1
|
Bazarbashi S, El Zawahry HM, Owaidah T, AlBader MA, Warsi A, Marashi M, Dawoud E, Jaafar H, Sholkamy SM, Haddad F, Cohen AT. The Role of Direct Oral Anticoagulants in the Treatment of Cancer-Associated Venous Thromboembolism: Review by Middle East and North African Experts. J Blood Med 2024; 15:171-189. [PMID: 38686358 PMCID: PMC11057512 DOI: 10.2147/jbm.s411520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 03/01/2024] [Indexed: 05/02/2024] Open
Abstract
Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is based on careful balancing of the risks and benefits of available classes of treatment: vitamin K antagonists, low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs). Results from randomized controlled trials have shown the consistent efficacy of DOACs versus LMWH in the treatment of cancer-associated venous thromboembolism (VTE). However, increased major gastrointestinal bleeding was observed for edoxaban and rivaroxaban, but not apixaban, compared with LMWH dalteparin. Most guidelines recommend DOACs for the treatment of cancer-associated VTE in patients without gastrointestinal or genitourinary cancer, and with considerations for renal impairment and drug-drug interactions. These updates represent a major paradigm shift for clinicians in the Middle East and North Africa. The decision to prescribe a DOAC for a patient with cancer is not always straightforward, particularly in challenging subgroups of patients with an increased risk of bleeding. In patients with gastrointestinal malignancies who are at high risk of major gastrointestinal bleeds, apixaban may be the preferred DOAC; however, caution should be exercised if patients have upper or unresected lower gastrointestinal tumors. In patients with gastrointestinal malignancies and upper or unresected lower gastrointestinal tumors, LMWH may be preferred. Vitamin K antagonists should be used only when DOACs and LMWH are unavailable or unsuitable. In this review, we discuss the overall evidence for DOACs in the treatment of cancer-associated VTE and provide treatment suggestions for challenging subgroups of patients with cancer associated VTE.
Collapse
Affiliation(s)
- Shouki Bazarbashi
- Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | - Heba Mohamed El Zawahry
- Department of Medical Oncology, The National Cancer Institute, Cairo University, Cairo, Egypt
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Ashraf Warsi
- Department of Adult Hematology, Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs–Western Region, Jeddah, Saudi Arabia
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs–Western Region, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs-Western Region, Jeddah, Saudi Arabia
| | - Mahmoud Marashi
- Hematology Department, Dubai Hospital, Dubai, United Arab Emirates
- Department of Hematology, Mediclinic City Hospital, Dubai, United Arab Emirates
| | - Emad Dawoud
- Department of Oncology, Tawam Hospital, Al Ain, United Arab Emirates
| | - Hassan Jaafar
- Department of Oncology, Sheikh Khalifa Specialty Hospital, Ras Al-Khaimah, United Arab Emirates
| | | | - Fady Haddad
- Vascular and Endovascular Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, King’s College London, London, UK
| |
Collapse
|
2
|
Bernardi E, Camporese G, Bortoluzzi C, Noventa F, Ceccato D, Tonello C, Vohong S, Campello E, Simion C, Imbalzano E, Di Micco P, Callegari E, Simioni P. Safety and Efficacy of Rivaroxaban as Extended-Phase Anticoagulation in Patients with Cancer and Venous Thromboembolism: A Preliminary Data Analysis from the Mac Project. Life (Basel) 2022; 12:1725. [PMID: 36362880 PMCID: PMC9699076 DOI: 10.3390/life12111725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/20/2022] [Accepted: 10/25/2022] [Indexed: 10/29/2023] Open
Abstract
Extended-phase anticoagulation with direct oral Xa inhibitors (OAXI) is suggested in patients with cancer-associated venous thromboembolism (CAT). We report on patients enrolled in the MAC (Monitoring AntiCoagulants) Project, given rivaroxaban as extended-phase anticoagulation after CAT. The primary efficacy outcome was the incidence of symptomatic recurrent VTE; the primary safety outcomes were incidence of major and non-major clinically relevant bleeding, adverse events, and all-cause mortality. The mean patients' follow-up was 19 months (SD 16); 64/604 (11%) had CAT. Recurrent VTE occurred in 9.3% and in 8.1% of patients with and without CAT (OR 1.2, 95% CI 0.5 to 2.9; p = 0.6). Major bleeding occurred in 4.7% and in 2.6%, respectively (OR = 1.8, 95% CI 0.5 to 6.6, p = 0.4), and non-major clinically-relevant bleeding in 4.7% and in 4.1% (OR = 1.2, 95% CI 0.3 to 3.9, p = 0.7). The relative figures for fatal haemorrhage and all-cause death were 1.6% versus 0%, and 1.6% versus 0.4%. Rivaroxaban appears to be effective and safe as extended-phase anticoagulation in patients with CAT. The mean treatment period was 3-times the standard 6-month course.
Collapse
Affiliation(s)
- Enrico Bernardi
- Emergency Department, Cà Foncello Hospital, Azienda Ulss 2 Marca Trevigiana, Piazzale Ospedale 1, 31100 Treviso, Italy
| | - Giuseppe Camporese
- UO Internal Medicine, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Cristiano Bortoluzzi
- Internal Medicine, San Giovanni e Paolo Hospital, Azienda Ulss 3 Serenissima, Via Don Tosatto 147, 30174 Mestre, Italy
| | - Franco Noventa
- QUOVADIS No-Profit Association, Studio Coppola, Galleria Ezzelino 5, 35139 Padova, Italy
| | - Davide Ceccato
- Unit of Angiology, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Chiara Tonello
- Unit of Angiology, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Stefania Vohong
- Internal Medicine, San Giovanni e Paolo Hospital, Azienda Ulss 3 Serenissima, Via Don Tosatto 147, 30174 Mestre, Italy
| | - Elena Campello
- UO Thromboembolic Disease, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Chiara Simion
- UO Thromboembolic Disease, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, Polyclinic Hospital University of Messina, Via Consolare Valeria 1, 98124 Messina, Italy
| | - Pierpaolo Di Micco
- Internal Medicine, “A. Rizzoli” Polyclinic Hospital, Azienda NA2 Nord, Via Fundera 2, 80076 Lacco Ameno, Italy
| | - Elena Callegari
- UO Internal Medicine 2, Cà Foncello Hospital, Azienda Ulss 2 Marca Trevigiana, Piazzale Ospedale 1, 31100 Treviso, Italy
| | - Paolo Simioni
- UO Thromboembolic Disease, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy
| |
Collapse
|
3
|
Chiasakul T, Zwicker JI. The impact of warfarin on overall survival in cancer patients. Thromb Res 2022; 213:S113-S119. [PMID: 35769870 PMCID: PMC9236137 DOI: 10.1016/j.thromres.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. Warfarin has largely been replaced by low-molecular-weight heparin (LMWHs) and direct oral anticoagulants (DOACs) as the standard of care in cancer-associated VTE. The survival benefit of these anticoagulants over warfarin in the cancer population was not demonstrated in clinical trials, possibly due to insufficient sample size and limited follow-up duration. There are emerging population-based studies suggesting that warfarin may be associated with improved overall survival in cancers and may have a protective effect against certain types of cancers. Warfarin may exert its anti-neoplastic properties through both coagulation pathway -dependent and -independent mechanisms, the latter of which are mediated by inhibition of the Gas6-AXL signaling pathway. Further research should emphasize on identifying clinical and laboratory predictors of beneficial effects of warfarin. In this review article, we summarize and update the current evidence regarding the potential impact of warfarin on the overall survival of cancer patients and incidence of cancer, as well as review the potential mechanism of such effect and future perspectives.
Collapse
|
4
|
Fioretti AM, Leopizzi T, Puzzovivo A, Giotta F, Lorusso V, Luzzi G, Oliva S. Cancer-Associated Thrombosis: Not All Low-Molecular-Weight Heparins Are the Same, Focus on Tinzaparin, A Narrative Review. Int J Clin Pract 2022; 2022:2582923. [PMID: 35936060 PMCID: PMC9325617 DOI: 10.1155/2022/2582923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 12/21/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is the second main cause of cancer death with high related mortality and morbidity, leading to anticancer agent delays and interruptions. The recommended therapy, low-molecular-weight heparin (LMWH), however, is burdensome for patients and costly for society, as treatment should last until cancer is no longer active, even indefinitely. Tinzaparin is a manageable, efficient, safe, and cost-effective option. Compared to the other LMWHs, advantages are single-daily dose and safety in the elderly and those with renal impairment (RI). The purpose of this review is to critically discuss recent data on its efficacy and safety in CAT.
Collapse
Affiliation(s)
- Agnese Maria Fioretti
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Tiziana Leopizzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Agata Puzzovivo
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Francesco Giotta
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Vito Lorusso
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Giovanni Luzzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Stefano Oliva
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| |
Collapse
|
5
|
Wang TF. Survival in patients with cancer-associated thrombosis in relation to anticoagulants: Re-vitalization of warfarin? J Thromb Haemost 2021; 19:2677-2679. [PMID: 34668299 DOI: 10.1111/jth.15527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
6
|
Comparing low-molecular-weight heparin dosing for treatment of venous thromboembolism in patients with obesity (RIETE registry). Blood Adv 2021; 4:2460-2467. [PMID: 32497167 DOI: 10.1182/bloodadvances.2019001373] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 04/25/2020] [Indexed: 01/13/2023] Open
Abstract
Because of the absence of comparative evidence, current guidelines and product monographs diverge in the dosing of low-molecular-weight heparin (LMWH) for obese patients with venous thromboembolism (VTE). We used the RIETE registry to compare the primary composite outcomes (VTE recurrence, major bleeding, or death) in patients with VTE who weighed >100 kg during LMWH therapy with capped doses of LMWH (18 000 IU/d) vs uncapped doses (>18 000 IU/d). Multivariable logistic regression analysis was used to account for possible confounders. A total of 2846 patients who weighed >100 kg were included: 454 (16%) received capped doses of LMWH, and the remaining 2392 received uncapped doses. Mean (standard deviation) LMWH treatment duration was 14.8 (20.6) and 14.3 (32.3) days, respectively. Thirty-one patients (1.9%) had VTE recurrences, 38 (1.3%) had bleeding episodes, 65 (2.3%) died, and 122 (4.3%) had at least 1 of the composite outcomes. Unadjusted outcome rates revealed that capped dosing was associated with a decrease in the composite outcome (rate ratio, 0.22; 95% confidence interval [CI], 0.04-0.75). Multivariable analysis confirmed that patients who received capped doses had significantly lower rates of the composite outcome (odds ratio, 0.16; 95% CI, 0.04-0.68) while receiving LMWH. These retrospective observational data suggest that capped dosing of LMWH is an acceptable alternative to uncapped dosing based on body weight, given the significantly lower composite event rate of VTE recurrence, major bleeding, and all-cause death.
Collapse
|
7
|
Zhang LP, Ren H, Du YX, Zheng XH, Zhang ZM, Wang CF. Combination of preoperative fibrinogen and D-dimer as a prognostic indicator in pancreatic ductal adenocarcinoma patients undergoing R0 resection. World J Gastrointest Surg 2021; 13:279-302. [PMID: 33796216 PMCID: PMC7993003 DOI: 10.4240/wjgs.v13.i3.279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/01/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Patients with malignant tumors frequently exhibit hyperactivation of the coagulation system and secondary increased fibrinolytic activity. Fibrinogen and D-dimer are common indicators that are crucial in the coagulation/fibrinolysis system. Both indicators have been verified to have predictive value in the overall survival (OS) of many patients with solid malignancies.
AIM To explore the prognostic significance of fibrinogen combined with D-dimer in pancreatic ductal adenocarcinoma (PDAC) patients undergoing radical R0 resection.
METHODS We retrospectively analyzed the clinical data of 282 patients with PDAC undergoing radical R0 resection in the Cancer Hospital, Chinese Academy of Medical Sciences, between January 2010 and December 2019. The surv_cutpoint function of R language was used to determine the optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration. Enrolled patients were further divided into the any-high group (high preoperative fibrinogen concentration and/or high preoperative D-dimer concentration) and the low-low group (low preoperative fibrinogen and D-dimer concentrations) according to the optimal cutoff values.
RESULTS The optimal cutoff values of the preoperative fibrinogen concentration and preoperative D-dimer concentration were 3.31 g/L and 0.53 mg/L, respectively. Furthermore, multivariate Cox regression analysis showed that the preoperative fibrinogen concentration (HR: 1.603, 95%CI: 1.201-2.140, P = 0.001) and preoperative D-dimer concentration (HR: 1.355, 95%CI: 1.019-1.801, P = 0.036) exhibited obvious correlations with the OS of PDAC patients undergoing radical R0 resection. A prognostic analysis was further performed based on the subgroup results by using fibrinogen combined with D-dimer. The median OS duration of the low-low group (31.17 mo) was significantly longer than that of the any-high group (15.43 mo). Additionally, multivariate Cox regression analysis revealed that the degree of differentiation (P < 0.001), lymph node metastasis (HR: 0.663, 95%CI: 0.497-0.883, P = 0.005), preoperative CA19-9 level (HR: 1.699, 95%CI: 1.258-2.293, P = 0.001), adjuvant therapy (HR: 1.582, 95%CI: 1.202-2.081, P = 0.001) and preoperative combined grouping (HR: 2.397, 95%CI: 1.723-3.335, P < 0.001) were independent predictors of OS in PDAC patients undergoing radical R0 resection.
CONCLUSION Preoperative fibrinogen combined with D-dimer plays a predictive role in OS, and low preoperative fibrinogen and D-dimer concentrations can indicate prolonged OS in PDAC patients undergoing radical R0 resection.
Collapse
Affiliation(s)
- Li-Peng Zhang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hu Ren
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong-Xing Du
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao-Hao Zheng
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Zong-Ming Zhang
- Department of General Surgery, Beijing Electric Power Hospital, State Grid Corporation of China, Capital Medical University, Beijing 100073, China
| | - Cheng-Feng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
- State Key Lab of Molecular Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| |
Collapse
|
8
|
Dhami SPS, Patmore S, O'Sullivan JM. Advances in the Management of Cancer-Associated Thrombosis. Semin Thromb Hemost 2021; 47:139-149. [PMID: 33636745 DOI: 10.1055/s-0041-1722863] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The association between cancer and venous thromboembolism (VTE) has been established for more than 150 years. Nevertheless, cancer-associated thrombosis still remains a major clinical challenge and is associated with significant morbidity and mortality for patients with cancer. The clinical presentation of cancer-associated thrombosis can be distinct from that of a patient without an underlying malignancy. Moreover, specific cancer types, including pancreatic cancer and hematological malignancies, as well as advanced stage disease can confer a significant thrombotic risk. This risk is further augmented by specific anticancer treatment modalities. The pathophysiology of cancer-associated thrombosis is complex and multifactorial. However, understanding the biological mechanisms underpinning VTE risk may provide insight into novel targeted prophylaxis in cancer patients. Over the last decade, low-molecular-weight heparin has been the preferred anticoagulant agent for patients with cancer-associated thrombosis due to improved efficacy compared with vitamin K antagonists. However, the advent of direct oral anticoagulants (DOACs) has added to the repertoire of ammunition now at the disposal of clinicians to aid in the management of cancer-associated thrombosis. Several randomized controlled trials have now been published, demonstrating DOAC as a noninferior alternative for both the treatment and prevention of cancer-associated thrombosis. Notwithstanding this, limitations for their widespread use remain, with the potential for increased bleeding risk, drug interactions, and poor DOAC metabolism. This review discusses the evidence base for the incidence and risk factors associated with VTE in cancer, development, and refinement of risk prediction models and novel advances in the therapeutic management of cancer-associated thrombosis.
Collapse
Affiliation(s)
- Sukhraj Pal Singh Dhami
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Sean Patmore
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Jamie M O'Sullivan
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| |
Collapse
|
9
|
Couturaud F, Bertoletti L, Pastre J, Roy PM, Le Mao R, Gagnadoux F, Paleiron N, Schmidt J, Sanchez O, De Magalhaes E, Kamara M, Hoffmann C, Bressollette L, Nonent M, Tromeur C, Salaun PY, Barillot S, Gatineau F, Mismetti P, Girard P, Lacut K, Lemarié CA, Meyer G, Leroyer C. Prevalence of Pulmonary Embolism Among Patients With COPD Hospitalized With Acutely Worsening Respiratory Symptoms. JAMA 2021; 325:59-68. [PMID: 33399840 PMCID: PMC7786241 DOI: 10.1001/jama.2020.23567] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE The prevalence of pulmonary embolism in patients with chronic obstructive pulmonary disease (COPD) and acutely worsening respiratory symptoms remains uncertain. OBJECTIVE To determine the prevalence of pulmonary embolism in patients with COPD admitted to the hospital for acutely worsening respiratory symptoms. DESIGN, SETTING, AND PARTICIPANTS Multicenter cross-sectional study with prospective follow-up conducted in 7 French hospitals. A predefined pulmonary embolism diagnostic algorithm based on Geneva score, D-dimer levels, and spiral computed tomographic pulmonary angiography plus leg compression ultrasound was applied within 48 hours of admission; all patients had 3-month follow-up. Patients were recruited from January 2014 to May 2017 and the final date of follow-up was August 22, 2017. EXPOSURES Acutely worsening respiratory symptoms in patients with COPD. MAIN OUTCOMES AND MEASURES The primary outcome was pulmonary embolism diagnosed within 48 hours of admission. Key secondary outcome was pulmonary embolism during a 3-month follow-up among patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulant treatment. Other outcomes were venous thromboembolism (pulmonary embolism and/or deep vein thrombosis) at admission and during follow-up, and 3-month mortality, whether venous thromboembolism was clinically suspected or not. RESULTS Among 740 included patients (mean age, 68.2 years [SD, 10.9 years]; 274 women [37.0%]), pulmonary embolism was confirmed within 48 hours of admission in 44 patients (5.9%; 95% CI, 4.5%-7.9%). Among the 670 patients deemed not to have venous thromboembolism at admission and who did not receive anticoagulation, pulmonary embolism occurred in 5 patients (0.7%; 95% CI, 0.3%-1.7%) during follow-up, including 3 deaths related to pulmonary embolism. The overall 3-month mortality rate was 6.8% (50 of 740; 95% CI, 5.2%-8.8%). The proportion of patients who died during follow-up was higher among those with venous thromboembolism at admission than the proportion of those without it at admission (14 [25.9%] of 54 patients vs 36 [5.2%] of 686; risk difference, 20.7%, 95% CI, 10.7%-33.8%; P < .001). The prevalence of venous thromboembolism was 11.7% (95% CI, 8.6%-15.9%) among patients in whom pulmonary embolism was suspected (n = 299) and was 4.3% (95% CI, 2.8%-6.6%) among those in whom pulmonary embolism was not suspected (n = 441). CONCLUSIONS AND RELEVANCE Among patients with chronic obstructive pulmonary disease admitted to the hospital with an acute worsening of respiratory symptoms, pulmonary embolism was detected in 5.9% of patients using a predefined diagnostic algorithm. Further research is needed to understand the possible role of systematic screening for pulmonary embolism in this patient population.
Collapse
Affiliation(s)
- Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Laurent Bertoletti
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Jean Pastre
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 1140, Université de Paris; Paris, France
| | - Pierre-Marie Roy
- FCRIN INNOVTE, France
- Service des urgences, Centre Hospitalo-Universitaire d’Angers, France
- Institut MITOVASC, EA 3860, Université d'Angers, Angers, France
| | - Raphael Le Mao
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Frédéric Gagnadoux
- Département de Pneumologie, Centre Hospitalo-Universitaire d’Angers, France
- INSERM UMR1063, Université d’Angers, Angers, France
| | - Nicolas Paleiron
- Service de pneumologie-allergologie-cancérologie thoracique, HIA Sainte Anne, Toulon, France
| | - Jeannot Schmidt
- FCRIN INNOVTE, France
- Service des urgences, Centre Hospitalo-Universitaire de Clermont-Ferrand, France
- UMR 6024 UCA-CNRS, Université de Clermont-Ferrand, Clermont-Ferrand, France
| | - Olivier Sanchez
- FCRIN INNOVTE, France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 1140, Université de Paris; Paris, France
| | - Elodie De Magalhaes
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Mariam Kamara
- Service des urgences, Centre Hospitalier de Quimper, Quimper, France
| | - Clément Hoffmann
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- Service d’Echo-doppler Vasculaire, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Luc Bressollette
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
- Service d’Echo-doppler Vasculaire, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Michel Nonent
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- Service de radiologie, Centre Hospitalo-Universitaire de Brest, Brest, France
| | - Cécile Tromeur
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Pierre-Yves Salaun
- FCRIN INNOVTE, France
- Service de Médecine Nucléaire, Centre Hospitalo-Universitaire de Brest, France
- EA 3878, Université de Bretagne Occidentale, Brest, France
| | - Sophie Barillot
- INSERM CIC 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Florence Gatineau
- INSERM CIC 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Patrick Mismetti
- FCRIN INNOVTE, France
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
- INSERM CIC 1408, INSERM UMR 1059, Université Jean Monnet, Saint-Etienne, France
| | - Philippe Girard
- FCRIN INNOVTE, France
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Karine Lacut
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| | - Catherine A. Lemarié
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
- INSERM 1078, Université de Bretagne Occidentale, Brest, France
| | - Guy Meyer
- FCRIN INNOVTE, France
- Service de Pneumologie et de Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- INSERM UMR S 970, Université de Paris, Paris, France
| | - Christophe Leroyer
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Brest, France
- EA 3878, INSERM CIC 1412, Université de Bretagne Occidentale, Brest, France
- FCRIN INNOVTE, France
| |
Collapse
|
10
|
Surgical Stress Promotes Tumor Progression: A Focus on the Impact of the Immune Response. J Clin Med 2020; 9:jcm9124096. [PMID: 33353113 PMCID: PMC7766515 DOI: 10.3390/jcm9124096] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/16/2020] [Accepted: 12/16/2020] [Indexed: 12/14/2022] Open
Abstract
Despite advances in systemic therapies, surgery is crucial for the management of solid malignancy. There is increasing evidence suggesting that the body's response to surgical stress resulting from tumor resection has direct effects on tumor cells or can alter the tumor microenvironment. Surgery can lead to the activation of early and key components of the innate and adaptative immune systems. Platelet activation and the subsequent pro-coagulation state can accelerate the growth of micrometastases. Neutrophil extracellular traps (NETs), an extracellular network of DNA released by neutrophils in response to inflammation, promote the adhesion of circulating tumor cells and the growth of existing micrometastatic disease. In addition, the immune response following cancer surgery can modulate the tumor immune microenvironment by promoting an immunosuppressive state leading to impaired recruitment of natural killer (NK) cells and regulatory T cells (Tregs). In this review, we will summarize the current understanding of mechanisms of tumor progression secondary to surgical stress. Furthermore, we will describe emerging and novel peri-operative solutions to decrease pro-tumorigenic effects from surgery.
Collapse
|
11
|
Beurskens DMH, Huckriede JP, Schrijver R, Hemker HC, Reutelingsperger CP, Nicolaes GAF. The Anticoagulant and Nonanticoagulant Properties of Heparin. Thromb Haemost 2020; 120:1371-1383. [PMID: 32820487 DOI: 10.1055/s-0040-1715460] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Heparins represent one of the most frequently used pharmacotherapeutics. Discovered around 1926, routine clinical anticoagulant use of heparin was initiated only after the publication of several seminal papers in the early 1970s by the group of Kakkar. It was shown that heparin prevents venous thromboembolism and mortality from pulmonary embolism in patients after surgery. With the subsequent development of low-molecular-weight heparins and synthetic heparin derivatives, a family of related drugs was created that continues to prove its clinical value in thromboprophylaxis and in prevention of clotting in extracorporeal devices. Fundamental and applied research has revealed a complex pharmacodynamic profile of heparins that goes beyond its anticoagulant use. Recognition of the complex multifaceted beneficial effects of heparin underscores its therapeutic potential in various clinical situations. In this review we focus on the anticoagulant and nonanticoagulant activities of heparin and, where possible, discuss the underlying molecular mechanisms that explain the diversity of heparin's biological actions.
Collapse
Affiliation(s)
- Danielle M H Beurskens
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Joram P Huckriede
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Roy Schrijver
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - H Coenraad Hemker
- Synapse BV, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Chris P Reutelingsperger
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Gerry A F Nicolaes
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| |
Collapse
|
12
|
Laporte S, Chapelle C, Trone JC, Bertoletti L, Girard P, Meyer G, Safieddine M, Cucherat M, Ollier E, Mismetti P. Early detection of the existence or absence of the treatment effect: A cumulative meta-analysis. J Clin Epidemiol 2020; 124:24-33. [DOI: 10.1016/j.jclinepi.2020.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 03/25/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023]
|
13
|
Atallah J, Khachfe HH, Berro J, Assi HI. The use of heparin and heparin-like molecules in cancer treatment: a review. Cancer Treat Res Commun 2020; 24:100192. [PMID: 32673846 DOI: 10.1016/j.ctarc.2020.100192] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Heparin and heparin-like molecules have shown some promise in the treatment of several cancers. These molecules have roles in angiogenesis, cell proliferation, immune system modulation, cell migration, and cellular invasion. The pathways and mechanisms used by these molecules to inhibit the proliferation of cancer cells aid in understanding the utilization of these molecules in potential treatments. Our aim is to review the use of heparin and heparin-like molecules in cancer treatment, explore the results, and discuss their potential downfalls. METHODS Publications on heparin and heparin-like molecules and compounds were collected from the PubMed and EMBASE databases. Boolean operators and MeSH terms related to heparin, heparin-like molecules, and cancer were used to conduct this search. The articles were reviewed by the authors. RESULTS Several heparin mimetics are showing promise in cancer treatment. Various studies using mimetics alone or in combination with chemotherapy have been conducted and have yielded mixed results. They work on multiple target molecules, mostly receptors such as fibroblast growth factor and endothelial growth factor. The main types of cancers targeted by these drugs are multiple myeloma, pancreatic cancer, hepatocellular carcinoma (HCC), and other solid tumors. CONCLUSION Although limited clinical evidence of efficacy and potential pitfalls are present, heparin and heparin-like molecules have shown potential in the management of cancer patients. Additional research is required to fully understand the biological mechanisms utilized by these molecules in cancer treatment.
Collapse
Affiliation(s)
- Johnny Atallah
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | - Hussein H Khachfe
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
| | - Juliett Berro
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hazem I Assi
- Department of Internal Medicine, Naef K. Basile Cancer Institute, American University of Beirut Medical Center, Beirut, Lebanon.
| |
Collapse
|
14
|
Cantrell R, Palumbo JS. The thrombin–inflammation axis in cancer progression. Thromb Res 2020; 191 Suppl 1:S117-S122. [DOI: 10.1016/s0049-3848(20)30408-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/18/2019] [Accepted: 11/21/2019] [Indexed: 02/07/2023]
|
15
|
Heparanase in Cancer Metastasis – Heparin as a Potential Inhibitor of Cell Adhesion Molecules. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1221:309-329. [DOI: 10.1007/978-3-030-34521-1_11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
16
|
Gelosa P, Castiglioni L, Camera M, Sironi L. Repurposing of drugs approved for cardiovascular diseases: Opportunity or mirage? Biochem Pharmacol 2020; 177:113895. [PMID: 32145263 DOI: 10.1016/j.bcp.2020.113895] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 02/27/2020] [Indexed: 02/08/2023]
Abstract
Drug repurposing is a promising way in drug discovery to identify new therapeutic uses -different from the original medical indication- for existing drugs. It has many advantages over traditional approaches to de novo drug discovery, since it can significantly reduce healthcare costs and development timeline. In this review, we discuss the possible repurposing of drugs approved for cardiovascular diseases, such as β-blockers, angiotensin converting enzyme inhibitors (ACE-Is), angiotensin II receptor blockers (ARBs), statins, aspirin, cardiac glycosides and low-molecular-weight heparins (LMWHs). Indeed, numerous experimental and epidemiological studies have reported promising anti-cancer activities for these drugs. It is worth mentioning, however, that the results of these studies are often controversial and very few data were obtained by controlled prospective clinical trials. Therefore, no final conclusion has yet been reached in this area and no final recommendations can be made. Moreover, β-blockers, ARBs and statins showed promising results in randomised controlled trials (RCTs) where pathological conditions other than cancer were considered. The results obtained have led or may lead to new indications for these drugs. For each drug or class of drugs, the potential molecular mechanisms of action justifying repurposing, results obtained in vitro and in animal models and data from epidemiological and randomized studies are described.
Collapse
Affiliation(s)
- Paolo Gelosa
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Laura Castiglioni
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy
| | - Marina Camera
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy; Centro Cardiologico Monzino IRCCS, Milan, Italy.
| | - Luigi Sironi
- Department of Pharmaceutical Sciences, University of Milan, Milan, Italy; Centro Cardiologico Monzino IRCCS, Milan, Italy
| |
Collapse
|
17
|
Shiba PTG, Sharma V. The impact of venous thromboembolism on the outcomes of patients with cervical carcinoma, a retrospective analysis at a single institution. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2019. [DOI: 10.1080/20742835.2019.1701257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Preyesh T Goven Shiba
- Department of Radiation Oncology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Vinay Sharma
- Department of Radiation Oncology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| |
Collapse
|
18
|
Francisco BJ, Palumbo JS. New insights into cancer's exploitation of platelets. J Thromb Haemost 2019; 17:2000-2003. [PMID: 31797541 DOI: 10.1111/jth.14624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 08/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Brenton J Francisco
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, The University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph S Palumbo
- Department of Pediatrics, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital, The University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
19
|
Wysokinski WE, Houghton DE, Casanegra AI, Vlazny DT, Bott‐Kitslaar DM, Froehling DA, Hodge DO, Peterson LG, Mcbane RD. Comparison of apixaban to rivaroxaban and enoxaparin in acute cancer-associated venous thromboembolism. Am J Hematol 2019; 94:1185-1192. [PMID: 31378995 DOI: 10.1002/ajh.25604] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 12/21/2022]
Abstract
To provide direct comparison between apixaban and rivaroxaban in patients with acute cancer-associated venous thromboembolism (Ca-VTE), consecutive patients treated with apixaban, rivaroxaban, or enoxaparin at Mayo Thrombophilia Clinic (March 1, 2013 to January 31, 2018)) were followed prospectively. The primary effectiveness outcome was venous thromboembolism (VTE) recurrence, and the secondary was mortality. The primary safety outcome was major bleeding, the secondary clinically relevant safety outcome was non-major bleeding (CRNMB), and the third a composite of major and CRNMB. There were 750 patients treated for acute Ca-VTE with apixaban (n = 224), rivaroxaban (n = 163), and enoxaparin (n = 363) within 14 days of diagnosis and for at least 3 months, or until study event. Recurrent VTE was diagnosed in 11 receiving apixaban, 7 receiving rivaroxaban (apixaban vs rivaroxaban hazard ratio (HR) 1.31, 95% confidence interval (95% CI) 0.51-3.36) and 17 in the enoxaparin receiving group (apixaban vs enoxaparin HR 1.14, 95% CI: 0.54, 2.42 and rivaroxaban vs enoxaparin HR 0.85, 95% Cl: 0.36, 2.06). There were 82 deaths in apixaban, 74 rivaroxaban (apixaban vs rivaroxaban HR 1.67, 95% Cl: 1.20, 2.33) and 171 in enoxaparin group (rivaroxaban vs enoxaparin HR 0.73, 95% Cl: 0.56, 0.96). Major bleeding occurred in 11 apixaban, 12 rivaroxaban (apixaban vs rivaroxaban HR 0.73, 95% Cl: 0.32, 1.66) and 21 enoxaparin group (apixaban vs enoxaparin HR 0.89, 95% Cl: 0.43, 1.84 and rivaroxaban vs enoxaparin HR 1.23, 95% Cl: 0.61, 2.50). The CRNMB rate was higher in rivaroxaban compared to apixaban (P = .03) and LMWH (P = .01) groups. Recurrence of VTE and major bleeding were similar in apixaban, rivaroxaban, and enoxaparin groups. Rivaroxaban was associated with higher CRNMB but lower mortality compared to apixaban and enoxaparin.
Collapse
Affiliation(s)
| | - Damon E. Houghton
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Ana I. Casanegra
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Danielle T. Vlazny
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | | | - David A. Froehling
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - David O. Hodge
- Department of Health Sciences ResearchMayo Clinic Jacksonville Florida
| | - Lisa G. Peterson
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| | - Robert D. Mcbane
- Vascular Medicine DivisionGonda Vascular Center, Mayo Clinic Rochester Minnesota
| |
Collapse
|
20
|
Okura Y, Ozaki K, Tanaka H, Takenouchi T, Sato N, Minamino T. The Impending Epidemic of Cardiovascular Diseases in Patients With Cancer in Japan. Circ J 2019; 83:2191-2202. [PMID: 31534064 DOI: 10.1253/circj.cj-19-0426] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Onco-cardiology, a new academic field, aims to improve the quality of life and prognosis of cancer patients and survivors with cardiovascular diseases (CVD). With the aging of the population, an epidemic of cancer with CVD is emerging in developed countries. Cancer and CVD share risk factors, pathophysiology, treatments, and preventive and rehabilitative measures. A multidisciplinary team-based approach is needed to support cancer treatment to maximize its effectiveness and minimize its cardiotoxic potential. Basic and clinical onco-cardiology are already being practiced harmoniously. However, systematization in academia and clinical practice and accumulation of evidence have just started. In this review, we present the epidemiology, common risk factors between cancer and CVD, future epidemic of CVD in patients with cancer, and the necessity for an onco-cardiological approach to managing the burden of CVD in cancer patients and survivors.
Collapse
Affiliation(s)
- Yuji Okura
- Department of Onco-cardiology, Niigata Cancer Center Hospital
| | - Kazuyuki Ozaki
- Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Hiroshi Tanaka
- Department of Respiratory Medicine, Niigata Cancer Center Hospital
| | | | - Nobuaki Sato
- Department of Breast Oncology, Niigata Cancer Center Hospital
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Niigata University Graduate School of Medical and Dental Sciences
| |
Collapse
|
21
|
Beyond the boundaries of cardiology: Still untapped anticancer properties of the cardiovascular system-related drugs. Pharmacol Res 2019; 147:104326. [DOI: 10.1016/j.phrs.2019.104326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 02/07/2023]
|
22
|
Randomised phase 3 study of adjuvant chemotherapy with or without nadroparin in patients with completely resected non-small-cell lung cancer: the NVALT-8 study. Br J Cancer 2019; 121:372-377. [PMID: 31337877 PMCID: PMC6738047 DOI: 10.1038/s41416-019-0533-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 06/13/2019] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background Retrospective studies suggest that low molecular weight heparin may delay the development of metastasis in patients with resected NSCLC. Methods Multicentre phase 3 study with patients with completely resected NSCLC who were randomised after surgery to receive chemotherapy with or without nadroparin. The main exclusion criteria were R1/2 and wedge/segmental resection. FDG-PET was required. The primary endpoint was recurrence-free survival (RFS). Results Among 235 registered patients, 202 were randomised (nadroparin: n = 100; control n = 102). Slow accrual enabled a decrease in the number of patients needed from 600 to 202, providing 80% power to compare RFS with 94 events (α = 0.05; 2-sided). There were no differences in bleeding events between the two groups. The median RFS was 65.2 months (95% CI, 36—NA) in the nadroparin arm and 37.7 months (95% CI, 22.7—NA) in the control arm (HR 0.77 (95% CI, 0.53–1.13, P = 0.19). FDG-PET SUVmax ≥10 predicted a greater likelihood of recurrence in the first year (HR 0.48, 95% CI 0.22–0.9, P = 0.05). Conclusions Adjuvant nadroparin did not improve RFS in patients with resected NSCLC. In this study, a high SUVmax predicted a greater likelihood of recurrence in the first year. Clinical trial registration Netherlands Trial registry: NTR1250/1217.
Collapse
|
23
|
Song AB, Rosovsky RP, Connors JM, Al-Samkari H. Direct oral anticoagulants for treatment and prevention of venous thromboembolism in cancer patients. Vasc Health Risk Manag 2019; 15:175-186. [PMID: 31417269 PMCID: PMC6593743 DOI: 10.2147/vhrm.s132556] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality in patients with cancer. Compared with the general population, cancer patients with VTE have higher rates of both VTE recurrence and bleeding. While low molecular weight heparin (LMWH) has been the mainstay of treatment for cancer-associated VTE for over a decade, direct oral anticoagulants (DOACs) have recently emerged as a new therapeutic option due to their ease of administration and because they do not require laboratory monitoring. Several large randomized clinical trials have been performed or are ongoing at the time of writing, comparing DOACs with LMWH in this population. Three of these trials have thus far been published and suggest that DOACs are a reasonable alternative to LMWH for management of cancer-associated VTE. Despite the advantages offered by DOACs, these agents may not be appropriate for certain patient groups owing to increased risk of bleeding, organ compromise, extremes of weight, and other issues. Finally, data are emerging suggesting that DOACs may be useful for primary thromboprophylaxis in cancer patients in conjunction with validated risk assessment scores. In this evidence-based review, data for the use of DOACs to treat cancer-associated VTE will be examined, focusing on efficacy, safety, and timing of treatment. Guidance on choosing the optimal anticoagulant for a given patient is also offered.
Collapse
Affiliation(s)
- Andrew B Song
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
24
|
Kirkilesis GI, Kakkos SK, Tsolakis IA. Editor's Choice – A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer. Eur J Vasc Endovasc Surg 2019; 57:685-701. [DOI: 10.1016/j.ejvs.2018.11.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/08/2018] [Indexed: 12/13/2022]
|
25
|
Li B, Liu Y, Hu T, Zhang Y, Zhang C, Li T, Wang C, Dong Z, Novakovic VA, Hu T, Shi J. Neutrophil extracellular traps enhance procoagulant activity in patients with oral squamous cell carcinoma. J Cancer Res Clin Oncol 2019; 145:1695-1707. [PMID: 31020419 DOI: 10.1007/s00432-019-02922-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 04/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hypercoagulability is a major cancer-associated complication linked to poor patient prognosis. The production of neutrophil extracellular traps (NETs) is increasingly found to be linked with the development and metastasis of cancer, as well as with thrombi formation in cancer patients. We hypothesized that the neutrophil NET release may be triggered by specific cytokines in oral squamous cell carcinoma (OSCC) patients, thereby predisposing them to a hypercoagulable state. Moreover, we have evaluated the interaction between NETs and endothelial cells (ECs). METHODS NET procoagulant activity was assessed based on fibrin and purified coagulation complex production assays, as well as by measuring coagulation time (CT). We further used confocal microscopy to quantify the exposure of phosphatidylserine (PS), fibrin strands, and cell FVa/Xa binding. RESULTS OSCC patients with stage III/IV exhibited elevated plasma NET levels compared to stage I/II or CTR (all P < 0.05). Neutrophils from OSCC patients are predisposed to amplified NET release compared to those from CTR. Furthermore, depleting IL-8, IL-6, and TNF-α led to a reduction in NET release in the plasma. OSCC NETs increased thrombin and fibrin generation and decreased CT significantly (P < 0.05). When NETs were isolated and used to treat ECs, these cells exhibited disrupted morphology by retracting from their cell-cell junctions and convert to a procoagulant phenotype. These effects could be attenuated by approximately 70% using DNase I. CONCLUSIONS Our findings are consistent with a model wherein OSCC drives a systemic inflammatory state, which, in turn, drives neutrophils to prime and release NETs, which drive the development of a hypercoagulable state. Intervening in this process may be a viable means of disrupting these undesirable coagulation dynamics in stage III/IV OSCC patients.
Collapse
Affiliation(s)
- Baorong Li
- Department of Stomatology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Yingmiao Liu
- Department of Stomatology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Tenglong Hu
- Department of Stomatology, The First Hospital, Harbin Medical University, Harbin, 150001, China. .,Department of Oral Anatomy and Physiology, Stomatology School, Harbin Medical University, Harbin, 150001, China.
| | - Yan Zhang
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Cong Zhang
- Department of Ultrasound, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Tao Li
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Chunxu Wang
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Zengxiang Dong
- Department of Cardiology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Valerie A Novakovic
- Department of Research and Surgery, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, 02132, USA
| | - Tianshui Hu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, 150001, China
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, 150001, China. .,Department of Research and Surgery, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, 02132, USA.
| |
Collapse
|
26
|
Liu Y, Li B, Hu TL, Li T, Zhang Y, Zhang C, Yu M, Wang C, Hou L, Dong Z, Hu TS, Novakovic VA, Shi J. Increased Phosphatidylserine on Blood Cells in Oral Squamous Cell Carcinoma. J Dent Res 2019; 98:763-771. [PMID: 30979345 DOI: 10.1177/0022034519843106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The specific function of phosphatidylserine (PS) in the context of the development of a hypercoagulable state among individuals with oral squamous cell carcinoma (OSCC) is uncertain. The goal of this study was therefore to assess the exposure of PS on microparticles (MPs) as well as on endothelial and blood cells and to assess procoagulant activity (PCA) as a function of the stage of OSCC progression. We recruited patients with OSCC (n = 63) as well as healthy controls (n = 26) to participate in this study. PS exposure was then assessed via confocal microscopy and flow cytometry, revealing that patients with stage III/IV OSCC exhibited higher frequencies of PS-exposing blood cells, MPs, and serum-cultured endothelial cells (ECs) than did patients with stage I/II OSCC or healthy controls. When we conducted functional coagulation assays, we discovered that PS+ blood cells, MPs, and serum-cultured ECs from patients with stage III/IV OSCC mediated more rapid coagulation and more substantial production of FXa, thrombin, and fibrin as compared with controls. When samples were treated with the PS antagonist lactadherin, this resulted in an 80% disruption of PCA. Strikingly, when pre- and postoperative samples were compared from patients with stage III/IV OSCC undergoing resective surgery, PCA was significantly reduced in the postoperative samples. After stimulating ECs with inflammatory cytokines, we found by confocal microscopy that they expose PS on their cell membranes, thus generating FVa and FXa binding sites and mediating the formation of fibrin. Together our findings provide evidence that PS+ blood cells and MPs are important mediators of the development of a hypercoagulable and prothrombotic state among individuals afflicted by advanced-stage OSCC. As such, a PS blockade may be a viable therapeutic strategy for treating such patients.
Collapse
Affiliation(s)
- Y Liu
- 1 Department of Stomatology, First Hospital, Harbin Medical University, Harbin, China
| | - B Li
- 1 Department of Stomatology, First Hospital, Harbin Medical University, Harbin, China
| | - T L Hu
- 1 Department of Stomatology, First Hospital, Harbin Medical University, Harbin, China.,2 Department of Oral Anatomy and Physiology, Stomatology School, Harbin Medical University, Harbin, China
| | - T Li
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - Y Zhang
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - C Zhang
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - M Yu
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - C Wang
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - L Hou
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - Z Dong
- 4 Department of Cardiology, First Hospital, Harbin Medical University, Harbin, China
| | - T S Hu
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China
| | - V A Novakovic
- 5 Departments of Research and Surgery, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - J Shi
- 3 Department of Hematology, First Hospital, Harbin Medical University, Harbin, China.,5 Departments of Research and Surgery, VA Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
27
|
Rhea IB, Lyon AR, Fradley MG. Anticoagulation of Cardiovascular Conditions in the Cancer Patient: Review of Old and New Therapies. Curr Oncol Rep 2019; 21:45. [DOI: 10.1007/s11912-019-0797-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
28
|
Grandoni F, Alberio L. Direct Oral Anticoagulant Drugs: On the Treatment of Cancer-Related Venous Thromboembolism and their Potential Anti-Neoplastic Effect. Cancers (Basel) 2019; 11:cancers11010046. [PMID: 30621261 PMCID: PMC6356803 DOI: 10.3390/cancers11010046] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 12/24/2018] [Accepted: 12/28/2018] [Indexed: 12/27/2022] Open
Abstract
Cancer patients develop a hypercoagulable state with a four- to seven-fold higher thromboembolic risk compared to non-cancer patients. Thromboembolic events can precede the diagnosis of cancer, but they more often occur at diagnosis or during treatment. After malignancy itself, they represent the second cause of death. Low molecular weight heparins are the backbone of the treatment of cancer-associated thromboembolism. This treatment paradigm is possibly changing, as direct oral anticoagulants (DOACs) may prove to be an alternative therapeutic option. The currently available DOACs were approved during the first and second decades of the 21st century for various clinical indications. Three molecules (apixaban, edoxaban and rivaroxaban) are targeting the activated factor X and one (dabigatran) is directed against the activated factor II, thrombin. The major trials analyzed the effect of these agents in the general population, with only a small proportion of cancer patients. Two published and several ongoing studies are specifically investigating the use of DOACs in cancer-associated thromboembolism. This article will review the current available literature on the use of DOACs in cancer patients. Furthermore, we will discuss published data suggesting potential anti-cancer actions exerted by non-anticoagulant effects of DOACs. As soon as more prospective data becomes available, DOACs are likely to be considered as a potential new therapeutic option in the armamentarium for patients suffering of cancer-associated thromboembolism.
Collapse
Affiliation(s)
- Francesco Grandoni
- Division of Haematology and Haematology Central Laboratory, CHUV, University Hospital of Lausanne, 1011 Lausanne, Switzerland.
| | - Lorenzo Alberio
- Division of Haematology and Haematology Central Laboratory, CHUV, University Hospital of Lausanne, 1011 Lausanne, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne, 1011 Lausanne, Switzerland.
| |
Collapse
|
29
|
|
30
|
Taghizadeh Kermani A, Hosseini S, Fanipakdel A, Joudi Mashhad M, Akhavan Rezayat K, Zardadi M, Gholami A, Javadinia SA, Ferns GA, Avan A. A randomized clinical trial on the antitumoral effects of low molecular weight heparin in the treatment of esophageal cancer. J Cell Physiol 2018; 234:4191-4199. [PMID: 30362518 DOI: 10.1002/jcp.27177] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 07/18/2018] [Indexed: 11/09/2022]
Abstract
The current treatment approaches for esophageal cancer are associated with poor survival, and there are ongoing efforts to find new and more effective therapeutic strategies. There are several reports on the antitumoral effects of low-molecular-weight heparins (LMWHs). We have assessed the possible survival benefit of LMWHs in esophageal malignancies. This was a randomized, single-blind, multicenter, Phase II clinical trial on nonmetastatic esophageal cancer candidate for neoadjuvant chemoradiotherapy. Patients were randomly assigned to the chemoradiotherapy-only arm or chemoradiotherapy plus enoxaparin arm using 1:1 allocation. Radiotherapy was delivered in 1.8-Gy daily fractions to a dose of 50.4 Gy in both groups. Paclitaxel 50 mg/m2 and carboplatin (AUC 2) were administered weekly, concurrent with radiotherapy. In the intervention group, patients received enoxaparin (40 mg) and chemoradiation daily. 4-6 weeks after treatment, all patients underwent esophagectomy. After a median follow up of 7 months, estimated 1 year disease-free survival (DFS) in the intervention group was 78.9% and was 70% in the control groups ( p = 0.5). Toxicity from the experimental treatment was minimal, and there were no treatment-related deaths. A pathologically complete response in intervention and control group was 64.8% and 62.5%, respectively ( p = 0.9). There was a nonsignificant trend toward improved survival by the addition of enoxaparin to the concurrent chemoradiotherapy regimen. However, 1 y DFS of both groups were high as expected. A longer follow-up and a larger sample size are required.
Collapse
Affiliation(s)
- Ali Taghizadeh Kermani
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sare Hosseini
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Azar Fanipakdel
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Joudi Mashhad
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Kambiz Akhavan Rezayat
- Gastroenterology and Hepatology Research Center, Emam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdi Zardadi
- Surgical Oncology Research Center, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Arezoo Gholami
- Department of Radiation Oncology, Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Alireza Javadinia
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Department of Medical Education, Brighton and Sussex Medical School Brighton & Sussex Medical School, Division of Medical Education, Brighton, UK
| | - Amir Avan
- Metabolic syndrome Research center, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
31
|
Noble S. Are new anticoagulants a safe and reasonable alternative to low molecular heparins? Thromb Res 2018; 164 Suppl 1:S157-S161. [PMID: 29703476 DOI: 10.1016/j.thromres.2018.01.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/17/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, United Kingdom.
| |
Collapse
|
32
|
Meyer G, Besse B, Doubre H, Charles-Nelson A, Aquilanti S, Izadifar A, Azarian R, Monnet I, Lamour C, Descourt R, Oliviero G, Taillade L, Chouaid C, Giraud F, Falcoz PE, Revel MP, Westeel V, Dixmier A, Tredaniel J, Dehette S, Decroisette C, Prevost A, Pichon E, Fabre E, Soria JC, Friard S, Stern JB, Jabot L, Dennewald G, Pavy G, Petitpretz P, Tourani JM, Alifano M, Chatellier G, Girard P. Anti-tumour effect of low molecular weight heparin in localised lung cancer: a phase III clinical trial. Eur Respir J 2018; 52:13993003.01220-2018. [DOI: 10.1183/13993003.01220-2018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 08/06/2018] [Indexed: 11/05/2022]
Abstract
The anti-tumour and anti-metastatic properties of heparins have not been tested in patients with early stage cancer. Whether adjuvant low molecular weight heparin (LMWH) tinzaparin impacts the survival of patients with resected non-small cell lung cancer (NSCLC) was investigated.Patients with completely resected stage I, II or IIIA NSCLC were randomly allocated to receive subcutaneous tinzaparin 100 IU·kg−1 once a day for 12 weeks or no treatment in addition to standard of care. The trial was open-label with blinded central adjudication of study outcomes. The primary outcome was overall survival.In 549 patients randomised to tinzaparin (n=269) or control (n=280), mean±sd age was 61.6±8.9 years, 190 (34.6%) patients had stage II−III disease, and 220 (40.1%) patients received adjuvant chemotherapy. Median follow-up was 5.7 years. There was no significant difference in overall survival between groups (hazard ratio (HR) 1.24, 95% CI 0.92–1.68; p=0.17). There was no difference in the cumulative incidence of recurrence between groups (subdistribution HR 0.94, 95% CI 0.68–1.30; p=0.70).Adjuvant tinzaparin had no detectable impact on overall and recurrence-free survival of patients with completely resected stage I−IIIA NSCLC. These results do not support further clinical evaluation of LMWHs as anti-tumour agents.
Collapse
|
33
|
Paderi J, Prestwich GD, Panitch A, Boone T, Stuart K. Glycan Therapeutics: Resurrecting an Almost Pharma‐Forgotten Drug Class. ADVANCED THERAPEUTICS 2018. [DOI: 10.1002/adtp.201800082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- John Paderi
- Symic Bio, Inc. 5980 Horton St. 94608 Emeryville CA USA
| | - Glenn D. Prestwich
- Symic Bio, Inc. 5980 Horton St. 94608 Emeryville CA USA
- Department of Medicinal ChemistryUniversity of Utah 84112 Salt Lake City UT USA
- Washington State University Health Sciences Spokane 99210 Spokane WA USA
| | - Alyssa Panitch
- Symic Bio, Inc. 5980 Horton St. 94608 Emeryville CA USA
- University of California 95616 Davis CA USA
| | - Tom Boone
- Symic Bio, Inc. 5980 Horton St. 94608 Emeryville CA USA
| | - Kate Stuart
- Symic Bio, Inc. 5980 Horton St. 94608 Emeryville CA USA
| |
Collapse
|
34
|
The Role of Direct Oral Anticoagulants in Treatment of Cancer-Associated Thrombosis. Cancers (Basel) 2018; 10:cancers10080271. [PMID: 30111746 PMCID: PMC6115910 DOI: 10.3390/cancers10080271] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/07/2018] [Accepted: 08/13/2018] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) complicates the clinical course of approximately 5–10% of all cancer patients. Anticoagulation of the cancer patient often presents unique challenges as these patients have both a higher risk of recurrent VTE and a higher risk of bleeding than patients without cancer. Although low molecular weight heparins (LMWH) are the standard of care for the management of cancer-associated VTE, their use requires once or twice daily subcutaneous injections, which can be a significant burden for many cancer patients who often require a long duration of anticoagulation. The direct oral anticoagulants (DOACs) are attractive options for patients with malignancy. DOACs offer immediate onset of action and short half-lives, properties similar to LMWH, but the oral route of administration is a significant advantage. Given the higher risks of recurrent VTE and bleeding, there has been concern about the efficacy and safety of DOACs in this patient population. Data are now emerging for the use of DOACs in the cancer patient population from dedicated clinical trials. While recently published data suggest that DOACs hold promise for the treatment of cancer associated VTE, additional studies are needed to establish DOACs as the standard-of-care treatment. Many such studies are currently underway. The available data for the use of DOACs in the treatment of cancer-associated VTE will be reviewed, focusing on efficacy, safety, and other considerations relevant to the cancer patient.
Collapse
|
35
|
Comparison of the effects of edoxaban, an oral direct factor Xa inhibitor, on venous thromboembolism between patients with and without cancer. J Cardiol 2018; 72:120-127. [DOI: 10.1016/j.jjcc.2018.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/13/2018] [Accepted: 03/05/2018] [Indexed: 12/21/2022]
|
36
|
Riess H, Ay C, Bauersachs R, Becattini C, Beyer-Westendorf J, Cajfinger F, Chau I, Cohen AT, Khorana AA, Maraveyas A, Renni M, Young AM. Use of Direct Oral Anticoagulants in Patients with Cancer: Practical Considerations for the Management of Patients with Nausea or Vomiting. Oncologist 2018; 23:822-839. [PMID: 29650686 PMCID: PMC6058321 DOI: 10.1634/theoncologist.2017-0473] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/23/2018] [Indexed: 01/14/2023] Open
Abstract
Direct oral anticoagulants (DOACs) have proven efficacy and safety and are approved for use in the prevention and treatment of thromboembolic events in patients with venous thromboembolism (VTE) and those with atrial fibrillation (AF). There is no clear guidance on the use of DOACs in the significant proportion of these patients who have or will develop concomitant cancer. The occurrence of nausea and vomiting in these patients, despite implementation of guideline-recommended antiemetic strategies, is a particular concern because it may affect oral drug intake and consequently outcomes with anticoagulation therapy.Here, we review recent data on the incidence and management of cancer-associated nausea and vomiting and the current evidence and guidance relating to the use of DOACs in patients with cancer. On the basis of this evidence, an international working group of experts in the fields of cancer-associated thrombosis/hemostasis, hematology, and oncology discussed key issues related to the use of DOACs in patients with VTE or AF and cancer who are at risk of nausea and vomiting and developed some consensus recommendations. We present these consensus recommendations, which outline strategies for the use and management of anticoagulants, including DOACs, in patients with VTE or AF and cancer for whom oral drug intake may pose challenges. Guidance is provided on managing patients with gastrointestinal obstruction or nausea and vomiting that is caused by cancer treatments or other cancer-related factors.The recommendations outlined in this review provide a useful reference for health care professionals and will help to improve the management of anticoagulation in patients with VTE or AF and cancer. IMPLICATIONS FOR PRACTICE Direct oral anticoagulants (DOACs) offer several advantages over traditional anticoagulants, including ease of administration and the lack of need for routine monitoring. However, the management of patients with an indication for anticoagulation and concomitant cancer, who are at high risk of thromboembolic events, presents several challenges for administering oral therapies, particularly with regard to the risk of nausea and vomiting. In the absence of robust data from randomized trials and specific guidelines, consensus recommendations were developed for healthcare professionals regarding the use of DOACs in patients with cancer, with a focus on the management of patients who are at risk of nausea and vomiting.
Collapse
Affiliation(s)
- Hanno Riess
- Department of Hematology, Oncology, and Tumor Immunology, Charité, University Hospital, Berlin, Germany
| | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Rupert Bauersachs
- Department of Vascular Medicine, Darmstadt Hospital, Darmstadt, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Frankfurt, Germany
| | | | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division of Haematology, University Hospital "Carl Gustav Carus" Dresden, Germany
- King's Thrombosis Service, Department of Haematology, King's College London, London, UK
| | | | - Ian Chau
- Gastrointestinal Unit, Department of Medicine, Royal Marsden Hospital, Sutton, UK
| | - Alexander T Cohen
- Thrombosis and Thrombophilia Unit, Department of Haematology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Maraveyas
- Joint Centre of Cancer Studies, Hull York Medical School, Castle Hill Hospital, Cottingham, UK
| | - Marcos Renni
- National Institute of Cancer, Ministry of Health, Rio de Janeiro, Brazil
| | - Annie M Young
- Cancer Research Centre, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
37
|
Kahale LA, Hakoum MB, Tsolakian IG, Matar CF, Terrenato I, Sperati F, Barba M, Yosuico VE, Schünemann H, Akl EA. Anticoagulation for the long-term treatment of venous thromboembolism in people with cancer. Cochrane Database Syst Rev 2018; 6:CD006650. [PMID: 29920657 PMCID: PMC6389342 DOI: 10.1002/14651858.cd006650.pub5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cancer increases the risk of thromboembolic events, especially in people receiving anticoagulation treatments. OBJECTIVES To compare the efficacy and safety of low molecular weight heparins (LMWHs), direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) for the long-term treatment of venous thromboembolism (VTE) in people with cancer. SEARCH METHODS We conducted a literature search including a major electronic search of the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE (Ovid), and Embase (Ovid); handsearching conference proceedings; checking references of included studies; use of the 'related citation' feature in PubMed and a search for ongoing studies in trial registries. As part of the living systematic review approach, we run searches continually, incorporating new evidence after it is identified. Last search date 14 May 2018. SELECTION CRITERIA Randomized controlled trials (RCTs) assessing the benefits and harms of long-term treatment with LMWHs, DOACs or VKAs in people with cancer and symptomatic VTE. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on study characteristics and risk of bias. Outcomes included: all-cause mortality, recurrent VTE, major bleeding, minor bleeding, thrombocytopenia, and health-related quality of life (QoL). We assessed the certainty of the evidence at the outcome level following the GRADE approach (GRADE handbook). MAIN RESULTS Of 15,785 citations, including 7602 unique citations, 16 RCTs fulfilled the eligibility criteria. These trials enrolled 5167 people with cancer and VTE.Low molecular weight heparins versus vitamin K antagonistsEight studies enrolling 2327 participants compared LMWHs with VKAs. Meta-analysis of five studies probably did not rule out a beneficial or harmful effect of LMWHs compared to VKAs on mortality up to 12 months of follow-up (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.13; risk difference (RD) 0 fewer per 1000, 95% CI 45 fewer to 48 more; moderate-certainty evidence). Meta-analysis of four studies did not rule out a beneficial or harmful effect of LMWHs compared to VKAs on major bleeding (RR 1.09, 95% CI 0.55 to 2.12; RD 4 more per 1000, 95% CI 19 fewer to 48 more, moderate-certainty evidence) or minor bleeding (RR 0.78, 95% CI 0.47 to 1.27; RD 38 fewer per 1000, 95% CI 92 fewer to 47 more; low-certainty evidence), or thrombocytopenia (RR 0.94, 95% CI 0.52 to 1.69). Meta-analysis of five studies showed that LMWHs probably reduced the recurrence of VTE compared to VKAs (RR 0.58, 95% CI 0.43 to 0.77; RD 53 fewer per 1000, 95% CI 29 fewer to 72 fewer, moderate-certainty evidence).Direct oral anticoagulants versus vitamin K antagonistsFive studies enrolling 982 participants compared DOACs with VKAs. Meta-analysis of four studies may not rule out a beneficial or harmful effect of DOACs compared to VKAs on mortality (RR 0.93, 95% CI 0.71 to 1.21; RD 12 fewer per 1000, 95% CI 51 fewer to 37 more; low-certainty evidence), recurrent VTE (RR 0.66, 95% CI 0.33 to 1.31; RD 14 fewer per 1000, 95% CI 27 fewer to 12 more; low-certainty evidence), major bleeding (RR 0.77, 95% CI 0.38 to 1.57, RD 8 fewer per 1000, 95% CI 22 fewer to 20 more; low-certainty evidence), or minor bleeding (RR 0.84, 95% CI 0.58 to 1.22; RD 21 fewer per 1000, 95% CI 54 fewer to 28 more; low-certainty evidence). One study reporting on DOAC versus VKA was published as abstract so is not included in the main analysis.Direct oral anticoagulants versus low molecular weight heparinsTwo studies enrolling 1455 participants compared DOAC with LMWH. The study by Raskob did not rule out a beneficial or harmful effect of DOACs compared to LMWH on mortality up to 12 months of follow-up (RR 1.07, 95% CI 0.92 to 1.25; RD 27 more per 1000, 95% CI 30 fewer to 95 more; low-certainty evidence). The data also showed that DOACs may have shown a likely reduction in VTE recurrence up to 12 months of follow-up compared to LMWH (RR 0.69, 95% CI 0.47 to 1.01; RD 36 fewer per 1000, 95% CI 62 fewer to 1 more; low-certainty evidence). DOAC may have increased major bleeding at 12 months of follow-up compared to LMWH (RR 1.71, 95% CI 1.01 to 2.88; RD 29 more per 1000, 95% CI 0 fewer to 78 more; low-certainty evidence) and likely increased minor bleeding up to 12 months of follow-up compared to LMWH (RR 1.31, 95% CI 0.95 to 1.80; RD 35 more per 1000, 95% CI 6 fewer to 92 more; low-certainty evidence). The second study on DOAC versus LMWH was published as an abstract and is not included in the main analysis.Idraparinux versus vitamin K antagonistsOne RCT with 284 participants compared once-weekly subcutaneous injection of idraparinux versus standard treatment (parenteral anticoagulation followed by warfarin or acenocoumarol) for three or six months. The data probably did not rule out a beneficial or harmful effect of idraparinux compared to VKAs on mortality at six months (RR 1.11, 95% CI 0.78 to 1.59; RD 31 more per 1000, 95% CI 62 fewer to 167 more; moderate-certainty evidence), VTE recurrence at six months (RR 0.46, 95% CI 0.16 to 1.32; RD 42 fewer per 1000, 95% CI 65 fewer to 25 more; low-certainty evidence) or major bleeding (RR 1.11, 95% CI 0.35 to 3.56; RD 4 more per 1000, 95% CI 25 fewer to 98 more; low-certainty evidence). AUTHORS' CONCLUSIONS For the long-term treatment of VTE in people with cancer, evidence shows that LMWHs compared to VKAs probably produces an important reduction in VTE and DOACs compared to LMWH, may likely reduce VTE but may increase risk of major bleeding. Decisions for a person with cancer and VTE to start long-term LMWHs versus oral anticoagulation should balance benefits and harms and integrate the person's values and preferences for the important outcomes and alternative management strategies.Editorial note: this is a living systematic review (LSR). LSRs offer new approaches 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)
- Lara A Kahale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Haemmerle M, Stone RL, Menter DG, Afshar-Kharghan V, Sood AK. The Platelet Lifeline to Cancer: Challenges and Opportunities. Cancer Cell 2018; 33:965-983. [PMID: 29657130 PMCID: PMC5997503 DOI: 10.1016/j.ccell.2018.03.002] [Citation(s) in RCA: 355] [Impact Index Per Article: 59.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 01/08/2018] [Accepted: 03/01/2018] [Indexed: 12/21/2022]
Abstract
Besides their function in limiting blood loss and promoting wound healing, experimental evidence has highlighted platelets as active players in all steps of tumorigenesis including tumor growth, tumor cell extravasation, and metastasis. Additionally, thrombocytosis in cancer patients is associated with adverse patient survival. Due to the secretion of large amounts of microparticles and exosomes, platelets are well positioned to coordinate both local and distant tumor-host crosstalk. Here, we present a review of recent discoveries in the field of platelet biology and the role of platelets in cancer progression as well as challenges in targeting platelets for cancer treatment.
Collapse
Affiliation(s)
- Monika Haemmerle
- Department of Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Institute of Pathology, Martin Luther University Halle-Wittenberg, 06112 Halle, Germany
| | - Rebecca L Stone
- Department of Obstetrics and Gynecology, Johns Hopkins Hospital, Baltimore, MD 21287-1281, USA
| | - David G Menter
- Department of Gastrointestinal Medical Oncology, Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Vahid Afshar-Kharghan
- Division of Internal Medicine, Benign Hematology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Anil K Sood
- Department of Gynecologic Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Center for RNA Interference and Non-Coding RNA, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; Department of Cancer Biology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| |
Collapse
|
39
|
Javadinia SA, Gholami A, Joudi Mashhad M, Ferns GA, Shahidsales S, Avan A, Kermani AT. Anti-tumoral effects of low molecular weight heparins: A focus on the treatment of esophageal cancer. J Cell Physiol 2018; 233:6523-6529. [PMID: 29741755 DOI: 10.1002/jcp.26613] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/22/2018] [Indexed: 12/19/2022]
Abstract
Esophageal cancer is one of the most prevalent types of cancer globally. With current treatment options, the survival is poor, and there are ongoing efforts to find new and more efficient therapeutic approaches. There are several reports on the anti-tumoral effects of low-molecular-weight heparins (LMWH). We have assessed the possible survival benefits and underlying mechanisms of LMWHs in malignancies with a focus on esophageal cancer. We conclude that the effects of LMWHs on survival of cancer patients is probably due to a combination of direct anti-tumoral, anti-angiogenic, and immunomodulatory effects and indirect effects on the coagulation system.
Collapse
Affiliation(s)
| | - Arezoo Gholami
- Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mona Joudi Mashhad
- Cancer Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Gordon A Ferns
- Division of Medical Education, Department of Medical Education, Brighton and Sussex Medical School Brighton & Sussex Medical School, Falmer, Brighton, Sussex, UK
| | | | - Amir Avan
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Taghizadeh Kermani
- Surgical Oncology Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| |
Collapse
|
40
|
Simmons B, Wysokinski W, Saadiq RA, Bott-Kitslaar D, Henkin S, Casanegra A, Lenz C, Daniels P, Bjarnason H, Vargas E, Hodge D, Holton SJ, Cerhan JR, Loprinzi C, McBane R. Efficacy and safety of rivaroxaban compared to enoxaparin in treatment of cancer-associated venous thromboembolism. Eur J Haematol 2018; 101:136-142. [PMID: 29617053 DOI: 10.1111/ejh.13074] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Low molecular weight heparin (LMWH) is the guideline-endorsed treatment for cancer-associated venous thromboembolism (cVTE). Study objectives were to compare the efficacy and safety of rivaroxaban and enoxaparin in cVTE. METHODS Using a cohort study design, consecutive patients with cVTE (3/1/2013-7/31/2016), enrolled in the Mayo Thrombophilia Clinic Direct Oral Anticoagulants Registry, were compared to contemporary cancer patients receiving enoxaparin. The cumulative incidence of venous thromboembolism (VTE) recurrence, major and clinically relevant non-major bleeding, and survival were assessed at 3 and 12 months. RESULTS Ninety-eight patients received rivaroxaban (51% female, mean age 63 ± 12 years) and 168 enoxaparin (34.5% female, mean age 62 ± 15 years). The most common cancers included gastrointestinal/pancreatic, genitourinary and hematologic cancers. More than half of patients had pulmonary emboli at presentation. More than half had metastases, and two-thirds were receiving chemotherapy. At 3 months, there were no differences in VTE recurrence (rivaroxaban 1.0% vs enoxaparin 4.2%; P = .15), major bleeding (rivaroxaban 5.1% vs enoxaparin 3.6%; P = .55), or all-cause mortality (rivaroxaban 4.1% vs enoxaparin 8.9%; P = .14). At 12 months, these outcomes did not differ by treatment strategy. CONCLUSION The results of this "real-world" experience with cVTE suggest that rivaroxaban may offer a safe and effective alternative to LMWH.
Collapse
Affiliation(s)
- Benjamin Simmons
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Waldemar Wysokinski
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Rayya A Saadiq
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dalene Bott-Kitslaar
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Stanislav Henkin
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Ana Casanegra
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Charles Lenz
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Paul Daniels
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Haraldur Bjarnason
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Emily Vargas
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - David Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL, USA
| | - Sara J Holton
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - James R Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Robert McBane
- Division of Vascular Diseases, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
41
|
Burbury K, MacManus MP. The coagulome and the oncomir: impact of cancer-associated haemostatic dysregulation on the risk of metastasis. Clin Exp Metastasis 2018; 35:237-246. [PMID: 29492795 DOI: 10.1007/s10585-018-9875-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 01/16/2018] [Indexed: 02/07/2023]
Abstract
Patients with cancer are at high risk of both thromboembolic and haemorrhagic events during the course of their disease. The pathogenesis of haemostatic dysfunction in cancer is complex and involves the interplay of multiple factors. There is growing evidence that interactions between malignancies and the coagulation system are not random but can represent coordinated and clinically-significant adaptations that enhance tumour cell survival, proliferation and metastatic potential. A detailed understanding of the interactions between the haemostatic systems and the pathophysiology of metastasis may not only provide insight into strategies that could potentially reduce the incidence of thrombohaemorrhagic events and complications, but could also help design strategies that are capable of modifying tumour biology, progression and metastatic potential in ways that could enhance anticancer therapies and thereby improve overall survival.
Collapse
Affiliation(s)
- Kate Burbury
- Departments of Haematology, Peter MacCallum Cancer Centre, A'Beckett Street, Locked Bag 1, Melbourne, VIC, 8006, Australia. .,The University of Melbourne, Melbourne, Australia.
| | - Michael P MacManus
- Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia.,The University of Melbourne, Melbourne, Australia
| |
Collapse
|
42
|
García-Escobar I, Beato-Zambrano C, Muñoz Langa J, Brozos Vázquez E, Obispo Portero B, Gutiérrez-Abad D, Muñoz Martín AJ. Pleiotropic effects of heparins: does anticoagulant treatment increase survival in cancer patients? Clin Transl Oncol 2018; 20:1097-1108. [PMID: 29470777 DOI: 10.1007/s12094-018-1835-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
The association between venous thromboembolism (VTE) and cancer has been recognized for more than 100 years. Numerous studies have been performed to investigate strategies to decrease VTE incidence and to establish whether treating VTE impacts cancer progression and overall survival. Accordingly, it is important to understand the role of the hemostatic system in tumorigenesis and progression, as there is abundant evidence associating it with cell survival and proliferation, tumor angiogenesis, invasion, and dissemination, and metastasis formation. In attempts to further the scientific evidence, several studies examine survival benefits in cancer patients treated with anticoagulant therapy, specifically treatment with vitamin K antagonists, unfractionated heparin, and low-molecular-weight heparin. Several studies and meta-analyses have been conducted with a special focus on brain tumors. However, no definitive conclusions have been obtained, and more well-designed clinical trials are needed.
Collapse
Affiliation(s)
- I García-Escobar
- Medical Oncology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain.
| | - C Beato-Zambrano
- Medical Oncology GU and Breast Cancer Department, Hospital Universitario Virgen Macarena, Seville, Spain
| | - J Muñoz Langa
- Medical Oncology, Hospital Universitario La Fe, Valencia, Spain
| | - E Brozos Vázquez
- Medical Oncology, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - B Obispo Portero
- Medical Oncology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - D Gutiérrez-Abad
- Medical Oncology, Hospital Universitario de Fuenlabrada, Madrid, Spain
| | - A J Muñoz Martín
- Medical Oncology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | |
Collapse
|
43
|
Goertz L, Schneider SW, Desch A, Mayer FT, Koett J, Nowak K, Karampinis I, Bohlmann MK, Umansky V, Bauer AT. Heparins that block VEGF-A-mediated von Willebrand factor fiber generation are potent inhibitors of hematogenous but not lymphatic metastasis. Oncotarget 2018; 7:68527-68545. [PMID: 27602496 PMCID: PMC5356571 DOI: 10.18632/oncotarget.11832] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 08/21/2016] [Indexed: 12/31/2022] Open
Abstract
Von Willebrand factor (VWF) serves as a nidus for platelet aggregation and thrombosis. We hypothesize that VWF fibers contribute to the development of venous thromboembolism (VTE) and to metastasis formation. Here, we show that vascular and lymphatic endothelial cells (ECs) express VWF in vitro and release VWF fibers after activation by tumor cell supernatants. In contrast, an ex vivo analysis of primary mouse tumors revealed the presence of VWF fibers in the blood microvasculature but not in lymphatic vessels. Unlike the anticoagulant Fondaparinux, an inhibitor of thrombin generation, the low-molecular-weight heparin (LMWH) Tinzaparin inhibited VWF fiber formation and vessel occlusion in tumor vessels by blocking thrombin-induced EC activation and vascular endothelial growth factor-A (VEGF-A)-mediated VWF release. Intradermal tumor cell inoculation in VWF- and ADAMTS13-deficient mice did not alter lymph node metastases compared with wild type animals. Interestingly, multiple tumor-free distal organs exhibited hallmarks of malignancy-related VTE, including luminal VWF fibers, platelet-rich thrombi and vessel occlusions. Furthermore, ADAMTS13 deficiency, characterized by prolonged intraluminal VWF network lifetimes, resulted in a severely increased number of metastatic foci in an experimental model of hematogenous lung seeding. Treatment with Tinzaparin inhibited tumor-induced release of VWF multimers, impeded platelet aggregation and decreased lung metastasis. Thus, our data strongly suggest a critical role of luminal VWF fibers in determining the occurrence of thrombosis and cancer metastasis. Moreover, the findings highlight LMWHs as therapeutic strategy to treat thrombotic complications while executing anti-metastatic activities.
Collapse
Affiliation(s)
- Lukas Goertz
- Experimental Dermatology, Department of Dermatology, Venereology, and Allergy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan Werner Schneider
- Department of Dermatology and Venereology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Desch
- Experimental Dermatology, Department of Dermatology, Venereology, and Allergy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Frank Thomas Mayer
- Experimental Dermatology, Department of Dermatology, Venereology, and Allergy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Julian Koett
- Experimental Dermatology, Department of Dermatology, Venereology, and Allergy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Kai Nowak
- Department of Surgery, Mannheim University Medical Center, Heidelberg University, Mannheim, Germany
| | - Ioannis Karampinis
- Department of Surgery, Mannheim University Medical Center, Heidelberg University, Mannheim, Germany
| | - Michael K Bohlmann
- Department of Obstetrics and Gynaecology, Mannheim University Medical Center, Heidelberg University, Mannheim, Germany
| | - Viktor Umansky
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University of Heidelberg, Mannheim, Germany
| | - Alexander Thomas Bauer
- Experimental Dermatology, Department of Dermatology, Venereology, and Allergy, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| |
Collapse
|
44
|
Ek L, Gezelius E, Bergman B, Bendahl PO, Anderson H, Sundberg J, Wallberg M, Falkmer U, Verma S, Belting M. Randomized phase III trial of low-molecular-weight heparin enoxaparin in addition to standard treatment in small-cell lung cancer: the RASTEN trial. Ann Oncol 2018; 29:398-404. [PMID: 29106448 PMCID: PMC5834130 DOI: 10.1093/annonc/mdx716] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Coagulation activation and venous thromboembolism (VTE) are hallmarks of malignant disease and represent a major cause of morbidity and mortality in cancer. Coagulation inhibition with low-molecular-weight heparin (LMWH) may improve survival specifically in small-cell lung cancer (SCLC) patients by preventing VTE and tumor progression; however, randomized trials with well-defined patient populations are needed to obtain conclusive data. The aim of RASTEN was to investigate the survival effect of LMWH enoxaparin in a homogenous population of SCLC patients. Patients and methods We carried out a randomized, multicenter, open-label trial to investigate the addition of enoxaparin at a supraprophylactic dose (1 mg/kg) to standard treatment in patients with newly diagnosed SCLC. The primary outcome was overall survival (OS), and secondary outcomes were progression-free survival (PFS), incidence of VTE and hemorrhagic events. Results In RASTEN, 390 patients were randomized over an 8-year period (2008-2016), of whom 186 and 191 were included in the final analysis in the LMWH and control arm, respectively. We found no evidence of a difference in OS or PFS by the addition of enoxaparin [hazard ratio (HR), 1.11; 95% confidence interval (CI) 0.89-1.38; P = 0.36 and HR, 1.18; 95% CI 0.95-1.46; P = 0.14, respectively]. Subgroup analysis of patients with limited and extensive disease did not show reduced mortality by enoxaparin. The incidence of VTE was significantly reduced in the LMWH arm (HR, 0.31; 95% CI 0.11-0.84; P = 0.02). Hemorrhagic events were more frequent in the LMWH-treated group but fatal bleedings occurred in both arms. Conclusion LMWH enoxaparin in addition to standard therapy did not improve OS in SCLC patients despite being administered at a supraprophylactic dose and despite resulting in a significant reduction in VTE incidence. Addition of LMWH cannot be generally recommended in the management of SCLC patients, and predictive biomarkers of VTE and LMWH-associated bleeding in cancer patients are warranted.
Collapse
Affiliation(s)
- L Ek
- Department of Heart and Lung Disease, Skåne University Hospital, Lund, Sweden
| | - E Gezelius
- Department of Hematology, Radiophysics and Oncology, Skåne University Hospital, Lund, Sweden; Department of Section of Oncology and Pathology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - B Bergman
- Department of Lung Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P O Bendahl
- Department of Section of Oncology and Pathology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - H Anderson
- Section of Cancer Epidemiology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - J Sundberg
- Department of Hematology, Radiophysics and Oncology, Skåne University Hospital, Lund, Sweden
| | - M Wallberg
- Department of Heart and Lung Disease, Skåne University Hospital, Lund, Sweden
| | - U Falkmer
- Department of Oncology, University Hospital, Aalborg, Denmark
| | - S Verma
- Department of Oncology, University of Calgary, Calgary, Canada
| | - M Belting
- Department of Hematology, Radiophysics and Oncology, Skåne University Hospital, Lund, Sweden; Department of Section of Oncology and Pathology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden.
| |
Collapse
|
45
|
Ponert JM, Schwarz S, Haschemi R, Müller J, Pötzsch B, Bendas G, Schlesinger M. The mechanisms how heparin affects the tumor cell induced VEGF and chemokine release from platelets to attenuate the early metastatic niche formation. PLoS One 2018; 13:e0191303. [PMID: 29346400 PMCID: PMC5773218 DOI: 10.1371/journal.pone.0191303] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/01/2018] [Indexed: 11/18/2022] Open
Abstract
Metastasis is responsible for the majority of cancer associated fatalities. Tumor cells leaving the primary tumor and entering the blood flow immediately interact with platelets. Activated platelets contribute in different ways to cancer cell survival and proliferation, e.g. in formation of the early metastatic niche by release of different growth factors and chemokines. Here we show that a direct interaction between platelets and MV3 melanoma or MCF7 breast cancer cells induces platelet activation and a VEGF release in citrated plasma that cannot be further elevated by the coagulation cascade and generated thrombin. In contrast, the release of platelet-derived chemokines CXCL5 and CXCL7 depends on both, a thrombin-mediated platelet activation and a direct interaction between tumor cells and platelets. Preincubation of platelets with therapeutic concentrations of unfractionated heparin reduces the tumor cell initiated VEGF release from platelets. In contrast, tumor cell induced CXCL5 and CXCL7 release from platelets was not impacted by heparin pretreatment in citrated plasma. In defibrinated, recalcified plasma, on the contrary, heparin is able to reduce CXCL5 and CXCL7 release from platelets by thrombin inhibition. Our data indicate that different chemokines and growth factors in diverse platelet granules are released in tightly regulated processes by various trigger mechanisms. We show for the first time that heparin is able to reduce the mediator release induced by different tumor cells both in a contact and coagulation dependent manner.
Collapse
Affiliation(s)
- Jan Moritz Ponert
- Department of Pharmacy, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Svenja Schwarz
- Department of Pharmacy, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Reza Haschemi
- Department of Pharmacy, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Jens Müller
- Institute for Experimental Hematology and Transfusion Medicine, University of Bonn Medical Centre, Bonn, Germany
| | - Bernd Pötzsch
- Institute for Experimental Hematology and Transfusion Medicine, University of Bonn Medical Centre, Bonn, Germany
| | - Gerd Bendas
- Department of Pharmacy, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
| | - Martin Schlesinger
- Department of Pharmacy, Rheinische Friedrich-Wilhelms-University Bonn, Bonn, Germany
- * E-mail:
| |
Collapse
|
46
|
Shaker RA, Abboud SH, Assad HC, Hadi N. Enoxaparin attenuates doxorubicin induced cardiotoxicity in rats via interfering with oxidative stress, inflammation and apoptosis. BMC Pharmacol Toxicol 2018; 19:3. [PMID: 29321061 PMCID: PMC5763526 DOI: 10.1186/s40360-017-0184-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/23/2017] [Indexed: 02/06/2023] Open
Abstract
Background Doxorubicin (DOX) is commonly used in the treatment of many types of cancers but its cardiotoxicity is limiting its clinical use. Beyond its anticoagulant action, enoxaparin (ENX), a low molecular weight heparin, has been shown to exert multiple pharmacological actions including antioxidant, anti-inflammatory and antiapoptotic effects. Therefore, the current study aimed to assess if ENX could ameliorate cardiotoxicity induced by DOX. Methods Twenty-one adult male Wistar albino rats were randomly allocated into three groups (n = 7 each) of control, receiving 0.9% saline (i.p.), DOX, receiving 2.5 mg/kg of DOX (i.p.) thrice weekly; and DOX + ENX, receiving ENX (250 IU/kg/day i.p.) and a DOX dose equivalent to that of the DOX only group. Results DOX-induced cardiotoxicity was indicated by marked increases in cardiac troponin I (cTnI) and severe histological lesions, which significantly correlated with cardiotoxicity, oxidative stress, inflammation and apoptosis markers, compared to controls. DOX group also showed elevations in malondialdehyde (MDA), a marker of oxidative stress, and reductions in total antioxidant capacity (TAC). Cardiac inflammatory markers including tumor necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1β) and caspase-3, an apoptotic marker, were also elevated in the DOX group. DOX, however, did not significantly alter brain natriuretic peptide (BNP) levels. ENX significantly attenuated, but not completely reversed, DOX-induced cardiotoxicity through lowering cTnI and improving cardiomyopathy histopathological scores as compared to the DOX group. ENX also decreased MDA, increased TAC of rats’ heart to levels relatively comparable to control. Significant reductions in TNF-α, IL-1β and caspase-3 were also observed following ENX treatment relative to the DOX only group. Conclusions Collectively, these results describe a cardioprotective effect for ENX against DOX-induced cardiotoxicity which is likely facilitated via suppression of oxidative stress, inflammation and apoptosis.
Collapse
Affiliation(s)
- Reem Ali Shaker
- Najaf Health Directorate, Ministry of Health, Najaf Governorate, Iraq
| | | | - Hayder Chasib Assad
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, University of Kufa, Najaf Governorate, Iraq.
| | - Najah Hadi
- Faculty of Medicine, University of Kufa, Najaf Governorate, Iraq
| |
Collapse
|
47
|
Crispel Y, Axelman E, Tatour M, Kogan I, Nevo N, Brenner B, Nadir Y. Peptides inhibiting heparanase procoagulant activity significantly reduce tumour growth and vascularisation in a mouse model. Thromb Haemost 2017; 116:669-78. [DOI: 10.1160/th16-02-0119] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 05/25/2016] [Indexed: 11/05/2022]
Abstract
SummaryHeparanase is implicated in angiogenesis and tumour progression. We previously demonstrated that heparanase might also affect the haemostatic system in a non-enzymatic manner. It forms a complex and enhances the activity of the blood coagulation initiator tissue factor (TF). Peptides that we generated from TF pathway inhibitor (TFPI)-2, which inhibit heparanase procoagulant activity, were recently demonstrated to attenuate inflammation in a sepsis mouse model. The present study was designated to explore peptides effects on tumour growth and vascularisation. Cell lines of mouse melanoma (B16), mouse breast cancer (EMT-6), and human breast cancer (MDA-231) were injected subcutaneously to mice. Inhibitory peptides 5, 6 and 7 were injected subcutaneously in the area opposite to the tumour side. In the three tumour cell lines, peptides 5, 6 and 7 inhibited tumour growth and vascularisation in a dose-dependent manner, reaching a 2/3 reduction compared to control tumours (p<0.001). Additionally, a survival advantage (p<0.05) and reduced plasma thrombin-antithrombin complex (p<0.05) were observed in the treatment groups. Peptides delayed tumour relapse by six days and inhibited relapsed tumour size (p<0.001). In vitro, peptides did not inhibit tumour cell proliferation, migration or heparanase degradation of heparan sulfate chains, but significantly decreased tube formation. In conclusion, peptides inhibiting heparanase procoagulant activity significantly reduced tumour growth, vascularisation, and relapse. The procoagulant domain in heparanase protein may play a role in tumour growth, suggesting a new mechanism of coagulation system involvement in cancer.
Collapse
|
48
|
Nizankowski R, Bochenek T. The treatment of venous thromboembolism with low-molecular-weight heparins. Thromb Haemost 2017; 107:699-716. [DOI: 10.1160/th11-08-0565] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Accepted: 01/13/2012] [Indexed: 11/05/2022]
Abstract
SummaryThe currently recommended method of venous thromboembolism (VTE) treatment is the application of vitamin K antagonists (VKA) in most patients, and low-molecular-weight heparins (LMWH) in selected groups. The VKA dose adjustment is difficult which might well render the treatment ineffective. The study aimed to compare LMWH with VKA in treating VTE in terms of efficacy and safety. A systematic review of literature and the meta-analysis of the treatment results were performed. The main differences between LMWH and VKA in terms of their respective effectiveness in treating VTE consist in appreciably more advantageous effects of LMWH in preventing deep venous thrombosis (DVT). The key difference in terms of respective safety is the greater effectiveness of LMWH in preventing minor bleedings. The advantage of LMWH in cancer patients consists predominantly in a significantly better protection against DVT episodes, whereas the advantage of LMWH in non-cancer patients is mainly owed to better protection against minor bleedings. In none of the analysed outcomes of VTE treatment, the application of VKA proved to hold any advantage over LMWH. Although, arguably, there might well be sufficient medical grounds to propose more widespread use of LMWH, it still remains a debatable issue whether the currently used therapeutic standard should also be modified accordingly. Apart from the actual findings of the present meta-analysis, pertinent economic considerations must also be addressed.
Collapse
|
49
|
Moutzouris JP, Chow V, Chung T, Curnow J, Kritharides L, Chwan Ng AC. Acute pulmonary embolism during warfarin therapy and long-term risk of recurrent fatal pulmonary embolism. Thromb Haemost 2017; 110:523-33. [DOI: 10.1160/th13-04-0288] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 05/17/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe clinical characteristics and long-term outcomes of patients presenting with acute pulmonary embolism (PE) during treatment with warfarin have not been described. Clinical details of all patients admitted to a tertiary institution from 2000-2007 with acute PE were retrieved retrospectively, baseline warfarin status and the international normalised ratio (INR) were recorded, and their outcomes tracked using a statewide death registry. Of 923 patients with clearly documented warfarin status included in this study, 83 (9%) were taking warfarin. Mean (± standard deviation) day-1 INR of those taking warfarin was 2.3 ± 0.9, with 67% of patients therapeutically anti-coagulated (INR ≥2.0) at presentation (49 patients with INR <2.5 and 34 with INR ≥2.5). Patients taking warfarin on admission were more likely to have heart failure, atrial fibrillation and valvular heart disease, with similar prevalence of malignancy and ischaemic heart disease, compared to patients not on warfarin. Total mortality of the cohort (mean follow-up 4.0 ± 2.5 years) was 31.6% (in-hospital mortality 1.5%), and was similar between warfarin and no warfarin groups. There was however a greater than four-fold increased risk of post-discharge death due to recurrent PE for the patients taking warfarin on admission (hazard ratio [HR] 4.43, 95% confidence interval [CI] 1.36-14.42, p=0.01). Among patients taking warfarin on admission, day-1 INR <2.5 significantly increased long-term all-cause mortality compared to INR ≥2.5 (adjusted HR 2.51, 95% CI 1.08-5.86, p=0.03). In conclusion, patients presenting with PE during treatment with warfarin have an increased risk of death from recurrent PE. Admission INR appears to have independent long-term prognostic importance in these patients.
Collapse
|
50
|
McBane Ii R, Loprinzi CL, Ashrani A, Perez-Botero J, Leon Ferre RA, Henkin S, Lenz CJ, Le-Rademacher JG, Wysokinski WE. Apixaban and dalteparin in active malignancy associated venous thromboembolism. The ADAM VTE Trial. Thromb Haemost 2017; 117:1952-1961. [PMID: 28837207 DOI: 10.1160/th17-03-0193] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/24/2017] [Indexed: 12/13/2022]
Abstract
Currently, low molecular weight heparin (LMWH) is the guideline endorsed treatment of patients with cancer associated venous thromboembolism (VTE). While apixaban is approved for the treatment of acute VTE, there are limited data supporting its use in cancer patients. The rationale and design of this investigator initiated Phase IV, multicenter, randomized, open label, superiority trial assessing the safety of apixaban versus dalteparin for cancer associated VTE is provided (ADAM-VTE; NCT02585713). The main aim of the ADAM-VTE trial is to test the hypothesis that apixaban is associated with a significantly lower rate of major bleeding compared to dalteparin in the treatment of cancer patients with acute VTE. The primary safety outcome is rate of major bleeding. Secondary efficacy objective is to assess the rates of recurrent VTE or arterial thromboembolism. Cancer patients with acute VTE (n=300) are randomized to receive apixaban (10 mg twice daily for 7 days followed by 5 mg twice daily thereafter) or dalteparin (200 IU/Kg daily for 30 days followed by 150 IU/kg daily thereafter) for 6 months. Stratification factors used for randomization include cancer stage and cancer specific risk of venous thromboembolism using the Khorana score. Participating centers are chosen from the Academic and Community Cancer Research United (ACCRU) consortium comprised of 90 oncology practices in the United States and Canada. Based on the hypothesis to be tested, we anticipate that these trial results will provide evidence supporting apixaban as an effective treatment of cancer associated VTE at lower rates of major bleeding compared to LMWH.
Collapse
Affiliation(s)
- Robert McBane Ii
- Robert D. McBane II, MD, Gonda Vascular Center, Mayo Clinic, 200 First Street SW, Rochester, MN, USA, Tel.: +1 507 266 3964, Fax: +1 507 266 1617, E-mail:
| | | | | | | | | | | | | | | | | |
Collapse
|