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Sánchez-López V, Marín-Romero S, Ferrer-Galván M, Elías-Hernández T, Lobo Beristain JL, Ballaz Quincoces A, Jara-Palomares L, Rodríguez Martorell FJ, Castro MJ, Marín Hinojosa C, López-Campos JL, Otero-Candelera R. Occult cancer in patients with unprovoked venous thromboembolism: A nested case-control study. Am J Clin Pathol 2024; 161:501-511. [PMID: 38340336 PMCID: PMC11063558 DOI: 10.1093/ajcp/aqad178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 02/07/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVES Detecting occult cancer in patients with unprovoked venous thromboembolism (VTE) remains a significant challenge. Our objective was to investigate the potential predictive role of coagulation-related biomarkers in the diagnosis of occult malignancies. METHODS We conducted a nested case-control study with a 1-year prospective cohort of 214 patients with unprovoked VTE, with a focus on identifying occult cancer. At the time of VTE diagnosis, we measured various biomarkers, including soluble P-selectin (sP-selectin), dimerized plasmin fragment D (D-dimer), platelets, leukocytes, hemoglobin, total extracellular vesicles (EVs), EVs expressing tissue factor on their surface (TF+EVs), and EVs expressing P-selectin on their surface (Psel+EVs) in all participants. RESULTS We observed statistically significant increased levels of sP-selectin (P = .015) in patients with occult cancer. Despite an increase in Psel+EVs, TF+EVs, D-dimer, and platelets within this group, however, no significant differences were found. When sP-selectin exceeded 62 ng/mL and D-dimer surpassed 10,000 µg/L, the diagnosis of occult cancer demonstrated a specificity of up to 91% (95% CI, 79.9%-96.7%). CONCLUSIONS The combination of sP-selectin and D-dimer can be a valuable biomarker in detecting occult cancer in patients with unprovoked VTE. Further research is necessary to ascertain whether easily measurable biomarkers such as sP-selectin and D-dimer can effectively distinguish between patients who have VTE with and without hidden malignancies.
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Affiliation(s)
- Verónica Sánchez-López
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Samira Marín-Romero
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Marta Ferrer-Galván
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Teresa Elías-Hernández
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - Luis Jara-Palomares
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | - María José Castro
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
| | - Carmen Marín Hinojosa
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - José Luis López-Campos
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Remedios Otero-Candelera
- Instituto de Biomedicina de Sevilla, Hospital Universitario Virgen del Rocio/CSIC/Universidad de Sevilla, Seville, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Medical Surgical Unit of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Seville, Spain
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Ma’koseh M, Abufara A, Albaghdadi D, Ghalayni R, Abdel-Razeq S, Alzughali E, Abdel Rahman F, Alhalaseh Y, Halahleh K, Abdel-Razeq H. The Application of Existing Risk Assessment Models (RAMS) to Predict the Occurrence of Venous Thromboembolic Events among Patients with Classic Hodgkin Lymphoma. J Clin Med 2024; 13:436. [PMID: 38256570 PMCID: PMC10816014 DOI: 10.3390/jcm13020436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 12/06/2023] [Accepted: 12/25/2023] [Indexed: 01/24/2024] Open
Abstract
Background: A majority of patients included in risk assessment models (RAMs) developed to predict venous thromboembolic events (VTE) in lymphoma were non-Hodgkin lymphoma. Our study aims to evaluate the incidence and predictors of VTE, utilizing different RAMs, in patients with classic Hodgkin lymphoma (cHL) treated with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). Methods: Adult patients with cHL, treated and followed at our center, were included. Correlations between different variables, Khorana score, and thrombosis in lymphoma (ThroLy) RAMs with VTE were examined using Fisher's exact test and logistic regression analysis. Results: A total of 321 patients were included, with a median age of 29 (range: 18-83) years. Of them, 169 (52.6%) had advanced-stage disease. Combined modality treatment was given to 169 (52.6%) patients. A total of 52 (16.2%) patients had relapsed or refractory disease. VTE were reported in 15 (4.7%) patients and were mostly during the administration of first-line (n = 8, 53.3%), or salvage chemotherapy (n = 6, 40.0%). There was no correlation between a Khorana score > 2 (p = 0.689) or ThroLy score > 3 (p = 0.335) and VTE. Older age (p = 0.014) and relapsed or refractory disease (p = 0.003) significantly correlated with VTE. Conclusions: VTE are uncommon in cHL. The commonly used RAMs failed to predict VTE. However, older age and relapsed or refractory disease significantly increased this risk.
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Affiliation(s)
- Mohammad Ma’koseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
- School of Medicine, The University of Jordan, Amman 11942, Jordan;
| | - Alaa Abufara
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | - Dana Albaghdadi
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | - Ruba Ghalayni
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | | | - Eman Alzughali
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | - Fadwa Abdel Rahman
- Department of Radiation Oncology, King Hussein Cancer Center, Amman 11941, Jordan;
| | - Yazan Alhalaseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | - Khalid Halahleh
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
| | - Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman 11941, Jordan; (M.M.); (A.A.); (D.A.); (R.G.); (E.A.); (Y.A.); (K.H.)
- School of Medicine, The University of Jordan, Amman 11942, Jordan;
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Zhang YF, Wang GD, Huang MG, Qiu ZQ, Si J, Xu MY. Association between the Khorana risk score and all-cause mortality in Japanese patients with gastric and colorectal cancer: A retrospective cohort study. World J Gastrointest Oncol 2023; 15:1784-1795. [PMID: 37969412 PMCID: PMC10631431 DOI: 10.4251/wjgo.v15.i10.1784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/21/2023] [Accepted: 09/18/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND The Khorana risk score (KRS) has poor predictive value for cancer-associated thrombosis in a single tumor type but is associated with early all-cause mortality from cancer. Evidence for the association between KRS and all-cause mortality in Japanese patients with gastric and colorectal cancer is limited. AIM To investigate whether KRS was independently related to all-cause mortality in Japanese patients with gastric and colorectal cancer after adjusting for other covariates and to shed light on its temporal validity. METHODS Data from Dryad database were used in this study. Patients in the Gastroenterology Department of Sapporo General Hospital, Sapporo, Japan, were enrolled. The starting and ending dates of the enrollment were January 1, 2008 and January 5, 2015, respectively. The cutoff date for follow-up was May 31, 2016. The independent and dependent (target) variables were the baseline measured using the KRS and final all-cause mortality, respectively. The KRS was categorized into three groups: Low-risk group (= 0 score), intermediate-risk group (1-2 score), and high-risk group (≥ 3 score). RESULTS Men and patients with Eastern Cooperative Oncology Group Performance Status (ECOG PS) ≥ 2 displayed a higher 2-year risk of death than women and those with ECOG PS 0-1 in the intermediate/high risk group for KRS. The higher the score, the higher the risk of early death; however, the relevance of this independent prediction decreased with longer survival. The overall survival of each patient was recorded via real-world follow-up and retrospective observations, and this study yielded the overall relationship between KRS and all-cause mortality. CONCLUSION The prechemotherapy baseline of KRS was independently associated with all-cause mortality within 2 years; however, this independent predictive relationship weakened as survival time increased.
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Affiliation(s)
- Yu-Feng Zhang
- Department of Oncology Radiotherapy, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji 311800, Zhejiang Province, China
| | - Guo-Dong Wang
- Department of Oncology Radiotherapy, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji 311800, Zhejiang Province, China
| | - Min-Guang Huang
- Department of Oncology Radiotherapy, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji 311800, Zhejiang Province, China
| | - Zhao-Qi Qiu
- Department of Oncology Radiotherapy, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji 311800, Zhejiang Province, China
| | - Jia Si
- Department of Electrocardiography, Zhuji Affiliated Hospital of Wenzhou Medical University, Zhuji 311800, Zhejiang Province, China
| | - Mao-Yi Xu
- Department of Oncology, The First Hospital of Jiaxing (Affiliated Hospital of Jiaxing University), Jiaxing 314000, Zhejiang Province, China
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Verzeroli C, Giaccherini C, Russo L, Bolognini S, Gamba S, Tartari CJ, Schieppati F, Ticozzi C, Vignoli A, Masci G, Sarmiento R, Spinelli D, Malighetti P, Tondini C, Petrelli F, Giuliani F, D'Alessio A, Gasparini G, Minelli M, De Braud F, Santoro A, Labianca R, Marchetti M, Falanga A. Utility of the Khorana and the new-Vienna CATS prediction scores in cancer patients of the HYPERCAN cohort. J Thromb Haemost 2023; 21:1869-1881. [PMID: 37054917 DOI: 10.1016/j.jtha.2023.03.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 02/24/2023] [Accepted: 03/16/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Risk assessment models (RAMs) are relevant approaches to identify cancer outpatients at high risk of venous thromboembolism (VTE). Among the proposed RAMs, the Khorana (KRS) and the new-Vienna CATS risk scores have been externally validated in ambulatory patients with cancer. OBJECTIVES To test KRS and new-Vienna CATS scores in 6-month VTE prediction and mortality in a large prospective cohort of metastatic cancer outpatients during chemotherapy. PATIENTS/METHODS Newly diagnosed patients with metastatic non-small cell lung, colorectal, gastric, or breast cancers were analyzed (n = 1286). The cumulative incidence of objectively confirmed VTE was estimated with death as a competing risk and multivariate Fine and Gray regression. RESULTS Within 6 months, 120 VTE events (9.7%) occurred. The KRS and the new-Vienna CATS scores showed comparable c-stat. Stratification by KRS provided VTE cumulative incidences of 6.2%, 11.4%, and 11.5% in the low-, intermediate-, and high-risk categories, respectively (p = ns), and of 8.5% vs. 11.8% (p = ns) in the low- vs. high-risk group by the single 2-point cut-off value stratification. Using a pre-defined 60-point cut-off by the new-Vienna CATS score, 6.6% and 12.2% cumulative incidences were obtained in the low- and high-risk groups, respectively (p < 0.001). Furthermore, having a KRS ≥2 = or a new-Vienna CATS score >60 points was also an independent risk factor for mortality. CONCLUSION In our cohort, the 2 RAMs showed a comparable discriminating potential; however, after the application of cut-off values, the new-Vienna CATS score provided statistically significant stratification for VTE. Both RAMs proved to be effective in identifying patients at increased risk of mortality.
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Affiliation(s)
- Cristina Verzeroli
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Cinzia Giaccherini
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Laura Russo
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Silvia Bolognini
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Gamba
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Carmen J Tartari
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Francesca Schieppati
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Ticozzi
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Alfonso Vignoli
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Giovanna Masci
- Oncology Unit, Istituti di Ricovero e Cura a Carattere Scientifico Humanitas Institute, Rozzano, Italy
| | | | - Daniele Spinelli
- Department of Statistics, University of Milan Bicocca, Milan, Italy
| | - Paolo Malighetti
- Department of Management Engineering, University of Bergamo, Italy
| | - Carlo Tondini
- Oncology Unit, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Fausto Petrelli
- Oncology Unit, Hospital Treviglio-Caravaggio, Treviglio, Italy
| | - Francesco Giuliani
- Oncology Unit, Istituti di Ricovero e Cura a Carattere Scientifico Cancer Institute Giovanni Paolo II, Bari, Italy
| | - Andrea D'Alessio
- Medical Oncology and Internal Medicine, Policlinico San Marco, Gruppo San Donato Zingonia-Bergamo, Italy
| | | | - Mauro Minelli
- Oncology Unit, Hospital San Giovanni Addolorata, Rome, Italy
| | - Filippo De Braud
- Oncology Unit, Istituti di Ricovero e Cura a Carattere Scientifico National Cancer Institute, Milan, Italy
| | - Armando Santoro
- Oncology Unit, Istituti di Ricovero e Cura a Carattere Scientifico Humanitas Institute, Rozzano, Italy
| | | | - Marina Marchetti
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, School of Medicine, Milan, Italy
| | - Anna Falanga
- Immunohematology and Transfusion Medicine, Aziende Socio Sanitarie Territoriali Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, School of Medicine, Milan, Italy.
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Farmakis IT, Barco S, Mavromanoli AC, Konstantinides SV, Valerio L. Performance Status and Long-Term Outcomes in Cancer-Associated Pulmonary Embolism. JACC: CARDIOONCOLOGY 2022; 4:507-518. [DOI: 10.1016/j.jaccao.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
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Cost-Utility Analysis Comparing Direct Oral Anticoagulant and Low Molecular Weight Heparin Therapies for Secondary Prevention of Cancer-Associated Thrombosis. Clin Drug Investig 2022; 42:1075-1083. [DOI: 10.1007/s40261-022-01217-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/03/2022]
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Mitigating acute chemotherapy-associated adverse events in patients with cancer. Nat Rev Clin Oncol 2022; 19:681-697. [PMID: 36221000 DOI: 10.1038/s41571-022-00685-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2022] [Indexed: 11/08/2022]
Abstract
Despite the enthusiasm surrounding novel targeted agents and immunotherapies, chemotherapy remains the mainstay treatment for most human malignancies, either alone or in combination. Yet, the burden of chemotherapy-associated adverse events (CAAEs) remains high and, importantly, is associated with considerable morbidity, mortality and costs that affect patients across multiple dimensions, including physical, emotional and social functioning. CAAEs can directly affect patient outcomes and indirectly increase the risk of cancer recurrence by compromising treatment intensity and continuity. Systematic efforts to identify and critically summarize the evidence on management approaches for CAAEs remain limited. Herein, we review the most common acute CAAEs having a major effect on survival, quality of life, function and/or continuation of optimal therapy. We focus on selected acute toxicities that occur during treatment, summarizing their underlying pathophysiology, multifactorial aetiologies, evidenced-based treatments, prevention strategies and management recommendations. We also summarize the available evidence on risk factors, validated risk assessment tools and other efforts to optimize symptom control in patients most likely to benefit in order to personalize the prevention and treatment of acute CAAEs. Finally, we discuss innovative symptom monitoring and supportive care interventions that are under development to further improve the outcomes of patients with cancer.
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Thrombin Generation and D-Dimer for Prediction of Disease Progression and Mortality in Patients with Metastatic Gastrointestinal Cancer. Cancers (Basel) 2022; 14:cancers14184347. [PMID: 36139507 PMCID: PMC9496981 DOI: 10.3390/cancers14184347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background: the tight and reciprocal interaction between cancer and hemostasis has stimulated investigations on the possible role of hemostatic biomarkers in predicting specific cancer outcomes, such as disease progression (DP) and overall survival (OS). In a prospective cohort of newly diagnosed metastatic gastrointestinal (GI) cancer patients from the HYPERCAN study, we aimed to assess whether the hemostatic biomarker levels measured before starting any anticancer therapy may specifically predict for 6-months DP (6m-DP) and for 1-year OS (1y OS). Methods: plasma samples were collected and tested for thrombin generation (TG) as global hemostatic assay, and for D-dimer, fibrinogen, and prothrombin fragment 1 + 2 as hypercoagulation biomarkers. DP and mortality were monitored during follow-up. Results: A prospective cohort of 462 colorectal and 164 gastric cancer patients was available for analysis. After 6 months, DP occurred in 148 patients, providing a cumulative incidence of 24.8% (21.4−28.4). D-dimer and TG endogenous thrombin potential (ETP) were identified as independent risk factors for 6m-DP by multivariate Fine−Gray proportional hazard regression model corrected for age, cancer site, and >1 metastatic site. After 1 year, we observed an OS of 75.7% (71.9−79.0). Multivariate Cox regression analysis corrected for age, site of cancer, and performance status identified D-dimer and ETP as independent risk factors for 1y OS. Patients with one or both hemostatic parameters above the dichotomizing threshold were at higher risk for both 6m-DP and 1-year mortality. Conclusion.: in newly diagnosed metastatic GI cancer patients, pretreatment ETP and D-dimer appear promising candidate biomarkers for predicting 6m-DP and 1y OS. In this setting, for the first time, the role of TG as a prognostic biomarker emerges in a large prospective cohort.
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Fioretti AM, Leopizzi T, Puzzovivo A, Giotta F, Lorusso V, Luzzi G, Oliva S. Edoxaban: front-line treatment for brachiocephalic vein thrombosis in primitive mediastinal seminoma: A case report and literature review. Medicine (Baltimore) 2022; 101:e29429. [PMID: 36042679 PMCID: PMC9410609 DOI: 10.1097/md.0000000000029429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin. PATIENT CONCERNS A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment. DIAGNOSIS Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography. INTERVENTION We decided to switch the anticoagulant treatment from enoxaparin to edoxaban. OUTCOME The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance. LESSONS We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.
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Affiliation(s)
- Agnese Maria Fioretti
- Cardio-Oncology Unit, IRCCS Istituto Tumori Giovanni Paolo II, Viale Orazio Flacco 65, 70124, Bari, Italy
- *Correspondence: Agnese Maria Fioretti, Cardio-Oncology Unit, IRCCS Istituto Tumori Giovanni Paolo II, Viale Orazio Flacco 65, 70124 Bari, Italy (e-mail: )
| | - 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
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Can thromboprophylaxis build a link for cancer patients undergoing surgical and/or chemotherapy treatment? The MeTHOS cohort study. Support Care Cancer 2022; 30:6973-6984. [PMID: 35552827 PMCID: PMC9213358 DOI: 10.1007/s00520-022-07096-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/27/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with active cancer have a 4-sevenfold increased risk for venous thromboembolism (VTE) especially during systematic anticancer treatment. Simultaneously, surgery is an additional risk factor. METHODS The Metaxas's Hospital THromboprophylaxis program in Oncological & Surgical Patients (MeTHOS) is a prospective, phase IV, observational, non-interventional cohort study, aiming to record the thromboprophylaxis practice patterns in high-risk active cancer patients undergoing surgical and/or chemotherapy treatment. RESULTS We are reporting results from 291 ambulatory patients (median age: 67 years, Q1-Q3: 59-73 years, 54.6% males) who received anti-neoplastic treatment and administered thromboprophylaxis. 59.8% had cardiovascular disease (mostly hypertension), 76.6% were reported as having at least one comorbidity, while 27.5% and 15.8% accumulated two and three comorbidities, respectively. 94.9% of the patients were receiving highly thrombogenic agents such as platinum-based agents, 5-FU, immunotherapy, antiangiogenics/anti-VEGF, or erythropoietin. 26.5% of the patients were initially surgically treated. In terms of anticoagulation, all patients were treated with tinzaparin (fixed dose, 10,000 Anti-Xa IU, OD). The median anticoagulation duration was 6.2 months. Six thrombotic events were observed (2.06%, 95% CI: 0.76-4.43%): 5 were DVT, and one PE. With respect to safety, 7 bleeding events occurred (2.6%, 95% CI: 1.0-5.3%); 6 of them were minor. CONCLUSIONS Thromboprophylaxis with LMWH in patients with active cancer and high thrombotic burden was safe and effective. Intermediate dose of tinzaparin seems to be an appropriate agent for cancer-associated thromboprophylaxis management. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT04248348.
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Incidental pulmonary emboli are associated with a very high probability of progressive malignant disease on staging CT scans. Jpn J Radiol 2022; 40:914-918. [PMID: 35460065 DOI: 10.1007/s11604-022-01280-3] [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: 01/28/2022] [Accepted: 04/05/2022] [Indexed: 12/17/2022]
Abstract
PURPOSE The link between malignancy and venous thromboembolism (VTE) is well established; the risk has been shown to be higher in certain tumour types and in patients receiving platinum-based chemotherapy regimens. 'Active' cancer is often quoted as being a particular risk factor for VTE, but the definition varies widely and the supporting evidence is weak. This study was conceived to establish whether incidental pulmonary emboli are associated with an increased likelihood of progressive disease on a staging computed tomography (CT) scan. MATERIALS AND METHODS All CT scans containing incidental PEs over the course of a year in a large specialist cancer hospital were examined (n = 306). An age-matched control group was assembled. Multivariate logistic regression analysis was performed to establish the relationship of several independent variables, including progressive disease, with the dependent variable of the presence or absence of incidental pulmonary emboli. RESULTS Progressive disease was present in 144 of 306 (47.1%) of the patients in the PE group but only 63 of 306 (20.6%) of the control group patients. Progressive disease on the staging CT scan was found to have an odds ratio for incidental PE of 3.46, with a 95% CI of 2.38-5.01. Receiving platinum-based chemotherapy resulted in an odds ratio of 3.89 (2.41-6.28) for PE. Receiving non-platinum-based systemic anti-cancer therapy (SACT) resulted in an odds ratio for PE of 1.71 (1.16-2.50). CONCLUSION The detection of an incidental PE on a staging CT scan is associated with a very high risk of progressive malignant disease.
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12
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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.
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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
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13
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Perrella G, Nagy M, Watson SP, Heemskerk JWM. Platelet GPVI (Glycoprotein VI) and Thrombotic Complications in the Venous System. Arterioscler Thromb Vasc Biol 2021; 41:2681-2692. [PMID: 34496636 PMCID: PMC9653110 DOI: 10.1161/atvbaha.121.316108] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
The immunoglobulin receptor GPVI (glycoprotein VI) is selectively expressed on megakaryocytes and platelets and is currently recognized as a receptor for not only collagen but also a variety of plasma and vascular proteins, including fibrin, fibrinogen, laminin, fibronectin, and galectin-3. Deficiency of GPVI is protective in mouse models of experimental thrombosis, pulmonary thromboembolism as well as in thromboinflammation, suggesting a role of GPVI in arterial and venous thrombus formation. In humans, platelet GPVI deficiency is associated with a mild bleeding phenotype, whereas a common variant rs1613662 in the GP6 gene is considered a risk factor for venous thromboembolism. However, preclinical studies on the inhibition of GPVI-ligand interactions are focused on arterial thrombotic complications. In this review we discuss the emerging evidence for GPVI in venous thrombus formation and leukocyte-dependent thromboinflammation, extending to venous thromboembolism, pulmonary thromboembolism, and cancer metastasis. We also recapitulate indications for circulating soluble GPVI as a biomarker of thrombosis-related complications. Collectively, we conclude that the current evidence suggests that platelet GPVI is also a suitable cotarget in the prevention of venous thrombosis due to its role in thrombus consolidation and platelet-leukocyte complex formation.
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Affiliation(s)
- Gina Perrella
- Department of Biochemistry, CARIM, Maastricht University, The Netherlands (G.P., M.N., J.W.M.H.).,Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, United Kingdom (G.P., S.P.W.)
| | - Magdolna Nagy
- Department of Biochemistry, CARIM, Maastricht University, The Netherlands (G.P., M.N., J.W.M.H.)
| | - Steve P Watson
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, United Kingdom (G.P., S.P.W.).,COMPARE, Universities of Birmingham and Nottingham, The Midlands, United Kingdom (S.P.W.)
| | - Johan W M Heemskerk
- Department of Biochemistry, CARIM, Maastricht University, The Netherlands (G.P., M.N., J.W.M.H.).,Now with Synapse Research Institute, Maastricht, the Netherlands (J.W.M.H.)
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14
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Lyman GH, Kuderer NM. Clinical practice guidelines for the treatment and prevention of cancer-associated thrombosis. Thromb Res 2021; 191 Suppl 1:S79-S84. [PMID: 32736784 DOI: 10.1016/s0049-3848(20)30402-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/13/2019] [Accepted: 12/23/2019] [Indexed: 12/20/2022]
Abstract
The risk of venous thromboembolism (VTE) is increased in patients with cancer and is greatest in those with cancers of the pancreas, stomach, brain, lung and ovary, late stage disease and in those undergoing treatment including chemotherapy, hormonal therapy, or surgery. VTE in patients with cancer is associated with a variety of adverse consequences including an increased risk of VTE recurrence, major bleeding, and early mortality. A VTE risk score for ambulatory patients receiving cancer chemotherapy has been extensively validated and has been used to select high risk patients for thromboprophylaxis trials. Several randomized controlled trials (RCTs) and meta-analyses of these trials have confirmed that LMWHs can significantly reduce the risk of VTE in patients with cancer. While the direct oral anticoagulants (DOACs) have been approved for the general population, previous guideline panels discouraged their use due to a lack of cancer-specific data. Recently RCTs for the treatment of established VTE in patients with cancer have demonstrated that the risk of recurrent VTE is lower while the risk of bleeding greater with DOACs compared to LMWH. Two thromboprophylaxis trials comparing low dose DOACs to placebo in high risk patients receiving cancer therapy have recently reported similar rates of VTE occurrence at 6 months in the control arms. A meta-analysis of the pooled results from these trials in higher risk ambulatory patients receiving cancer therapy confirmed a significant reduction in overall VTE incidence as well as pre-planned secondary outcomes on treatment. Several clinical practice guidelines addressing VTE in patients with malignant disease have been updated including those from the American Society of Clinical Oncology (ASCO). The addition of DOACs as an option for the management of VTE in patients with cancer is the latest major change to previous guidelines issued by these organizations. The updated recommendations from these guidelines are summarized in this review.
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Affiliation(s)
- Gary H Lyman
- Fred Hutchinson Cancer Research Center, Seattle, WA, USA; University of Washington, Seattle, WA, USA.
| | - Nicole M Kuderer
- University of Washington, Seattle, WA, USA; Advanced Cancer Research Group, Seattle, WA, USA
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15
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Abdel-Razeq H, Ma’koseh M, Abdel-Razeq R, Amarin R, Abufara A, Mansour R, Manasrah M, Al-Rwashdeh M, Bater R. The Application of the Lymphoma International Prognostic Index to Predict Venous Thromboembolic Events in Diffuse Large B-Cell Lymphoma Patients. Front Oncol 2021; 11:677776. [PMID: 34123847 PMCID: PMC8195619 DOI: 10.3389/fonc.2021.677776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/04/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Venous thromboembolic events (VTE) are commonly encountered in patients with lymphoma. Several risk assessments models (RAM) had attempted to identify higher risk patients with varying success. The International Prognostic Index (IPI) is a clinicopathological tool developed to help predict both response to treatment and prognosis of patients with diffuse large B-cell lymphoma (DLBCL). OBJECTIVE In this study, we utilize the IPI index to identify group of patients with DLBCL at higher risk for VTE. PATIENTS/METHODS Patients with pathologically-confirmed diagnosis of DLBCL and with image-confirmed VTE, treated and followed at our institution were included. Rates of VTE was calculated for each risk category. RESULTS A total of 373 patients, median age 49 (range: 18-90) years were included. VTE were reported in 56 (15.0%) patients; 51 (91.1%) had active disease while 29 (51.8%) were ambulatory at time of VTE diagnosis. VTE rates were particularly high among patients with poor performance status (26.2%, P=0.028) and high LDH (19.0%, P=0.023). Applying the age-adjusted IPI separated patients into two risk categories; VTE were diagnosed in 9.7% in patients with "low and low-intermediate" scores compared to 19.8% in patients with "high and high-intermediate" scores, P=0.020. CONCLUSIONS The original IPI and its modified versions, routinely used at diagnosis as a prognostic and predictive tool for patients with DLBCL, can also be utilized to define high risk patients for VTE; the risk of whom might be high enough to recommend thromboprophylaxis even in the ambulatory settings. More work is needed to refine and improve currently available RAMs.
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Affiliation(s)
- Hikmat Abdel-Razeq
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
- School of Medicine, University of Jordan, Amman, Jordan
| | - Mohammad Ma’koseh
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Rula Amarin
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Alaa Abufara
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Razan Mansour
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | - Mohammad Manasrah
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
| | | | - Rayan Bater
- Department of Internal Medicine, King Hussein Cancer Center, Amman, Jordan
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16
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Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv 2021; 5:927-974. [PMID: 33570602 PMCID: PMC7903232 DOI: 10.1182/bloodadvances.2020003442] [Citation(s) in RCA: 418] [Impact Index Per Article: 139.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/29/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. RESULTS Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. CONCLUSIONS Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.
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Affiliation(s)
- Gary H Lyman
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, ON, Canada
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - Marcello Di Nisio
- Department of Medicine and Aging Sciences, University G. D'Annunzio, Chieti, Italy
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH
| | - Andrew D Leavitt
- Department of Laboratory Medicine and
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Medical Oncology, BC Cancer, Vancouver site, Provincial Health Services Authority, Vancouver, BC, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Simon Noble
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | | | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Lara A Kahale
- American University of Beirut (AUB) Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Center, American University of Beirut, Beirut, Lebanon; and
| | - Pablo Alonso-Coello
- Cochrane Iberoamérica, Biomedical Research Institute Sant Pau-CIBERESP, Barcelona, Spain
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17
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Khorana AA, Kuderer NM, McCrae K, Milentijevic D, Germain G, Laliberté F, MacKnight SD, Lefebvre P, Lyman GH, Streiff MB. Healthcare costs of patients with cancer stratified by Khorana score risk levels. J Med Econ 2021; 24:866-873. [PMID: 34181497 DOI: 10.1080/13696998.2021.1948681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIMS Patients with cancer are at high risk of venous thromboembolism (VTE), which entails a high economic burden. The risk of cancer-associated VTE can be assessed using the Khorana score (KS), a validated VTE risk prediction algorithm. This study compared healthcare costs associated with different KS in a population of patients newly diagnosed with cancer. METHODS The Optum Clinformatics DataMart database (01/01/2012-09/30/2017) was used to select adult patients with ≥1 hospitalization or ≥2 outpatient claims with a cancer diagnosis (index date) initiated on systemic therapy or radiation therapy. Patients were classified in mutually exclusive cohorts based on KS (i.e. KS = 0, 1, 2 or ≥3). The observation period spanned from index to the earliest among the end of data availability, death, end of insurance coverage, or 12 months. RESULTS In total 6,194 patients (KS = 0: 2,488; KS = 1: 2,125; KS = 2: 1,074; KS ≥ 3: 507) were included. On average, patients were aged 68 years, 48-52% were female, and the Quan-Charlson comorbidity index ranged between 1.1 and 1.4. Over the observation period, all-cause total healthcare costs per patient per month (PPPM) were $8,826 (KS = 0), $11,598 (KS = 1), $14,028 (KS = 2), and $16,211 (KS ≥ 3). Using the KS = 0 cohort as a reference, adjusted PPPM costs were $2,506, $4,775, and $6,452 higher in the KS = 1, KS = 2, and KS ≥ 3 cohorts, respectively. Hospitalization and outpatient costs were the main drivers of these differences. Similar results were found for VTE-related costs, which represented 4-11% of the total all-cause cost difference between KS cohorts. LIMITATIONS Residual confounders; results may not be generalized to patients with other insurance plans or those who received treatments other than systemic therapy or radiation therapy. CONCLUSIONS This real-world analysis found that cancer patients at higher risk of VTE (based on KS) incurred significantly greater all-cause and VTE-related healthcare costs compared with cancer patients at lower risk of VTE.
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Affiliation(s)
- Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | - Keith McCrae
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | | | | | | | | | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, and University of Washington, Seattle, WA, USA
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, John Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Iqbal U, Elsayed AS, Ozair S, Jing Z, James G, Li Q, Hussein AA, Guru KA. Validation of the Khorana Score for Prediction of Venous Thromboembolism After Robot-Assisted Radical Cystectomy. J Endourol 2020; 35:821-827. [PMID: 33218263 DOI: 10.1089/end.2020.0800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction: The Khorana score (KS) is used to predict the risk of venous thromboembolism (VTE) for cancer patients. We sought to assess the association between KS and VTE for patients who underwent robot-assisted radical cystectomy (RARC). Materials and Methods: We reviewed our prospectively maintained quality assurance RARC database between 2005 and 2020. KS was calculated for all patients (one point for each body mass index [BMI] ≥35 kg/m2, platelet count ≥350 × 109/L, leukocyte count >11 × 109/L, and hemoglobin level <10 g/dL, or use of erythropoiesis-stimulating agents). All patients received one point by default for the cancer type (bladder). Patients were divided into intermediate-risk (KS 1-2) or high-risk (KS ≥3) groups. Receiver operating characteristic curve was used to assess the ability of KS to predict VTE. Kaplan-Meier curves were stratified based on their KS risk and used to depict overall survival (OS). Multivariate analysis (MVA) was used to identify variables associated with VTE. Results: Out of 589 patients, 33 (6%) developed VTE (18 had deep vein thrombosis and 15 had pulmonary embolism). Five hundred forty-six (93%) patients had intermediate-risk KS and 30 (5%) of them developed VTE. Forty-three (7%) patients were classified as high-risk KS and 3 (7%) developed VTE. This difference was not significant (p = 0.73). The KS area under the curve for VTE prediction was 0.51. On MVA, BMI ≥35 kg/m2 (odds ratio [OR] 2.69, confidence interval [CI] 1.19-6.11, p = 0.02), longer inpatient stay (OR 1.04, CI 1.003-1.07, p = 0.03), and ≥pT3 disease (OR 2.29, CI 1.11-4.71, p = 0.03) were associated with VTE, whereas KS was not associated with VTE (p = 0.68). Five-year OS of patients with intermediate KS was 53% compared with 30% for high-risk KS (log rank p < 0.01). Conclusion: KS underestimated VTE risk after RARC and showed poor accuracy. This highlights the need to develop procedure-specific tools to estimate the risk of VTE after RARC.
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Affiliation(s)
- Umar Iqbal
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ahmed S Elsayed
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Sadat Ozair
- Department of Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Zhe Jing
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Gaybrielle James
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Qiang Li
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Ahmed A Hussein
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Khurshid A Guru
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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19
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Khorana AA, DeSancho MT, Liebman H, Rosovsky R, Connors JM, Zwicker J. Prediction and Prevention of Cancer-Associated Thromboembolism. Oncologist 2020; 26:e2-e7. [PMID: 33274815 DOI: 10.1002/onco.13569] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/30/2020] [Indexed: 12/15/2022] Open
Abstract
Venous and arterial thromboembolism are prevalent, highly burdensome, and associated with risk of worse outcomes for patients with cancer. Risk for venous thromboembolism (VTE) varies widely across specific cancer subpopulations. The ability to predict risk of cancer-associated VTE is critical because an optimal thromboprophylaxis strategy is best achieved by targeting high-risk patients with cancer and avoiding prophylaxis in patients with cancer at low risk for VTE. A validated risk tool for solid tumors has been available for a decade. Newer tools have focused on specific populations, such as patients with multiple myeloma. Emerging studies continue to optimize risk prediction approaches in patients with cancer. Recent randomized trials have specifically addressed risk-adapted thromboprophylaxis using direct oral anticoagulants, and revised guidelines have included these new data to formulate recommendations for outpatient thromboprophylaxis. Implementation science approaches to enhance use of outpatient prophylaxis in the context of these guideline changes are under way. However, major knowledge gaps remain, including a lack of data for inpatient thromboprophylaxis in the cancer setting and a lack of formal tools for identifying risk of bleeding. This review describes optimal approaches to risk prediction and patient selection for primary pharmacologic thromboprophylaxis of cancer-associated VTE, addresses barriers to implementing these practices, and highlights strategies to overcome them. IMPLICATIONS FOR PRACTICE: Risk for venous thromboembolism (VTE) varies widely among patients with cancer. Individual risk can be determined using validated approaches. Inpatient and postsurgical thromboprophylaxis is more widely accepted. However, most patients with cancer develop VTE in the outpatient setting. Recent randomized trials have demonstrated benefit to risk-adapted outpatient thromboprophylaxis. High-risk patients may therefore be considered for outpatient thromboprophylaxis as recommended by recently updated guidelines. System-wide implementation approaches are necessary to improve compliance with prophylaxis.
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Affiliation(s)
- Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maria T DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, New York, USA
| | - Howard Liebman
- Jane Anne Nohl Division of Hematology, Department of Medicine, University of Southern California - Keck School of Medicine, Los Angeles, California, USA
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Zwicker
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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20
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Muñoz-Unceta N, Zugazagoitia J, Manzano A, Jiménez-Aguilar E, Olmedo ME, Cacho JD, Oliveira J, Dómine M, Ortega-Morán L, Aguado C, Luna AM, Fernández L, Pérez J, Font C, Salvador C, Corral J, Benítez G, Ros S, Biosca M, Calvo V, Martínez J, Sánchez-Cánovas M, López R, Sereno M, Mielgo X, Aparisi F, Carmona M, Carrión R, Ponce-Aix S, Soares M, Martínez-Salas I, García-Morillo M, Juan-Vidal O, Blasco A, Muñoz AJ, Paz-Ares L. High risk of thrombosis in patients with advanced lung cancer harboring rearrangements in ROS1. Eur J Cancer 2020; 141:193-198. [DOI: 10.1016/j.ejca.2020.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/01/2020] [Accepted: 10/09/2020] [Indexed: 12/19/2022]
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21
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Khorana AA, Kuderer NM, McCrae K, Milentijevic D, Germain G, Laliberté F, MacKnight SD, Lefebvre P, Lyman GH, Streiff MB. Cancer associated thrombosis and mortality in patients with cancer stratified by khorana score risk levels. Cancer Med 2020; 9:8062-8073. [PMID: 32954653 PMCID: PMC7643641 DOI: 10.1002/cam4.3437] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Khorana score (KS) clinical algorithm is used to predict VTE risk in cancer patients. The study objective was to evaluate VTE and survival rates among patients newly diagnosed with cancer and stratified by KS in a real-world population. METHODS Data from the Optum® Clinformatics® DataMart database between 01/01/2012-09/30/2017 was used to identify adults with ≥ 1 hospitalization or ≥ 2 outpatient claims with a cancer diagnosis (index date). Only patients who were initiated on chemotherapy or radiation therapy were included. Patients were classified based on KS (KS = 0, 1, 2 or ≥ 3). Time-to-first VTE and survival were evaluated from the index date to the earliest among end of data availability or insurance coverage, death, or 12 months post-index using Kaplan-Meier (KM) analyses. RESULTS A total of 2,488 (KS = 0); 2,125 (KS = 1), 1,074 (KS = 2), and 507 (KS ≥ 3) cancer patients were included. The 12-month KM rates of VTE were 3.1%, 5.4%, 7.9%, and 14.9% (associated median time to VTE of 2.7, 3.0, 1.4, and 1.7 months) among KS = 0, 1, 2, and ≥ 3 cohorts, respectively. Corresponding adjusted hazard ratios (95% CIs) relative to the KS = 0 cohort were 1.72 (1.25-2.38), 2.46 (1.73-3.50), and 4.99 (3.40-7.31) for the KS = 1, 2, and ≥ 3 cohorts, respectively (all P < .001). Regardless of KS, patients with VTE had significantly lower survival rates than those without. CONCLUSIONS This real-world claims-based cohort study of newly diagnosed cancer patients showed significantly higher rates of VTE with increased KS, confirming its predictive ability. Moreover, VTE was associated with lower survival rates within each KS cohort.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Gary H. Lyman
- Fred Hutchinson Cancer Research Centerand University of WashingtonSeattleWAUSA
| | - Michael B. Streiff
- Division of HematologyDepartment of MedicineJohn Hopkins University School of MedicineBaltimoreMDUSA
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Li Z, Zhang G, Zhang M, Mei J, Weng H, Peng Z. Development and Validation of a Risk Score for Prediction of Venous Thromboembolism in Patients With Lung Cancer. Clin Appl Thromb Hemost 2020; 26:1076029620910793. [PMID: 32162530 PMCID: PMC7288811 DOI: 10.1177/1076029620910793] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This study aimed to develop and validate a risk score for early prediction of venous thromboembolism (VTE) in patients with lung cancer. A total of 827 patients with lung cancer from February 2013 to February 2018 in our hospital were retrospectively analyzed. Demographic and clinicopathological variables independently correlated to VTE were applied to develop the risk score in the development group while examined in the validation group. The regression coefficients of multivariable logistic regression test were applied to assign a risk score system. The incidence of VTE was 12.3%, 12.7%, and 11.8% in all patients, in the development and validation groups, respectively. The 496 patients in the development group were classified into 3 groups: low risk (scores ≤3), moderate risk (scores 4-5), and high risk (scores ≥6). The risk of VTE was significantly and positively related to the risk scores in both development and validation groups. The risk score system aided proper stratification of patients with either high or low risk of VTE in the development and validation groups (c statistic = 0.819 and 0.827, respectively). This risk score system based on the factors with most significant correlation showed good predictive ability and is potentially useful for predicting VTE in patients with lung cancer. However, it was developed and validated by a retrospective analysis and has significant limitations, and a prospective validation with all the classic variables assessing the thrombotic risk is needed for a solid conclusion.
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Affiliation(s)
- Zilun Li
- Division of Vascular Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Guolong Zhang
- Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Mengping Zhang
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Mei
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huiwen Weng
- Department of Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhenwei Peng
- Department of Radiation Oncology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Maraveyas A. Latest advances in preventing thromboembolic disease in the ambulatory oncology patient. Thromb Res 2020; 191 Suppl 1:S91-S98. [PMID: 32736786 DOI: 10.1016/s0049-3848(20)30404-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/23/2019] [Accepted: 12/30/2019] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is often cited as a major cause of death and morbidity in cancer patients. Even a non-lethal VTE causes distress and is commonly perceived by patients as a set-back in the cancer journey and a threat to the cancer treatment. It is also known that the risk of VTE varies between cancers (cancer-related risk factors), between patients (patient-related risk factors), and also within the cancer journey of a single patient. Risk can increase during treatments like surgery and chemotherapy and decline during remission. Neither the low molecular weight heparins nor the vitamin K analogues have gained an established role in thromboprevention guidance other than in 'the high risk' patient, who remains a rather ambiguous entity. The recently published randomised studies of rivaroxaban and apixaban in moderate- to high-risk thrombosis patients, assigned by the Khorana Risk Score, has seen the inclusion of direct oral anticoagulants (DOACs) in recent guidelines (e.g. the American Society of Clinical Oncology 2019 guidelines) for this indication. The ease of administration and the demonstrated greater patient adherence to oral agents has heightened the expectation that a practice-changing thromboprevention study in cancer patients should be realizable. However, key unmet needs that pose familiar challenges remain and as yet do not have satisfactory solutions. Anticoagulants carry risks of bleeding that are higher in the cancer population. There is therefore the challenge of sufficient risk reduction of VTE from the intervention balanced against the number of patients that may be harmed from bleeding. There is also the challenge of penetrating the risk threshold beyond which oncologists would deem thromboprevention a clinically meaningful praxis. Thus, identifying the high-risk groups of patients or targeting the length or timing of the thromboprevention to when the risks are highest are major questions that remain the subject of ongoing research. Notably all this is taking place against a backdrop of changing therapeutics for many cancers (e.g. targeted agents, checkpoint inhibitors and combinations) and their assorted impact on VTE incidence. In this review, past data for the ambulatory cancer patient are summarised, the latest evidence for the direct oral anticoagulants apixaban and rivaroxaban are analysed and the challenges of identifying the high-risk patients that have the greater chance of benefiting from thromboprophylaxis are discussed.
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Affiliation(s)
- Anthony Maraveyas
- Hull University Teaching Hospital NHS Trust, Hull York Medical School, University of Hull, Hull, UK.
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Tsoukalas N, Papakotoulas P, Christopoulou A, Ardavanis A, Koumakis G, Papandreou C, Papatsimpas G, Papakostas P, Samelis G, Andreadis C, Aravantinos G, Ziras N, Kalofonos C, Samantas E, Souggleri M, Makrantonakis P, Pentheroudakis G, Athanasiadis A, Stergiou H, Tripodaki ES, Bokas A, Grivas A, Timotheadou E, Bournakis E, Varthalitis I, Boukovinas I. Real-World Data on Thromboprophylaxis in Active Cancer Patients: Where Are We? Are We Getting There? Cancers (Basel) 2020; 12:cancers12071907. [PMID: 32679747 PMCID: PMC7409213 DOI: 10.3390/cancers12071907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Cancer patients are at high risk for cancer-associated thrombosis (CAT). CAT is the second leading cause of death in these patients but it can be preventable with thromboprophylaxis. Patients and Methods: An observational, prospective, multicenter study aiming to record CAT management in clinical practice was conducted by the Hellenic Society of Medical Oncology (HeSMO). Results: A total of 426 active cancer patients (mean age 65.3 years, mean BMI: 26.1 kg/m2) who received thromboprophylaxis, were included from 18 oncology units. Tumor types were lung 25.1%, pancreas 13.9%, breast 8.7%, stomach 8.5%, ovarian 7.8%, and others 36%, while 69% had metastases. A total of 71% had a Khorana score ≤2 and 61% received High Thrombotic Risk Chemotherapy Agents (HTRCAs, e.g., platinum). For thromboprophylaxis patients received mainly Low Molecular Weight Heparins (LMWHs), on higher than prophylactic doses in 50% of cases. Overall, 16 (3.8%) thrombotic events and 6 (1.4%) bleeding events were recorded. Notably, patients on higher doses of LMWHs compared to patients who received standard prophylactic doses had 70% lower odds to develop thrombotic events (OR: 0.3, 95% CI: 0.10–1.0, p = 0.04). Conclusion: CAT is an important issue in oncology. Along with the Khorana score, factors as metastases and use of HTRCAs should also be taken into consideration. Thromboprophylaxis for active cancer patients with LMWHs, even on higher doses is safe and efficient.
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Affiliation(s)
- Nikolaos Tsoukalas
- 401 General Military Hospital, 11525 Athens, Greece
- Correspondence: ; Tel.: +30-6977366056
| | - Pavlos Papakotoulas
- “Theagenio” Anticancer Hospital, 54639 Thessaloniki, Greece; (P.P.); (C.A.); (A.B.)
| | | | - Alexandros Ardavanis
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Georgios Koumakis
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | | | | | | | | | | | | | | | | | | | - Maria Souggleri
- ‘‘Saint Andrew’’ General Hospital, 26335 Patras, Greece; (A.C.); (M.S.)
| | | | | | | | - Helen Stergiou
- “Bioclinic” Hospital, 54622 Thessaloniki, Greece; (H.S.); (I.B.)
| | - Elli-Sofia Tripodaki
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Alexandros Bokas
- “Theagenio” Anticancer Hospital, 54639 Thessaloniki, Greece; (P.P.); (C.A.); (A.B.)
| | - Anastasios Grivas
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Eleni Timotheadou
- “Papageorgiou” General Hospital, 56429 Thessaloniki, Greece; (C.P.); (E.T.)
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Ahmed G, Nasir HG, Hall K, Weissmann L. Validation of the Khorana Score to Assess Venous Thromboembolism and Its Association with Mortality in Cancer Patients: A Retrospective Community-based Observational Experience. Cureus 2020; 12:e7883. [PMID: 32489737 PMCID: PMC7255532 DOI: 10.7759/cureus.7883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 04/29/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Khorana score (KS) stratifies patients into low, intermediate, and high risk groups for venous thromboembolism (VTE). We examined the generalizability of the KS to risk of VTE and association with mortality. METHODS A retrospective cohort study was conducted at Mount Auburn Hospital, Cambridge, Massachusetts. Patients aged 18 years or older undergoing chemotherapy were included. All patients were evaluated for a six-month period. Primary study endpoints were VTE or mortality. RESULTS Some 277 participants were included with a mean age of 63.95 (standard deviation, SD ± 12.47). The incidence proportion was 6.13% and a total of 17 VTE events were reported over a 2.5-year period. Compared to those with a low KS (0), those with a high KS (3 or above) had 6.4 times (p=0.032) while with an intermediate KS (1-2) had 2.6 times the odds of having a VTE event (p=0.22). Those who had a VTE had 4.03 times the odds of death compared to those who did not have a VTE (p=0.006). Compared to those with a low KS, those with a high KS had 5.7 times (p=0.02) the odds of six-month mortality and 5.04 odds (p=0.001) of mortality at any time. CONCLUSION High KS was associated with increased odds of VTE and mortality in our study.
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Affiliation(s)
- Gulrayz Ahmed
- Internal Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | - Kathryn Hall
- Preventive Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Lisa Weissmann
- Internal Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, USA
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The Incidence of Venous Thromboembolism and Impact on Survival in Hodgkin Lymphoma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:542-547. [PMID: 32245743 DOI: 10.1016/j.clml.2020.02.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 02/22/2020] [Accepted: 02/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Thrombosis increase the acute and long-term morbidity and mortality in malignancy patients. We analyzed venous thromboembolism (VTE) in patients with Hodgkin lymphoma, the impact of VTE on survival, predisposing factors for VTE, and predicting value of Khorana and ThroLy score models. PATIENTS AND METHODS We included 150 adult patients with Hodgkin lymphoma between January 2010 and 2018 at our university hospital. RESULTS VTE was observed in 31 patients (20.7%). The types of VTE were 18 upper and 3 lower extremity deep vein thrombosis and 10 pulmonary embolism (1 with lower extremity deep vein thrombosis). Twenty-nine patients developed VTE during the treatment with a median time of episode as 5 months. In logistic regression analysis, a body mass index of >32 kg/m2, high fibrinogen levels, initial thrombocytosis and leukocytosis, splenic and extranodal involvement, presence of a central venous line, advanced stage, line of treatment status of thromboprophylaxis, VTE timing, and better Eastern Cooperative Oncology Group performance scores were observed to be related with VTE. Kaplan Meier survival analysis showed a negative impact of VTE on survival. Khorana and ThroLy risk assessment models were found predictive for VTE (P = .000 and P = .003, respectively), although only ThroLy score was associated with the survival. CONCLUSION Thromboprophylaxis and precautions for VTE in patients with Hodgkin lymphoma according to validated risk assessment models can improve prognosis and quality of life owing to the impact of VTE on survival in the study.
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Barni S, Rosati G, Lonardi S, Pella N, Banzi M, Zampino MG, Dotti KF, Rimassa L, Marchetti P, Maiello E, Artioli F, Ferrari D, Labianca R, Bidoli P, Zaniboni A, Sobrero A, Iaffaioli V, De Placido S, Frassineti GL, Ciarlo A, Buonadonna A, Silvestris N, Piazza E, Pavesi L, Moroni M, Clerico M, Aglietta M, Giordani P, Galli F, Galli F, Petrelli F. Khorana score and thromboembolic risk in stage II-III colorectal cancer patients: a post hoc analysis from the adjuvant TOSCA trial. Ther Adv Med Oncol 2020; 12:1758835919899850. [PMID: 32010236 PMCID: PMC6974756 DOI: 10.1177/1758835919899850] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022] Open
Abstract
Background: The risk of venous thromboembolic events (VTE) during adjuvant chemotherapy
for colorectal cancer (CRC) is unknown. We aim to evaluate if the Khorana
score (KS) can predict this risk, and if it represents a prognostic factor
for overall survival (OS) through a post hoc analysis of
the phase III TOSCA trial of different durations (3- versus
6-months) of adjuvant chemotherapy. Methods: A logistic regression model was used to test the associations between the
risk of VTE and the KS. The results are expressed as odds ratios (OR) with
95% confidence intervals (95% CI). To assess the effect of the KS on OS,
multivariable analyses using Cox regression models were performed. The
results are expressed as hazard ratios (HR) with 95% CI. Results: Among 1380 CRC patients with available data, the VTE risk
(n = 72 events: 5.2%) was similar in the two duration arms
(5.5% versus 4.9%), with 0.2% of patients belonging to the
high-risk KS group. Rates of VTE were similar in the low- and
intermediate-risk groups (4.8% versus 6.4%). KS did not
represent an independent predictive factor for VTE occurrence. Chemotherapy
duration was not associated with VTE risk. In addition, KS was not
prognostic for OS in multivariate analysis (HR: 0.92, 95% CI, 0.63–1.36;
p = 0.6835). Conclusions: The use of the KS did not predict VTEs in a low–moderate thromboembolic risk
population as CRC. These data did not support the use of KS to predict VTE
during adjuvant chemotherapy, and suggest that other risk assessment models
should be researched.
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Affiliation(s)
- Sandro Barni
- Oncology Unit, Medical Science Department, ASST Bergamo Ovest, Treviglio (BG), Italy
| | - Gerardo Rosati
- Medical Oncology Unit, Ospedale San Carlo, Potenza, Italy
| | - Sara Lonardi
- Medical Oncology Unit 1, Istituto Oncologico Veneto-IRCCS, Padova, Italy
| | - Nicoletta Pella
- Medical Oncology Unit, Azienda Ospedaliero Universitaria Santa Maria della Misericordia, Udine, Italy
| | - Maria Banzi
- Medical Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Maria G Zampino
- Gastrointestinal Medical Oncology Unit and Neuroendocrine Tumors, Istituto Europeo di Oncologia-IRCCS, Milano, Italy
| | - Katia F Dotti
- Medical Oncology Unit, Fondazione Istituto Nazionale Tumori-IRCCS, Milano, Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, Humanitas Clinical and Research Center, Rozzano (MI), Italy
| | - Paolo Marchetti
- Medical Oncology Unit, Sant'Andrea Hospital, Sapienza University of Rome and IDI-IRCCS, Roma, Italy
| | - Evaristo Maiello
- Medical Oncology Unit, Hospital Casa Sollievo della Sofferenza-IRCCS, San Giovanni Rotondo, Italy
| | | | - Daris Ferrari
- Medical Oncology Unit, Azienda Ospedaliera San Paolo, Milano, Italy
| | | | - Paolo Bidoli
- Medical Oncology Unit San Gerardo dei Tintori Hospital, Monza, Italy
| | | | | | - Vincenzo Iaffaioli
- Abdominal Medical Oncology, National Cancer Institute, IRCCS Foundation Pascale, Napoli, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, Federico II University, Napoli, Italy
| | - Gian Luca Frassineti
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRST, IRCCS, Meldola, Italy
| | | | - Angela Buonadonna
- Medical Oncology Unit Centro di Riferimento Oncologico Aviano-IRCCS, Aviano, Italy
| | - Nicola Silvestris
- Medical Oncology Unit Ospedale Oncologico 'Giovanni Paolo II' and Scientific Directorate-IRCCS, Bari, Italy
| | - Elena Piazza
- Medical Oncology Unit AOU Sacco Hospital, Milano, Italy
| | - Lorenzo Pavesi
- Medical Oncology Unit Fondazione Maugeri-IRCCS, Pavia, Italy
| | - Mauro Moroni
- Medical Oncology Unit AO San Carlo Borromeo, Milano, Italy
| | - Mario Clerico
- Medical Oncology Department ASL Biella, Biella, Italy
| | - Massimo Aglietta
- Candiolo Cancer Institute FPO-IRCCS, Candiolo, Italy, Department of Oncology, University of Torino, Torino, Italy
| | - Paolo Giordani
- Medical Oncology Unit AO Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Francesca Galli
- Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fabio Galli
- Laboratory of Methodology for Clinical Research, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milano, Italy
| | - Fausto Petrelli
- Oncology Unit, Medical Science Department, ASST Bergamo Ovest, Piazzale Ospedale 1, Treviglio (BG), 24047, Italy
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Aonuma AO, Nakamura M, Sakamaki K, Murai T, Matsuda C, Itaya K, Sone T, Yagisawa M, Koike Y, Endo A, Tsukuda Y, Ono Y, Nagasaka A, Nishikawa S, Yamanaka T, Sakamoto N. Incidence of cancer-associated thromboembolism in Japanese gastric and colorectal cancer patients receiving chemotherapy: a single-institutional retrospective cohort analysis (Sapporo CAT study). BMJ Open 2019; 9:e028563. [PMID: 31439602 PMCID: PMC6707673 DOI: 10.1136/bmjopen-2018-028563] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Few data regarding the incidence of cancer-associated thromboembolism (TE) are available for Asian populations. We investigated the incidence of TE (TEi) and its risk factors among gastric and colorectal cancer (GCC) patients received chemotherapy in a daily practice setting. DESIGN A retrospective cohort study. SETTING A single-institutional study that used data from Sapporo City General Hospital, Japan, on patients treated between January 2008 and May 2015. PARTICIPANTS Five hundred Japanese GCC patients who started chemotherapy from January 2008 to May 2015. PRIMARY AND SECONDARY OUTCOME MEASURES TE was diagnosed by reviewing all the reports of contrast-enhanced CT performed during the follow-up period. All types of thrombosis detected by CT or additional imaging tests, such as venous TE, arterial TE and cerebral infarction, were defined as TE. Medical records of all identified patients were reviewed and potential risk factors for TE, including clinicopathological backgrounds, were collected. We defined the following patients as 'active cancer'; patients with unresectable advanced GCC, cancer recurrence during or after completing adjuvant chemotherapy and/or presence of other malignant tumours. RESULTS Of the 500 patients, 70 patients (14.0%) developed TE during the follow-up period. TEi was 9.2% and 17.3% in GCC patients, 18.1% and 3.5% in active and non-active cancer patients, and 24.0% and 12.9% in multiple and single primary, respectively. Multivariate logistic regression analysis showed that colorectal cancer (CRC) (OR 2.371; 95% CI 1.328 to 4.233), active cancer (OR 7.593; 95% CI 2.950 to 19.543) and multiple primary (OR 2.527; 95% CI 1.189 to 5.370) were independently associated with TEi. CONCLUSION TEi was 14.0% among Japanese GCC patients received chemotherapy, and was significantly higher among patients with CRC, active cancer and multiple primary than among those with gastric cancer, non-active cancer and single primary, respectively. TRIAL REGISTRATION NUMBER UMIN000018912.
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Affiliation(s)
- Ayane Oba Aonuma
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Michio Nakamura
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Kentaro Sakamaki
- Department of Biostatistics and Bioinformatics, University of Tokyo, Tokyo, Japan
| | - Taichi Murai
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Chika Matsuda
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Kazufumi Itaya
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Takayuki Sone
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Masataka Yagisawa
- Department of Gastroenterology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yuta Koike
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Ayana Endo
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yoko Tsukuda
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Yuji Ono
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Atsushi Nagasaka
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | - Shuji Nishikawa
- Department of Gastroenterology, Sapporo City General Hospital, Sapporo, Japan
| | | | - Naoya Sakamoto
- Department of Gastroenterology and Hepatology, Hokkaido University, Sapporo, Japan
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Gutierrez A, Patell R, Rybicki L, Khorana AA. Predicting outcomes in patients with cancer and atrial fibrillation. Ther Adv Cardiovasc Dis 2019; 13:1753944719860676. [PMID: 31319783 PMCID: PMC6643169 DOI: 10.1177/1753944719860676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: The role of cancer-specific factors for ischemic stroke and mortality in
patients with cancer and atrial fibrillation (AF) is unknown. We evaluated
the utility of a previously validated risk tool for venous thromboembolism
(VTE) in cancer outpatients [Khorana score (KS)] in predicting stroke and
mortality in cancer patients with AF. Methods: We conducted a retrospective cohort study of patients with cancer and AF at
the Cleveland Clinic from 2008 to 2014. Outcomes, CHADS2, CHA2DS2-VASc, and
KS scores were calculated from date of cancer diagnosis. Prognostic factors
were identified with Fine and Gray regression (for stroke) or Cox
proportional hazards analysis (for mortality). Results: The study population comprised 1181 patients. Genitourinary (19%), lung
(18%), and gastrointestinal (13%) were the most frequent cancers. Overall,
67% had CHADS2 ⩾ 2, 57% had an intermediate KS (1–2), and 7% high KS (⩾3).
Median follow up was 26.5 months (range 0.03–76). At a median of 8.2 months
(range 0–61), 45 patients (3.8%) developed a stroke and 418 (35%) died. In
multivariable analysis a high KS (HR 4.5, 95% CI 3.2–6.3,
p < 0.001) was associated with a quadruple risk of death
and every point increase in CHADS2 score had a 20% increased risk of death
(HR 1.19, 95% CI 1.1–1.2, p < 0.001). The addition of KS
did not improve risk stratification for ischemic stroke to CHADS2. Conclusion: In patients with cancer and AF, CHADS2 and CHA2DS2-VASc but not KS were
predictive of ischemic stroke. A high KS represented a unique predictor of
mortality beyond traditional risk scores.
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Affiliation(s)
- Alejandra Gutierrez
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Rushad Patell
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lisa Rybicki
- Department of Quantitative Health Sciences. Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute Cleveland Clinic, 9500 Euclid Avenue, R35 Cleveland, OH 44195, USA
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Fuentes HE, Tafur AJ, Caprini JA, Alatri A, Trujillo-Santos J, Farge-Bancel D, Rosa V, Font L, Vilaseca A, Monreal M. Prediction of early mortality in patients with cancer-associated thrombosis in the RIETE Database. INT ANGIOL 2019; 38:173-184. [PMID: 31112023 DOI: 10.23736/s0392-9590.19.04110-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Proper risk stratification of patients for early mortality after cancer-associated thrombosis may lead to personalized anticoagulation protocols. Therefore, we aimed to derive and validate a scoring system to predict early mortality in this population. To this end, we selected patients with active cancer and thrombosis from the Computerized Registry of Patients with Venous Thromboembolism database. METHODS The main outcome was all cause mortality within the month following a thrombotic event. We used a simple random selection to split are data in a derivation and a validation cohort. In the derivation cohort, we used recursive partitioning and binary logistic regression to identify groups at risk and to determine the likelihood of the primary outcome. The risk score was developed based on odds ratios from the final multivariate model, and then tested in the validation cohort. RESULTS In 10,025 eligible patients, we identified 6 predictors of 30-day mortality: leukocytosis ≥11.5x109/L; platelet count ≤160x109/L, metastasis, recent immobility, initial presentation as pulmonary embolism and Body Mass Index <18.5. The model divided the population into 3 risk categories: low (score 0-3), moderate (score 4-6), and high (score ≥7). The AUC for the overall score was 0.74, and using a cutoff ≥7 points, the model had a negative predictive value of 94.4%, a positive predictive value of 23.1%, a sensitivity of 73.3%, and a specificity of 64.6% in the validation cohort. CONCLUSIONS Our validated risk model may assist physicians in the selection of patients for outpatient management, and perhaps anticoagulant, considering expanding anticoagulation options.
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Affiliation(s)
- Harry E Fuentes
- Department of Hematology Oncology, Mayo Clinic, Rochester, MN, USA -
| | - Alfonso J Tafur
- Division of Vascular Medicine, Department of Internal Medicine Cardiology, NorthShore University HealthSystem, Evanston, IL, USA.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Joseph A Caprini
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.,NorthShore University, HealthSystem-Emeritus, Evanston, IL, USA
| | - Adriano Alatri
- Division of Angiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Javier Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Murcia, Spain
| | | | - Vladimir Rosa
- Department of Internal Medicine, Virgen de Arrixaca University Hospital, Murcia, Spain
| | - Llorenç Font
- Department of Hematology, Tortosa Verge de la Cinta Hospital, Tarragona, Spain
| | - Alicia Vilaseca
- Department of Hematology and Hemostasis, San Camilo Clinic, Buenos Aires, Argentina
| | - Manuel Monreal
- Department of Internal Medicine, Germans Trias i Pujol University Hospital, Badalona, Barcelona, Spain
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Cai R, Zimmermann C, Krzyzanowska M, Granton J, Hannon B. Thromboprophylaxis for inpatients with advanced cancer in palliative care settings: A systematic review and narrative synthesis. Palliat Med 2019; 33:486-499. [PMID: 30819046 DOI: 10.1177/0269216319830860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with advanced cancer have an elevated risk of venous thromboembolism. Increasingly, patients are admitted to palliative care settings for brief admissions, with greater numbers of discharges (vs deaths) reported internationally. There is limited guidance around the use of thromboprophylaxis or incidence of venous thromboembolism for these patients. AIM The aim of this study was to review the use of thromboprophylaxis as well as incidence of venous thromboembolism and bleeding in palliative care units or residential hospices for patients with advanced cancer. DESIGN A systematic review using Cochrane methods. DATA SOURCES Medline, Embase and the Cochrane Library were searched up to 28 September 2018 along with a grey literature search; the reference lists of selected papers were hand-searched. Inclusion criteria were original papers assessing thromboprophylaxis use in palliative care units or residential hospices for adult inpatients with cancer. Two reviewers independently selected and appraised papers using a tool designed for disparate data. Heterogeneity in study design made a meta-analysis not possible. RESULTS A total of 11 full-text papers (9 quantitative and 2 qualitative) and 11 abstracts were included. Thromboprophylaxis use ranged between 4% and 53%; venous thromboembolism rates between 0.5% and 20%; and bleeding incidence was between 0.01% and 9.8%. Risk assessment tools were used infrequently and adherence to international thromboprophylaxis guidelines ranged between 5% and 71%. Physician opinions differed around the use of thromboprophylaxis; patients were largely accepting of thromboprophylaxis if it was offered. CONCLUSION There is limited evidence around the optimal use of thromboprophylaxis for patients with advanced cancer admitted to palliative care settings. Although some patients may derive benefit, further research in this area is warranted.
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Affiliation(s)
- Runting Cai
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Camilla Zimmermann
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Monika Krzyzanowska
- 2 Department of Medicine, University of Toronto, Toronto, ON, Canada.,3 Department of Medical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - John Granton
- 2 Department of Medicine, University of Toronto, Toronto, ON, Canada.,4 Division of Respiratory Medicine, University Health Network, Toronto, ON, Canada
| | - Breffni Hannon
- 1 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,2 Department of Medicine, University of Toronto, Toronto, ON, Canada
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Fuentes HE, Oramas DM, Paz LH, Wang Y, Andrade XA, Tafur AJ. Venous Thromboembolism Is an Independent Predictor of Mortality Among Patients with Gastric Cancer. J Gastrointest Cancer 2019. [PMID: 28634671 DOI: 10.1007/s12029-017-9981-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is an independent predictor of death among patients with cancer. Patients with gastric cancer (GC) are at higher risk for VTE when compared to other solid tumors, and if one considers its prevalence, GC may be responsible for one of the highest incidences of cancer-associated thrombosis. The impact of VTE on mortality is not well defined among patients with GC. AIM The aim of this study is to measure the impact of VTE as independent predictor of GC mortality. METHODS Chart review of patients with GC treated in the Department of Oncology at John Stroger Hospital between the years of 2010 and 2015. VTE events were objectively confirmed with imaging in all cases. Active GC was defined as biopsy-proven metastatic disease or on active chemotherapy. Along with cancer-specific data, we abstracted risk assessments tools, non-GC-specific, validated for VTE and mortality prediction cancer, including the Khorana score (KRS), platelet lymphocyte ratio (PLR), and neutrophil lymphocyte ratio (NLR). Continuous variables are expressed by the median as appropriate according to normality. Categorical variables are expressed as percentages. SPSS version 22 was used and chi-square, Mann-Whitney U, Kaplan-Meier curve, and Cox proportional hazard with forward modeling were applied. RESULTS We included 112 patients in the analysis. The patients were predominantly men (66%), 58-year-old, with adenocarcinoma (84%) and advanced disease (59%). The median follow-up was 21.3 months (IQR 8.9-42.4). Cumulative incidence of VTE at 1 year was 9%. The median time from diagnosis to VTE occurrence was 59 days (IQR 36 to 258). Patients with VTE had worse OS when compared to the non-VTE group (medians 11.87 vs 29.97 months, p = 0.02). Patients stratified as high risk by the PLR had worse OS (medians 22.6 vs 42.77 months, p = 0.02). There was no statistical difference in OS among patients stratified as high risk by the KRS (medians 23.7 vs 42.5, p = 0.16) and NLR (medians 24.1 vs 42.7 months, p = 0.21). In multivariate analysis, the independent predictors of mortality were VTE (hazard ratio (HR), 2.9; 95% CI, 1.4 to 6.6; p < 0.01), adenocarcinoma (HR, 3.1; 95% CI, 1.1 to 9.0; p = 0.03), advanced disease (HR, 2.8; 95% CI, 1.4 to 5.8; p < 0.01), and PLR (HR, 2.2; 95% CI, 1.3 to 3.8; p < 0.01). CONCLUSION VTE is associated with worse survival among patients with GC along with adenocarcinoma, advanced disease, and PLR. Moreover, these findings were independent of other cancer- and treatment-specific variables. Although potentially predictive in other cancer types, NLR and KRS were not associated with worse survival in this cohort.
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Affiliation(s)
- Harry E Fuentes
- Department of Internal Medicine, John Stroger Jr. Hospital, 1900 West Polk Street, Chicago, IL, 60612, USA.
| | - D M Oramas
- Department of Pathology, University of Illinois at Chicago, Chicago, IL, USA
| | - L H Paz
- Department of Internal Medicine, John Stroger Jr. Hospital, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - Y Wang
- Department of Internal Medicine, John Stroger Jr. Hospital, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - X A Andrade
- Department of Internal Medicine, John Stroger Jr. Hospital, 1900 West Polk Street, Chicago, IL, 60612, USA
| | - A J Tafur
- Cardiology - Vascular Medicine, NorthShore University HealthSystem, Evanston, IL, USA
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Predictive factors for cancer-associated thrombosis in a large retrospective single-center study. Support Care Cancer 2019; 27:1163-1170. [DOI: 10.1007/s00520-018-4602-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 12/10/2018] [Indexed: 12/21/2022]
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Dimakakos E, Livanios K, Gkiozos I, Harpidou A, Ntalakou E, Kainis L, Syrigos K. Response to the letter to the editor: "New data for venous thromboembolism in patients with small cell lung cancer: A review". Phlebology 2018; 34:139-140. [PMID: 30403153 DOI: 10.1177/0268355518812596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Evangelos Dimakakos
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Konstantinos Livanios
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Ioannis Gkiozos
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Adriani Harpidou
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Eleutheria Ntalakou
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Llias Kainis
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
| | - Konstantinos Syrigos
- Oncology Unit GPP, Sotiria General Hospital, Athens School of Medicine, Athens, Greece
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Freund N, Sabroe JE, Bytzer P, Madsen SM. Compliance with Guidelines on Thromboprophylaxis for Acutely Admitted Medical Patients. Adv Ther 2018; 35:1873-1883. [PMID: 30367365 DOI: 10.1007/s12325-018-0821-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The risk of venous thromboembolism (VTE) is increased by more than 100-fold among hospitalised medical patients compared to subjects in the community. The Danish Council for the Use of Expensive Hospital Medicines has published national guidelines on thromboprophylaxis (TP) in which the risks of VTE and bleeding are balanced. We wanted to investigate the proportion of acutely admitted medical patients for whom thromboprophylaxis was indicated and to what extent the guidelines were followed. METHODS Data from patients hospitalised at two medical wards were screened. We registered the proportion of patients for whom mechanical or pharmacologic TP (MTP and PTP, respectively) was indicated and whether national guidelines were followed. All data extraction and analyses were performed retrospectively. RESULTS After exclusion criteria were applied, 340 cases remained. PTP was indicated in 26 patients (7.6%) but only 4 patients were treated besides 12 patients who were already in anticoagulant treatment at submission. Conversely, 8/306 patients, in whom TP was not indicated, were started on PTP. MTP was indicated in 8/340 patients (2.4%) but therapy was not initiated in any of them. The majority (320/340, 94.1%) of cases was managed in accordance with existing guidelines. However, this high proportion was mainly explained by the large number of untreated patients, where TP was not indicated. CONCLUSION A large proportion of hospitalised medical patients was managed in conflict with national guidelines. A systematic approach to TP in patients with acute medical illness should be implemented. Plain language summary available for this article.
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Affiliation(s)
- Nanna Freund
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
| | - Jonas E Sabroe
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark
| | - Peter Bytzer
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Søren M Madsen
- Department of Medicine, Zealand University Hospital Køge, Køge, Denmark.
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Figueroa R, Alfonso A, López-Picazo J, Gil-Bazo I, García-Mouriz A, Hermida J, Páramo JA, Lecumberri R. Insights into venous thromboembolism prevention in hospitalized cancer patients: Lessons from a prospective study. PLoS One 2018; 13:e0200220. [PMID: 30071038 PMCID: PMC6071981 DOI: 10.1371/journal.pone.0200220] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/21/2018] [Indexed: 11/30/2022] Open
Abstract
Hospitalized cancer patients are at high risk of venous thromboembolism (VTE). Despite current recommendations in clinical guidelines, thromboprophylaxis with low molecular weight heparin (LMWH) is underused. We performed an observational prospective study to analyse factors influencing prophylaxis use, VTE events and mortality in cancer-hospitalized patients. 1072 consecutive adult cancer patients were included in an University Hospital from April 2014 to February 2017, and followed-up for 30 days after discharge. The rate of LMWH prophylaxis was 67.6% (95% confidence interval [CI] 64.7% to 70.4%), with a 2.8% rate of VTE events (95% CI 1.9% to 3.9%) and 3.5% rate of major bleeding events (95% CI 2.5% to 4.8%). 80% of VTE events occurred despite appropriate thromboprophylaxis. Overall, 30-day mortality rate was 13.2% (95% CI 11.2% to 15.3%). Active chemotherapy treatment, hospital stay ≥ 4 days, and metastatic disease were associated with a higher use of LMWH. On the contrary, patients with hematologic malignancies, anemia or thrombocytopenia were less prone to receive thromboprophylaxis. The main reasons for not prescribing LMWH prophylaxis were thrombocytopenia (23.9%) and active/recent bleeding (21.8%). The PRETEMED score, used for VTE risk stratification, correlated with 30-day mortality. There is room for improvement in thromboprophylaxis use among hospitalized-cancer patients, especially among those with hematologic malignancies. A relevant number of VTE events occurred despite prophylaxis with LMWH. Therefore, identification of risk factors for thromboprophylaxis failure is needed.
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Affiliation(s)
- Rocío Figueroa
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
| | - Ana Alfonso
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
| | | | - Ignacio Gil-Bazo
- Oncology Department, University Clinic of Navarra, Pamplona, Spain
| | | | - José Hermida
- Centre for Applied Medical Research, University of Navarra, Pamplona, Spain
- Centro de Investigación Biomédica en Red (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - José Antonio Páramo
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
- Centro de Investigación Biomédica en Red (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
| | - Ramón Lecumberri
- Hematology Service, University Clinic of Navarra, Pamplona, Spain
- Centro de Investigación Biomédica en Red (CIBER-CV), Instituto de Salud Carlos III, Madrid, Spain
- * E-mail:
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The association of venous thromboembolism with survival in pediatric cancer patients: a population-based cohort study. Ann Hematol 2018; 97:1903-1908. [PMID: 29846760 DOI: 10.1007/s00277-018-3371-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 05/08/2018] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is a well-recognized complication in pediatric oncology patients. Studies in adult oncology patients have suggested a potential negative association between VTE and survival, but this association has not been examined in pediatric patients yet. The aim of this study was to assess the association of VTE with survival in pediatric oncology patients. Data from all pediatric oncology patients treated at the two tertiary care centers in Atlantic Canada were pooled to create a population-based cohort. The association between VTE and survival was analyzed using a Cox proportional hazards model stratified by diagnosis group (leukemia, lymphoma, and other; sarcoma) and adjusted for age at diagnosis and sex. Out of 939 patients included in this study, 73 had a VTE (8%) and 131 (14%) patients died during the study period. Children in the leukemia/lymphoma/other group with a VTE had significantly poorer survival relative to children in the same group who did not have a VTE. Although children with sarcoma and VTE had poorer survival compared to children with sarcoma with no VTE, this association was not statistically significant. In this population-based study, we found a negative association between VTE and survival in pediatric oncology patients. If future studies confirm this association, this finding may have prognostic implications and potentially offer new avenues for the management of pediatric patients with cancer.
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Vathiotis I, Dimakakos EP, Boura P, Ntineri A, Charpidou A, Gerotziafas G, Syrigos K. Khorana Score: Νew Predictor of Early Mortality in Patients With Lung Adenocarcinoma. Clin Appl Thromb Hemost 2018; 24:1347-1351. [PMID: 29806470 PMCID: PMC6714766 DOI: 10.1177/1076029618777153] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE) is a typical complication in patients with lung cancer. Khorana score is an established tool for thromboembolic risk stratification of ambulatory patients with cancer undergoing outpatient chemotherapy. The aim of this study was to evaluate the predictive value of the Khorana score for VTE and death in patients with lung adenocarcinoma during first-line or adjuvant chemotherapy. Medical records of 130 patients with lung adenocarcinoma receiving first-line or adjuvant chemotherapy were retrospectively studied during the time period June 2013 to May 2015. Venous thromboembolism occurred in 13 (10.0%) patients. Thromboembolic events were significantly correlated with reduced survival during treatment period (hazard ratio [HR]: 3.24; 95% confidence interval [CI]: 1.11-9.49; P = .032). The VTE rates did not present statistically significant difference between different Khorana score groups ( P = .96). In univariate analysis, the risk of death during treatment period (median: 16 weeks) was 3.75 times higher in high-risk versus intermediate-risk patients (HR: 3.75, 95% CI: 1.36-10.36; P = .001) and had 2.25 times higher per point increase in the Khorana score (HR: 2.25, 95% CI: 1.36-3.73; P = .002); the above results were also reproduced in multivariate analysis. Khorana score represents a valuable tool for identifying patients with cancer in low thromboembolic risk but does not preserve its predictive value for higher risk individuals. Khorana score is an independent risk factor for death in patients with lung adenocarcinoma receiving first-line or adjuvant chemotherapy.
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Affiliation(s)
- Ioannis Vathiotis
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Evangelos P. Dimakakos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
- Evangelos P. Dimakakos, Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Aisopou 10, Marousi 15122, Greece.
| | - Paraskevi Boura
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Angeliki Ntineri
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Andiani Charpidou
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Grigoris Gerotziafas
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - Konstantinos Syrigos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
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Rupa-Matysek J, Brzeźniakiewicz-Janus K, Gil L, Krasiński Z, Komarnicki M. Evaluation of the ThroLy score for the prediction of venous thromboembolism in newly diagnosed patients treated for lymphoid malignancies in clinical practice. Cancer Med 2018; 7:2868-2875. [PMID: 29761831 PMCID: PMC6051175 DOI: 10.1002/cam4.1540] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 04/12/2018] [Accepted: 04/15/2018] [Indexed: 12/13/2022] Open
Abstract
The utility in clinical practice of a recently developed and validated predictive model for venous thromboembolism (VTE) events in lymphoma patients, known as the thrombosis lymphoma (ThroLy) score, is unknown. We evaluated the association of ThroLy with VTE in patients treated for diffuse large B-cell lymphoma (DLBCL) or Hodgkin lymphoma (HL) undergoing ambulatory first-line chemotherapy. Retrospective analyses were performed on 428 patients (median age 50), 241 were newly diagnosed DLBCL, and 187 had HL. During initial chemotherapy, 64 (15%) patients developed VTE. According to the ThroLy, 322 (75.2%) patients were considered low risk, 88 (20.6%) patients had intermediate risk and 18 (4.2%) patients high risk for VTE development. Patients with DLBCL were more often in the high-risk ThroLy group and had more VTE events than HL. VTE occurred in; 38.9% (n = 7) high-risk patients, 29.5% (n = 26) intermediate risk, and 9.6% (n = 31) low risk according to the ThroLy score. However, in multivariate analysis, high ThroLy (OR 5.13; 95% CI: 1.83-14.36, P = .002), intermediate ThroLy (OR 3.96; 95% CI: 2.19-7.17, P < .001), and aggressive lymphoma-DLBCL (OR 1.91; 95% CI: 1.05-3.47, P = .034) were all significantly associated with development of VTE, 48% of the VTE events occurred in the low-risk ThroLy score group (the ROC AUC (95% CI) 0.40-0.70 and C statistic-0.55). In our study, the ThroLy score was not a suitably accurate model for predicting VTE events in patients at higher risk of VTE. Further research should be conducted to identify new biomarkers that will predict these events and to establish a new VTE risk assessment model.
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Affiliation(s)
- Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Zbigniew Krasiński
- Department of General and Vascular Surgery, Poznan University of Medical Sciences, Poznań, Poland
| | - Mieczysław Komarnicki
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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40
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Rupa-Matysek J, Gil L, Barańska M, Dytfeld D, Komarnicki M. Mean platelet volume as a predictive marker for venous thromboembolism in patients treated for Hodgkin lymphoma. Oncotarget 2018; 9:21190-21200. [PMID: 29765530 PMCID: PMC5940371 DOI: 10.18632/oncotarget.25002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 03/14/2018] [Indexed: 12/14/2022] Open
Abstract
Mean platelet volume (MPV) is reported to be associated with the risk of venous thromboembolism (VTE) and mortality in patients with cancer. We sought to determine the association of MPV with symptomatic VTE occurrence in patients treated for newly diagnosed Hodgkin lymphoma (HL) and their outcomes. We retrospectively studied 167 consecutive adult patients treated with HL. During first-line treatment 12 (7.2%) patients developed VTE and 14 (8%) died within the observation period. The pre-chemotherapy values of MPV were significantly lower in VTE patients than those without (p=0.0343). Patients with MPV≤25th percentile (6.8 fl) had an increased risk of VTE occurrence (p=0.0244). In multivariate analysis, MPV≤25th percentile (OR 2.21; 95%CI 1.07-4.57, p=0.033), advanced stage (OR 2.08; 95%CI 1.06-4.07, p=0.033) and bulky disease (OR 2.23; 95%CI 1.16-4.31, p=0.016) were significant factors for developing VTE. Only the impact of MPV≤25th percentile on VTE-free survival rates was found. VTE occurred in 43% (n=3) of the high-risk patients of the Thrombosis Lymphoma (ThroLy) score and in 17% (n=2) of the high-risk of the Khorana Risk Score (KRS). Neither the KRS nor the ThroLy score could identify patients at a high risk of VTE with a high degree of accuracy. We expanded the ThroLy score with the addition of the MPV≤25th percentile to more accurately identify HL patients with a higher risk of VTE. Our study indicates that the pre-chemotherapy MPV value, while of no use as an overall prognosis predictor, may still represent a useful prognostic marker for a significant VTE risk especially when incorporated into VTE-risk assessment models.
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Affiliation(s)
- Joanna Rupa-Matysek
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Lidia Gil
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Marta Barańska
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Dominik Dytfeld
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
| | - Mieczysław Komarnicki
- Department of Haematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Poznań, Poland
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Tafur AJ, Fuentes H, Caprini JA, Rivas A, Uresandi F, Duce R, Lopez-Reyes R, Visona A, Merah A, Monreal M. Predictors of Early Mortality in Cancer-Associated Thrombosis: Analysis of the RIETE Database. TH OPEN 2018; 2:e158-e166. [PMID: 31249939 PMCID: PMC6524871 DOI: 10.1055/s-0038-1642022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/13/2018] [Indexed: 12/13/2022] Open
Abstract
Cancer-associated thrombosis (CT) carries a high, heterogeneous, and poorly predicted likelihood of mortality. Thus, we aimed to define predictors of 30-day mortality in 10,025 patients with CT. In a randomly selected derivation cohort, we used recursive partitioning analysis to detect variables that select for a risk of mortality within 30 days. In a validation cohort, we evaluated our results using Cochran–Armitage test. The most common types of cancer were lung (16%), breast (14%), and colorectal (14%); median age was 69 years (range, 14–101); most had metastatic disease (63%); 13% of patients died within 30 days. In the derivation cohort (
n
= 6,660), a white blood cell (WBC) count in the highest quartile predicted early mortality (odds ratio, 7.8; 95% confidence interval [CI], 4.6–13.1); and the presence of metastatic disease, pulmonary embolism (PE), and immobility defined the risk of those with normal WBC count. We defined death risk according four sequential questions: (1) Does the patient have an elevated WBC count? (Yes, group D). (2) If no, does the patient have metastasis? (No, group A). (3) If yes, is the patient immobile? (Yes, group D). (4) If no, does the patient have a PE? (Yes, group C; no, group B). In the validation cohort (
n
= 3,365), the 30-day risk of death was 2.9% in group A (95% CI, 1.9–4.3), compared with 25% in group D (95% CI, 22.5–27.5), and there was a rate escalation between groups (
p
for trend < 0.01). In conclusion, with four sequential questions, the risk of death in CT can be easily stratified. An elevated WBC count at baseline predicted 30-day mortality better than metastases, PE, or immobility.
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Affiliation(s)
- Alfonso J Tafur
- NorthShore University HealthSystem, Evanston, Illinois, United States
| | - Harry Fuentes
- John Stroger Cook County Hospital, Chicago, Illinois, United States
| | - Joseph A Caprini
- NorthShore University HealthSystem, Evanston, Illinois, United States
| | | | - F Uresandi
- Hospital de Cruces, Barakaldo, Vizcaya, Spain
| | | | | | - Adriana Visona
- Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Adel Merah
- Université Jean-Monnet, Service de Medecine Vasculaire et Therapeutique, CHU de Saint Etienne, Saint-Etienne, France
| | - Manuel Monreal
- Hospital Universitario Germans Trias i Pujol de Badalona, Universidad Católica de Murcia, Barcelona, Spain
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Nagler M, ten Cate H, Prins MH, ten Cate‐Hoek AJ. Risk factors for recurrence in deep vein thrombosis patients following a tailored anticoagulant treatment incorporating residual vein obstruction. Res Pract Thromb Haemost 2018; 2:299-309. [PMID: 30046732 PMCID: PMC6055496 DOI: 10.1002/rth2.12079] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 12/21/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Finding the optimal duration of anticoagulant treatment following an acute event of deep vein thrombosis (DVT) is challenging. Residual venous obstruction (RVO) has been identified as a risk factor for recurrence, but data on management strategies incorporating the presence of RVO and associated recurrence rates in defined clinical care pathways (CCP) are lacking. OBJECTIVES We aimed to investigate the long-term clinical outcomes and predictors of venous thromboembolism (VTE) recurrence in a contemporary cohort of patients with proximal DVT and managed in a CCP incorporating the presence of RVO. PATIENTS All patients treated at the Maastricht University Medical Center within an established clinical care pathway from June 2003 through June 2013 were prospectively followed for up to 11 years in a prospective management study. RESULTS Of 479 patients diagnosed with proximal DVT, 474 completed the two-year CCP (99%), and 457 (94.7%) the extended follow-up (2231.2 patient-years; median follow-up 4.6 years). Overall VTE recurrence was 2.9 per 100 patient-years, 1.3 if provoked by surgery, 2.1 if a non-surgical transient risk factor was present and 4.0 if unprovoked. Predictors of recurrent events were unprovoked VTE (adjusted hazard ratio [HR] 4.6; 95% CI 1.7, 11.9), elevated D-dimer one month after treatment was stopped (HR 3.3; 1.8, 6.1), male sex (HR 2.8; 1.5, 5.1), high factor VIII (HR 2.2; 1.2, 4.0) and use of contraceptives (HR 0.1; 0.0, 0.9). CONCLUSIONS Patients with DVT managed within an established clinical care pathway incorporating the presence of RVO had relatively low incidences of VTE recurrence.
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Affiliation(s)
- Michael Nagler
- Department of Hematology and Central Hematology LaboratoryInselspital University HospitalBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Hugo ten Cate
- Thrombosis Expertise Center and Laboratory of Clinical Thrombosis and Hemostasis, and Cardiovascular Research InstituteMaastricht University Medical CenterMaastrichtThe Netherlands
| | - Martin H. Prins
- Department of Clinical Epidemiology and Medical Technology AssessmentMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Arina J. ten Cate‐Hoek
- Thrombosis Expertise Center and Laboratory of Clinical Thrombosis and Hemostasis, and Cardiovascular Research InstituteMaastricht University Medical CenterMaastrichtThe Netherlands
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Risk prediction of cancer-associated thrombosis: Appraising the first decade and developing the future. Thromb Res 2018; 164 Suppl 1:S70-S76. [PMID: 29395243 DOI: 10.1016/j.thromres.2018.01.036] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/18/2018] [Accepted: 01/19/2018] [Indexed: 12/21/2022]
Abstract
Cancer-associated venous thromboembolism (VTE) has major consequences for patients, including morbidity and risk of mortality. However, there is substantial variation in risk depending on a multitude of clinical risk factors and many cancer patients are at low risk for VTE. This critical concept of risk variation has led to efforts to identify patients at high or low risk for developing VTE. Our research group and others have focused on understanding and predicting risk of cancer-associated VTE. This narrative review describe research efforts conducted over the past decade, beginning with the 2008 publication of the first validated risk assessment tool in this setting. We describe current applications of the "Khorana score" including identification of high- and low-risk patients, selecting and excluding patients for thromboprophylaxis and screening high-risk patients for early detection of VTE. New approaches to risk prediction including precision medicine and next-generation sequencing are discussed. Finally, we offer suggestions on improving the field of risk prediction in this setting in the near future.
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Rupa-Matysek J, Gil L, Kaźmierczak M, Barańska M, Komarnicki M. Prediction of venous thromboembolism in newly diagnosed patients treated for lymphoid malignancies: validation of the Khorana Risk Score. Med Oncol 2017; 35:5. [PMID: 29209847 PMCID: PMC5717131 DOI: 10.1007/s12032-017-1065-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 11/29/2017] [Indexed: 01/01/2023]
Abstract
The utility of the venous thromboembolism (VTE) risk assessment model known as the Khorana Risk Score (KRS) in patients with lymphoid malignancies receiving outpatient chemotherapy is not defined. We evaluated the association of the KRS with VTE in patients treated for diffuse large B cell lymphoma (DLBCL) or Hodgkin lymphoma (HL). Retrospective analyses were performed in 428 patients, 241 of whom were newly diagnosed with DLBCL and 187 of whom had HL. During the initial therapy, 64 (15%) patients developed VTE and 56 died during follow-up. More VTE events occurred in patients with DLBCL than in patients with HL. According to the KRS, 364 (85%) and 64 (15%) patients were considered to be at intermediate risk and high risk of VTE development, respectively. The high-risk KRS patients were more often diagnosed with HL than DLBCL (19 vs. 10%, P = 0.0143). The KRS did not discriminate between high- and intermediate-risk patients with respect to VTE occurrence (17 vs. 15%, P = 0.5868). In our patients, the KRS did not adequately predict VTE (positive predictive value 15%, negative predictive value 82% and C statistic 0.51). In the multivariate analysis, bulky disease (OR 2.34; 95% CI 1.62-3.36, P < 0.0001), poor prognostic disease (OR 1.32; 95% CI 1.01-1.74, P = 0.049) and DLBCL histological subtype (OR 1.61; 95% CI 1.17-2.19, P = 0.003) were all significantly associated with the VTE development. In this cohort of patients with lymphoid malignancies, the KRS did not adequately stratify or predict VTE events in patients at a higher risk of VTE. This finding suggests the need for the development of a disease-specific VTE assessment model.
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Affiliation(s)
- Joanna Rupa-Matysek
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznan, Poland.
| | - Lidia Gil
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznan, Poland
| | - Maciej Kaźmierczak
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznan, Poland
| | - Marta Barańska
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznan, Poland
| | - Mieczysław Komarnicki
- Department of Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences, Szamarzewskiego 84, 60-569, Poznan, Poland
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Sohal DPS, Kuderer NM, Shepherd FA, Pabinger I, Agnelli G, Liebman HA, Meyer G, Kalady MF, McCrae K, Lyman GH, Khorana AA. Clinical Predictors of Early Mortality in Colorectal Cancer Patients Undergoing Chemotherapy: Results From a Global Prospective Cohort Study. JNCI Cancer Spectr 2017; 1:pkx009. [PMID: 31360835 PMCID: PMC6649852 DOI: 10.1093/jncics/pkx009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/11/2017] [Accepted: 10/19/2017] [Indexed: 02/06/2023] Open
Abstract
Background Early mortality is a major problem in colorectal cancer (CRC). We have shown that Khorana Score is predictive of early mortality in other cancers. Here, we evaluated the value of this score and other prognostic variables in predicting early mortality in CRC. Methods CANTARISK was a prospective, noninterventional, global cohort study in patients with CRC initiating a new chemotherapy regimen. Data were collected at zero, two, four, and six months. Early mortality was defined as death within six months of enrollment. All data were compiled centrally and analyzed after the study closed. Statistically significant univariate associations were tested in multivariable models; adjusted odds ratios (ORs) are presented. Statistical tests were two-sided. Results From 2011 to 2012, 1789 CRC patients were enrolled. The median age was 62 years; 71% were Caucasian. One-third (35%) had a rectal primary, and 65% had metastatic disease. There were 184 (10.3%) patients who died during their first six months in the study. For low, intermediate, and high Khorana Score, there were 8.1%, 11.2% and 32.5% deaths, respectively. In multivariable analyses, Khorana Score was an independent predictor of early death (OR for high/intermediate vs low score = 1.70, P = .0027), in addition to age (OR for each incremental year = 1.03, P = .0014), presence of metastatic disease (OR = 3.28, P < .0001), and Easter Cooperative Oncology Group Performance Status Score of 2 or higher (OR = 3.85, P < .0001). Conclusions This study demonstrates that Khorana Score is predictive of early mortality in CRC patients. Intermediate- or high-risk patients, as defined by this score, may benefit from additional interventions aimed at reducing early mortality.
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Affiliation(s)
- Davendra P S Sohal
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Nicole M Kuderer
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Frances A Shepherd
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Ingrid Pabinger
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Giancarlo Agnelli
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Howard A Liebman
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Guy Meyer
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Matthew F Kalady
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Keith McCrae
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Gary H Lyman
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
| | - Alok A Khorana
- Hematology/Oncology, Cleveland Clinic, Cleveland, OH (DPSS, MFK, KM, AAK); Hematology/Oncology, University of Washington, Seattle, WA (NMK, GHL); Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada (FAS); Haematology and Haemostaseology, Medical University of Vienna, Vienna, Austria (IP); Stroke Unit, Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy (GA); Jane Anne Nohl Devision of Hematology, University of Southern California, Los Angeles, CA (HAL); Respiratory and Intensive Care Medicine, Universite Paris Descartes, Paris, France (GM)
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Kuderer NM, Poniewierski MS, Culakova E, Lyman GH, Khorana AA, Pabinger I, Agnelli G, Liebman HA, Vicaut E, Meyer G, Shepherd FA. Predictors of Venous Thromboembolism and Early Mortality in Lung Cancer: Results from a Global Prospective Study (CANTARISK). Oncologist 2017; 23:247-255. [PMID: 28951500 DOI: 10.1634/theoncologist.2017-0205] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/17/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Patients with lung cancer are known to be at increased risk for venous thromboembolism (VTE). Venous thromboembolism is associated with increased risk for early mortality. However, there have been no studies performing a comprehensive assessment of risk factors for VTE or early mortality in lung cancer patients undergoing systemic chemotherapy in a global real-world setting. MATERIALS AND METHODS CANTARISK is a prospective, global, noninterventional cohort study including patients with lung cancer initiating a new cancer therapy. Clinical data were collected until 6-month follow-up. The impact of patient-, disease-, and treatment-related factors on the occurrence of VTE and early mortality was evaluated in univariable and multivariable Cox regression analyses. A previously validated VTE risk score (VTE-RS) was also calculated (also known as Khorana score). RESULTS Of 1,980 patients with lung cancer who were enrolled from 2011 to 2012, 84% had non-small cell lung cancer. During the first 6 months, 121 patients developed a VTE (6.1%), of which 47% had pulmonary embolism, 46% deep vein thrombosis, 3% catheter-associated thrombosis, and 4% visceral thrombosis. Independent predictors for VTE included female sex, North America location, leg immobilization, and presence of a central venous catheter. The VTE-RS was not significantly associated with VTE in either univariable or multivariable analysis in this population. During the study period, 472 patients died, representing 20%, 24%, 36%, and 25% with VTE-RS 1, 2, ≥3, or unknown, respectively (p < .0001). Significant independent predictors of early mortality include older age, current/former smoking, chronic obstructive pulmonary disease, Eastern Cooperative Oncology Group performance status ≥2, no prior surgery, and metastatic disease, as well as the VTE-RS. CONCLUSION In this global, prospective, real-world analysis, several demographic, geographic, and clinical factors are independent risk factors for VTE and early mortality in patients with lung cancer. The VTE-RS represents a significant independent predictor of early mortality but not for VTE in lung cancer in the era of targeted therapy. IMPLICATIONS FOR PRACTICE Multiple risk factors for both venous thromboembolism (VTE) and early mortality in patients with lung cancer receiving systemic chemotherapy should guide best practice by better informing clinical evaluation and treatment decision-making. The Khorana risk score is of value in assessing the risk of early all-cause mortality along with other clinical parameters in patients with lung cancer receiving systemic therapy. Further study is needed to fully evaluate the validity of the risk score in predicting the risk of VTE in the modern era of lung cancer therapy.
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Affiliation(s)
- Nicole M Kuderer
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Marek S Poniewierski
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Eva Culakova
- Department of Medicine, University of Rochester, Rochester, New York, USA
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alok A Khorana
- Department of Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ingrid Pabinger
- Department of Medicine, Medical University of Vienna, Vienna, Austria
| | - Giancarlo Agnelli
- Department of Internal Medicine, University of Perugia, Perugia, Italy
| | - Howard A Liebman
- Department of Medicine, University of Southern California, Los Angeles, California, USA
| | - Eric Vicaut
- Department of Medicine, Université Paris Descartes, Paris, France
| | - Guy Meyer
- Department of Medicine, Université Paris Descartes, Paris, France
| | - Frances A Shepherd
- Cancer Clinical Research Unit, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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47
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Khorana AA, Vadhan-Raj S, Kuderer NM, Wun T, Liebman H, Soff G, Belani C, O'Reilly EM, McBane R, Eikelboom J, Damaraju CV, Beyers K, Dietrich F, Kakkar AK, Riess H, Peixoto RD, Lyman GH. Rivaroxaban for Preventing Venous Thromboembolism in High-Risk Ambulatory Patients with Cancer: Rationale and Design of the CASSINI Trial. Rationale and Design of the CASSINI Trial. Thromb Haemost 2017; 117:2135-2145. [PMID: 28933799 PMCID: PMC6328370 DOI: 10.1160/th17-03-0171] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Venous thromboembolism (VTE) is a frequent complication of cancer associated with morbidity, mortality, increased hospitalizations and higher health care costs. Cancer patients at increased risk for VTE can be identified using a validated risk assessment score, and the incidence of VTE can be reduced in high-risk settings using anticoagulation. Rivaroxaban is a potent, oral, direct, factor Xa inhibitor approved for the prevention and treatment of thromboembolic events, including VTE. CASSINI is a double-blind, randomized, parallel-group, multicentre study comparing rivaroxaban with placebo in adult ambulatory patients with various cancers who are initiating systemic cancer therapy and are at high risk of VTE (Khorana score ≥ 2). Patients with primary brain tumours or those at risk for bleeding are excluded. Approximately 700 patients will be randomized 1:1 to rivaroxaban 10 mg daily or placebo for up to 6 months if there is no evidence of VTE from compression ultrasonography (CU) during screening or from routine care imaging within 30 days prior to randomization. Mandatory CU will also be performed at weeks 8 and 16 (±7 days), and at study end (±3 days). The primary efficacy hypothesis is that anticoagulation with rivaroxaban reduces the composite of objectively confirmed symptomatic or asymptomatic, lower-extremity, proximal deep-vein thrombosis (DVT); symptomatic, upper-extremity DVT; symptomatic or incidental pulmonary embolism; and VTE-related death compared with placebo. The primary safety objective is to assess major bleeding events (Clinical trial information: NCT02555878).
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Affiliation(s)
| | - Saroj Vadhan-Raj
- The University of Texas M.D. Anderson Cancer Center, Houston, Texas, United States
| | | | - Ted Wun
- University of California Davis Comprehensive Cancer Center, Sacramento, California, United States
| | - Howard Liebman
- University of Southern California Keck School of Medicine, Los Angeles, California, United States
| | - Gerald Soff
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | - Chandra Belani
- Penn State Hershey Cancer Institute, Hershey, Pennsylvania, United States
| | - Eileen M O'Reilly
- Memorial Sloan Kettering Cancer Center, New York, New York, United States
| | | | | | - C V Damaraju
- Janssen Research and Development, Raritan, New Jersey, United States
| | - Karen Beyers
- Janssen Research and Development, Raritan, New Jersey, United States
| | - Flavia Dietrich
- Janssen Research and Development, Raritan, New Jersey, United States
| | - Ajay K Kakkar
- University College London and Thrombosis Research Institute, London, United Kingdom
| | - Hanno Riess
- Charité University Hospitals, Berlin, Germany
| | - Renata D'Alpino Peixoto
- Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Gary H Lyman
- Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, United States
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Suero-Abreu GA, Cheng JZ, Then RK. Multiple recurrent ischaemic strokes in a patient with cancer: is there a role for the initiation of anticoagulation therapy for secondary stroke prevention? BMJ Case Rep 2017; 2017:bcr-2016-218105. [PMID: 28578306 PMCID: PMC5534754 DOI: 10.1136/bcr-2016-218105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
A 52-year-old woman with a medical history of cervical and thyroid cancer, hypertension, dyslipidaemia, uncontrolled diabetes and heavy smoking was diagnosed with a new metastatic cholangiocarcinoma. While undergoing palliative chemotherapy, she developed dysarthria and left-sided weakness. Imaging studies showed multiple bilateral ischaemic strokes. On hospital days 2 and 5, she developed worsening neurological symptoms and imaging studies revealed new areas of ischaemia on respective days. Subsequent workup did not revealed a clear aetiology for the multiple ischaemic events and hypercoagulability studies were only significant for a mildly elevated serum D-dimer level. Although guidelines are unclear, full-dose anticoagulation with low molecular weight heparin was initiated given her high risk of stroke recurrence. She was discharged to acute rehabilitation but, within a month, she experienced complications of her malignant disease progression and a new pulmonary thromboembolism. The patient died soon after being discharged home with hospice care.
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Affiliation(s)
- Giselle Alexandra Suero-Abreu
- Department of Medicine, Rutgers University New Jersey Medical School, Newark, New Jersey, USA.,Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Jia Zhen Cheng
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ryna Karina Then
- Department of Neurology, Cooper University Hospital, Camden, New Jersey, USA
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49
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Wang Y, Attar BM, Fuentes HE, Yu J, Zhang H, Tafur AJ. Performance of Khorana Risk Score for Prediction of Venous Thromboembolism in Patients With Hepatocellular Carcinoma. Clin Appl Thromb Hemost 2017; 24:471-476. [PMID: 28288526 DOI: 10.1177/1076029617699088] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Cancer-associated venous thromboembolism (VTE) is one of the leading causes of mortality and morbidity among patients with malignancy. The Khorana risk score (KRS) is currently the best validated risk assessment model to stratify risks of VTE development in ambulatory patients with cancer. In the current study, we assessed the performance of KRS in patients with hepatocellular carcinoma (HCC). We retrospectively analyzed patients with diagnosis of HCC (screened by International Classification of Diseases [ ICD-9] and ICD-10 code, confirmed with radiographic examination and/or histopathology) at a large public hospital over 15 years (January 2000 through July 2015). Cases with VTE were identified through radiographic examination and blindly adjudicated. Khorana risk score was calculated for each patient, and its association with VTE development and mortality was assessed. Among 270 patients with HCC, 16 (5.9%) cases of VTE were identified, including 7 (43.8%) pulmonary embolism, 4 (25%) peripheral deep vein thrombosis, and 6 (37.5%) intra-abdominal thrombosis. One hundred eighty-four (68.1%) patients had a KRS of 0 and 86 (31.9%) patients had a KRS >0. Most of the thrombotic (n = 9, 56%) events occurred in the low-risk group. In univariate analysis, only prechemotherapy leukocyte count equal to or greater than 11 000/μL was statistically significant in the prediction of VTE incidence. After adjusting for confounding factors in multivariate analysis, KRS >0 was not predictive of VTE (hazard ratio [HR] = 1.83, 95% confidence interval [CI] = 0.81-4.15, P = .15) or mortality (HR = 1.61, 95% CI = 0.92-2.81, P = .09). Khorana risk score did not predict VTE development or mortality in patients with HCC. Design of HCC-specific risk assessment model for VTE development is necessary.
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Affiliation(s)
- Y Wang
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - B M Attar
- 2 Division of Gastroenterology and Hepatology, John Stroger Jr. Hospital, Chicago, IL, USA
| | - H E Fuentes
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - J Yu
- 1 Department of Internal Medicine, John Stroger Jr. Hospital, Chicago, IL, USA
| | - Huiyuan Zhang
- 3 Collaborative Research Unit, John Stroger Jr. Hospital, Chicago, IL, USA
| | - A J Tafur
- 4 Cardiology-Vascular Medicine, Northshore University Healthsystem, Evanston, IL, USA
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Tafur AJ, Caprini JA, Cote L, Trujillo-Santos J, Del Toro J, Garcia-Bragado F, Tolosa C, Barillari G, Visona A, Monreal M. Predictors of active cancer thromboembolic outcomes. RIETE experience of the Khorana score in cancer-associated thrombosis. Thromb Haemost 2017; 117:1192-1198. [PMID: 28276571 DOI: 10.1160/th16-11-0840] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/23/2017] [Indexed: 12/14/2022]
Abstract
Even though the Khorana risk score (KRS) has been validated to predict against the development of VTE among patients with cancer, it has a low positive predictive value. It is also unknown whether the score predicts outcomes in patients with cancer with established VTE. We selected a cohort of patients with active cancer from the RIETE (Registro Informatizado Enfermedad TromboEmbolica) registry to assess the prognostic value of the KRS at inception in predicting the likelihood of VTE recurrences, major bleeding and mortality during the course of anticoagulant therapy. We analysed 7948 consecutive patients with cancer-associated VTE. Of these, 2253 (28 %) scored 0 points, 4550 (57 %) 1-2 points and 1145 (14 %) scored ≥3 points. During the course of anticoagulation, amongst patient with low, moderate and high risk KRS, the rate of VTE recurrences was of 6.21 (95 %CI: 4.99-7.63), 11.2 (95 %CI: 9.91-12.7) and 19.4 (95 %CI: 15.4-24.1) events per 100 patient-years; the rate of major bleeding of 5.24 (95 %CI: 4.13-6.56), 10.3 (95 %CI: 9.02-11.7) and 19.4 (95 %CI: 15.4-24.1) bleeds per 100 patient-years and the mortality rate of 25.3 (95 %CI: 22.8-28.0), 58.5 (95 %CI: 55.5-61.7) and 120 (95 %CI: 110-131) deaths per 100 patient-years, respectively. The C-statistic was 0.53 (0.50-0.56) for recurrent VTE, 0.56 (95 %CI: 0.54-0.59) for major bleeding and 0.54 (95 %CI: 0.52-0.56) for death. In conclusion, most VTEs occur in patients with low or moderate risk scores. The KRS did not accurately predict VTE recurrence, major bleeding, or mortality among patients with cancer-associated thrombosis.
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Affiliation(s)
- Alfonso J Tafur
- Alfonso J. Tafur, MD, NorthShore University HealthSystem, 9650 Gross Point Road, Suite 4900, Skokie, IL 60076, USA, Tel.: +1 847 663 8050, Fax: +1 224 251 4407, E-mail:
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