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Falanga A, Lorusso D, Colombo N, Cormio G, Cosmi B, Scandurra G, Zanagnolo V, Marietta M. Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention. Cancers (Basel) 2024; 16:1769. [PMID: 38730721 PMCID: PMC11083004 DOI: 10.3390/cancers16091769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Domenica Lorusso
- Fondazione Policlinico Universitario A. Gemelli, Catholic University of Sacred Heart, 00168 Rome, Italy
| | - Nicoletta Colombo
- Department of Medicine and Surgery, University of Milan-Bicocca, 20900 Monza, Italy; (A.F.); (N.C.)
- Gynecologic Oncology Program, European Institute of Oncology, IRCCS, 20141 Milan, Italy
| | - Gennaro Cormio
- Gynecologic Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, 70124 Bari, Italy;
- Department of Interdisciplinary Medicine (DIM), University “A. Moro”, 70124 Bari, Italy
| | - Benilde Cosmi
- Angiology and Blood Coagulation Unit, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy;
- Angiology and Blood Coagulation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Giuseppa Scandurra
- Unità Operativa Oncologia Medica, Ospedale Cannizzaro di Catania, 95126 Catania, Italy;
| | | | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, 41125 Modena, Italy;
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Cho H, Choi JH, Kang SY, Lee HW, Choi YW, Kim TH, Ahn MS, Kim CH, Shin YS, Jang JY, Oh YT, Heo J, Sheen SS. Analysis of thromboembolic events in head and neck cancer patients who underwent concurrent chemoradiotherapy with cisplatin. Korean J Intern Med 2022; 37:653-659. [PMID: 35439872 PMCID: PMC9082433 DOI: 10.3904/kjim.2021.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/25/2021] [Accepted: 12/24/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The study investigated the incidence of thromboembolic events (TEE) in head and neck (H&N) cancer patients who received concurrent chemoradiotherapy (CCRT) with cisplatin, and analyzed the factors affecting TEE occurrence. METHODS Two hundred and fifty-seven patients who started CCRT with cisplatin for H&N cancer from January 2005 to December 2019 were analyzed. RESULTS TEE occurred in five patients, an incidence rate of 1.9%. The 2-, 4-, and 6-month cumulative incidences of TEE were 0.8%, 1.6%, and 1.9%, respectively. Khorana score was the only factor associated with TEE occurrence (p = 0.010). CONCLUSION The incidence of TEE in H&N cancer patients who underwent CCRT with cisplatin was relatively low when compared to other types of cancer. However, patients with a high Khorana score require more careful surveillance for possible TEE occurrence.
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Affiliation(s)
- Hundo Cho
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Jin-Hyuk Choi
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Seok Yun Kang
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Hyun Woo Lee
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Yong Won Choi
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Tae-Hwan Kim
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Mi Sun Ahn
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Chul-Ho Kim
- Department of Otolaryngology, Ajou University School of Medicine, Suwon,
Korea
| | - Yoo Seob Shin
- Department of Otolaryngology, Ajou University School of Medicine, Suwon,
Korea
| | - Jeon Yeob Jang
- Department of Otolaryngology, Ajou University School of Medicine, Suwon,
Korea
| | - Young-Taek Oh
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Jaesung Heo
- Department of Radiation Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon,
Korea
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Afzal A, Suhong L, Gage BF, Schoen MW, Carson K, Thomas T, Sanfilippo K. Splanchnic vein thrombosis predicts worse survival in patients with advanced pancreatic cancer. Thromb Res 2019; 185:125-131. [PMID: 31812026 DOI: 10.1016/j.thromres.2019.11.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Pancreatic cancer is a thrombogenic malignancy with nearly half of venous thrombotic events occurring in the splanchnic circulation. The effect of splanchnic vein thrombosis on mortality in pancreatic cancer is unknown. We studied the effect of splanchnic vein thrombosis on mortality in veterans with advanced pancreatic adenocarcinoma, and explored the association of anticoagulant therapy on mortality and hemorrhage. METHODS Using International Classification of Diseases (ICD) codes, we identified eligible patients and outcomes in the Veterans Health Administration database. Using Cox proportional hazards regression, we analyzed the association between splanchnic vein thrombosis and mortality among patients with advanced pancreatic cancer. We used propensity score inverse probability-of-treatment weighting to balance the groups who did and did not receive anticoagulation. To understand the role of anticoagulant therapy, we used Cox proportional hazards regression to analyze mortality and competing risk analysis to assess the risk of hemorrhage. RESULTS Of the patients with advanced pancreatic cancer (N = 6164), 122 developed splanchnic vein thrombosis. Splanchnic vein thrombosis was associated with a two-fold increase in mortality, aHR 2.02, 95% CI 1.65-2.47. The finding held true after restricting the analysis to patients undergoing treatment for pancreatic cancer, and after adjusting for immortal time bias by a 30-day landmark analysis. Anticoagulant therapy did not affect mortality (aHR 0.99, 95% CI 0.65-1.51), and increased the risk of hemorrhage (aHR 2.7, 95% CI 1.02-7.07). CONCLUSION Splanchnic vein thrombosis predicts worse survival in patients with advanced pancreatic adenocarcinoma. Anticoagulant therapy may not mitigate this increased mortality, and increases the risk of hemorrhage.
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Affiliation(s)
- Amber Afzal
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America; Division of Hematology, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America.
| | - Luo Suhong
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Brian F Gage
- Division of General Medical Sciences, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America
| | - Martin W Schoen
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Kenneth Carson
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Theodore Thomas
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America
| | - Kristen Sanfilippo
- St Louis Veterans Health Administration Medical Center Research Service, St. Louis, MO, United States of America; Division of Hematology, Department of Medicine, Washington University School of Medicine in St Louis, MO, United States of America
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Kim SY, Burns ZT, Henry DH. The assessment of thrombotic risk using a predictive model in metastatic cancer patients undergoing first-line therapy. Thromb Res 2012; 130:967-70. [PMID: 23036533 DOI: 10.1016/j.thromres.2012.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/09/2012] [Accepted: 09/12/2012] [Indexed: 11/17/2022]
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Trujillo-santos J, Monreal M. Thirty-day mortality rate in women with cancer and venous thromboembolism. Findings from the Registro Informatizado de la Enfermedad Trombo Embólica Registry: . Curr Opin Pulm Med 2012; 18:393-8. [DOI: 10.1097/mcp.0b013e32835463a4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lyman GH, Kuderer NM. Prevention and treatment of venous thromboembolism among patients with cancer: The American Society of Clinical Oncology Guidelines. Thromb Res 2010; 125 Suppl 2:S120-7. [DOI: 10.1016/s0049-3848(10)70029-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Venous thromboembolism (VTE) is a frequent complication of malignancy, and its incidence has increased markedly in recent years. VTE itself can directly lead to patient mortality, and is the second leading cause of death in patients with cancer. Furthermore, emerging data suggest that activation of coagulation in malignancy is integrally linked with tumor biology, particularly with angiogenesis. The development of the clinical hypercoagulable state is also linked with adverse prognosis in patients with cancer, including patients receiving systemic chemotherapy. This review focuses on the clinical evidence documenting a link between VTE and adverse short-term and long-term prognosis in patients with cancer.
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Affiliation(s)
- Alok A Khorana
- James P. Wilmot Cancer Center, and the Department of Medicine, University of Rochester, Rochester, NY 14642, USA.
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Abstract
Venous thromboembolism (VTE) is a frequent complication of cancer and cancer treatment and is associated with multiple clinical consequences, including recurrent VTE, bleeding, and an increase in the risk of death. Although the risks associated with VTE have been well recognized in surgical cancer patients, there is also considerable and increasing risk in medical cancer patients. VTE risk factors in medical cancer patients include the type and stage of cancer, major comorbid illnesses, current hospitalization, active chemotherapy, hormone therapy, and antiangiogenic agents. Low-molecular-weight heparins (LMWHs) are recommended commonly for the prevention of VTE in hospitalized cancer patients and in higher risk ambulatory cancer patients because of their favorable risk-to-benefit profile. These agents have demonstrated effectiveness in both the primary and secondary prevention of VTE in medical cancer patients. Extended-duration anticoagulant therapy is often recommended to reduce the risk of VTE recurrence in patients with cancer. LMWHs are often used for long-term prophylaxis because of a reduced need for coagulation monitoring, few major bleeding episodes, and once-daily dosing. Despite clinical and practical benefits, a substantial proportion of medical cancer patients do not receive VTE prophylaxis. To improve the appropriate prevention and treatment of VTE in cancer patients, guidelines have been published recently by the American Society of Clinical Oncology and the National Comprehensive Cancer Network. Widespread dissemination and application of these guidelines are encouraged to improve the appropriate use of these agents and to improve clinical outcomes in medical cancer patients at risk for VTE and its complications.
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Affiliation(s)
- Gary H Lyman
- Department of Medicine, Duke University School of Medicine and the Duke Comprehensive Cancer Center, Durham, North Carolina 27710, USA.
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Hicks LK, Cheung MC, Ding K, Hasan B, Seymour L, Le Maître A, Leighl NB, Shepherd FA. Venous thromboembolism and nonsmall cell lung cancer. Cancer 2009; 115:5516-25. [DOI: 10.1002/cncr.24596] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Affiliation(s)
- Gary H Lyman
- Duke University and Duke Comprehensive Cancer Center, Durham, NC, USA
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Abstract
Changes in the hemostatic system and chronic hemostatic activation are frequently observed in patients with cancer, even in the absence of venous thromboembolism (VTE). VTE is a leading cause of death among patients with cancer and contributes to long-term mortality in patients with early as well as advanced-stage cancer. Mounting evidence suggests that components of the clotting cascade and associated vascular factors play an integral part in tumor progression, invasion, angiogenesis, and metastasis formation. Furthermore, there are intriguing in vitro and animal findings that anticoagulants, in particular the low molecular weight heparins (LMWHs), exert an antineoplastic effect through multiple mechanisms, including interference with tumor cell adhesion, invasion, metastasis formation, angiogenesis, and the immune system. Several relatively small randomized controlled clinical trials of anticoagulation as cancer therapy in patients without a VTE diagnosis have been completed. These comprise studies with LMWH, unfractionated heparin, and vitamin K antagonists, with overall encouraging but nonconclusive results and some limitations. Meta-analyses performed for the American Society of Clinical Oncology VTE Guidelines Committee and the Cochrane Collaboration suggest overall favorable effects of anticoagulation on survival of patients with cancer, mainly with LMWH. However, definitive clinical trials have been elusive and questions remain regarding the importance of tumor type and stage on treatment efficacy, the impact of fatal thromboembolic events, optimal anticoagulation therapy, and safety with differing chemotherapy regimens. Although the LMWHs and related agents hold promise for improving outcomes in patients with cancer, additional studies of their efficacy and safety in this setting are needed.
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Affiliation(s)
- Nicole M Kuderer
- Division of Hematology, Oncology and Cellular Therapy, Duke Comprehensive Cancer Center, Duke University Medical Center, DUMC 3841, Durham, NC 27710, USA.
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