombosis associated with GCS remained nonsignificant in propensity-stratified (adjusted OR, 1.11; 95% CI, 0.59-2.10) and propensity-matched (conditional OR, 0.92; 95% CI, 0.42-2.02) analysis. Similar figures were observed for distal and any deep vein thrombosis. The rates of deep vein thrombosis did not differ according to the length of stockings. CONCLUSIONS Prophylaxis with GCS is not associated with a lower rate of deep vein thrombosis in nonsurgical elderly patients in routine practice. Randomized studies are needed to assess the efficacy of GCS when properly used in this setting.
Collapse
Affiliation(s)
- Jose Labarere
- ThEMAS TIMC-IMAG UMR CNRS 5525 UJF, Grenoble, France.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
O'Connell CL, Boswell WD, Duddalwar V, Caton A, Mark LS, Vigen C, Liebman HA. Unsuspected pulmonary emboli in cancer patients: clinical correlates and relevance. J Clin Oncol 2006; 24:4928-32. [PMID: 17050877 DOI: 10.1200/jco.2006.06.5870] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Advances in computed tomography (CT) scanning have led to the detection of unsuspected pulmonary emboli (PE) on routine cancer staging scans. We hypothesized that these patients had signs or symptoms suggestive of PE that may have been overlooked by their health care providers. PATIENTS AND METHODS A retrospective chart review was performed on 59 patients found on routine cancer staging CT scans to have unsuspected PE. Information on patient demographics, malignancy characteristics, risk factors for venous thromboembolism (VTE), and symptoms was recorded. A retrospective case-control analysis was then performed using two age- and stage-matched control patients for each patient who had similar staging CT scans performed during the same period. RESULTS Fifty-two patients with unsuspected PE were identified. Forty-four percent had signs or symptoms commonly associated with PE; when fatigue was included, 75% were symptomatic. Ninety-two control patients were identified for 46 of the case patients. Patients with unsuspected PE were significantly more likely to have had a prior history of VTE (20% v 3%; P = .007). The patients with PE were significantly more likely than control patients to complain of fatigue (54% v 20%; P = .0002) and shortness of breath (22% v 8%; P = .02). There was no difference between the groups in administration of chemotherapy within 30 days, central venous catheter use, or erythropoietin therapy. CONCLUSION Seventy-five percent of patients found to have unsuspected PE on cancer staging CT scans were symptomatic. Fatigue and shortness of breath were significantly more common in patients with unsuspected PE than in control patients.
Collapse
Affiliation(s)
- Casey L O'Connell
- Division of Hematology, Department of Medicine, University of Southern California-Keck School of Medicine, Los Angeles, CA, USA.
| | | | | | | | | | | | | |
Collapse
|
35
|
Noble SIR, Finlay IG. Have palliative care teams' attitudes toward venous thromboembolism changed? A survey of thromboprophylaxis practice across British specialist palliative care units in the years 2000 and 2005. J Pain Symptom Manage 2006; 32:38-43. [PMID: 16824983 DOI: 10.1016/j.jpainsymman.2005.11.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2005] [Indexed: 11/22/2022]
Abstract
Palliative care patients are highly prothrombotic, yet there are no national guidelines for the prevention of venous thromboembolism (VTE). A survey was undertaken to explore thromboprophylaxis practice within British palliative care inpatient units and whether it changed over 5 years in keeping with emerging evidence. A descriptive semistructured telephone survey was conducted in April, 2000 and March, 2005 to explore current thromboprophylaxis practice. Seventy-four percent of units participated in 2000 and 91% participated in 2005. Units surveyed in 2000 revealed that 2% had thromboprophylaxis guidelines and up to 75% would stop ongoing low molecular weight heparin (LMWH) in a highly prothrombotic, good prognosis inpatient. The survey in 2005 indicated that thromboprophylaxis guidelines were being developed in 19% of units and only 18% of units surveyed would stop LMWH in a patient already receiving thromboprophylaxis (P < 0.001). There appears to be a growing awareness of the problem of VTE in British palliative care inpatients, as evidenced by changes in attitudes and practice. Reasons for this are discussed.
Collapse
|
36
|
Falanga A, Zacharski L. Deep vein thrombosis in cancer: the scale of the problem and approaches to management. Ann Oncol 2005; 16:696-701. [PMID: 15802275 DOI: 10.1093/annonc/mdi165] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patients with cancer have long been recognised to be at high risk of venous thromboembolism (VTE), although the condition remains under diagnosed and under treated in these patients. As a consequence, the morbidity and mortality due to deep venous thrombosis and pulmonary embolism remains unacceptably high in this group. Furthermore, the management of VTE in the presence of malignancy is complex, due both to the effects of the cancer itself and its treatments. Conventional long-term management of VTE involves the use of vitamin K antagonists (VKAs), such as warfarin, to reduce the risk of recurrence. However, this approach is associated with a range of practical difficulties including the need for regular laboratory monitoring, the potential for drug interactions, in addition to the risk of treatment resistance and bleeding in patients with cancer. Recent research indicates that the use of low molecular weight heparin (LMWH) therapy instead of VKAs may be beneficial in these patients. In particular, evidence from a large clinical trial of the LMWH dalteparin indicates that this agent offers an effective alternative to VKAs in the long-term management of VTE, that is free from the practical problems associated with the use of VKAs and without increasing the risk of bleeding.
Collapse
Affiliation(s)
- A Falanga
- Department of Hematology-Oncology, Ospedali Riuniti, Bergamo, Italy.
| | | |
Collapse
|
37
|
Abstract
PURPOSE OF THE REVIEW To assess the current evidence from recent clinical trials investigating antithrombotic agents for the prophylaxis and treatment of venous thromboembolism in cancer patients and for the effects of these agents on cancer progression. RECENT FINDINGS A growing body of evidence supports the preventive use of antithrombotic strategies in subgroups of cancer patients. Moreover, in the long-term management of deep venous thrombosis in cancer patients, low-molecular-weight heparin seems to represent a valid alternative to vitamin K antagonists. Finally, several studies have claimed a direct anticancer activity and a positive impact on prognosis of some antithrombotic agents, eg, aspirin and low-molecular-weight heparin. SUMMARY Although recent evidence suggests low-molecular-weight heparin as a possible option in the management and prevention of venous thromboembolism in cancer patients, more evidence from large randomized, prospective, controlled trials is needed to determine the exact the magnitude of the risk-benefit ratio associated with its use. The promising results on the effects of antithrombotic agents in the prognosis of cancer patients deserve further evaluation to estimate the potential and the feasibility of this approach.
Collapse
Affiliation(s)
- Marcello Di Nisio
- Department of Vascular Medicine and of Oncology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|