Lung cancer is the leading cause of cancer death worldwide. Non-small-cell lung cancer (nsclc) is the most common form of lung cancer, with a median age at diagnosis of 70 years. These elderly patients are often underrepresented in the randomized clinical trials upon which chemotherapy plans are based. The objective of the present study was to determine the patterns of treatment and survival in elderly patients with advanced nsclc in Manitoba. An eligible cohort of elderly patients over 70 years of age at diagnosis (n = 497) with advanced nsclc was identified from the provincial cancer registry database for the period 2001–2004. Of the 497 patients identified, only 147 had been evaluated by a medical oncologist, and 82 of the 147 had received chemotherapy treatment, which is 16.5% of the initial cohort. Patients who received chemotherapy were younger than those who did not receive chemotherapy. Most patients receiving chemotherapy (84%) received doublet chemotherapy, with an almost equal split between cisplatin and carboplatin treatment. The median survival times for patients in this cohort were 64 weeks (stage iii nsclc) and 56 weeks (stage iv) with chemotherapy treatment, and 46 weeks (stage iii) and 26 weeks (stage iv) without chemotherapy. Although 50% of patients with advanced nsclc are more than 70 years of age, few are evaluated by a medical oncologist and even fewer are treated with chemotherapy. However, it should be noted that, in the elderly patients who were treated, survival times are comparable to those experienced by younger patients, which is indicative of a benefit of chemotherapy treatment for those elderly patients.
Zoann Nugent is to be retracted from the author list[...].
Venothromboembolism (VTE) in patients with active malignancy is associated with adverse outcomes and effective anticoagulation for extended duration with either oral vitamin K antagonist (VKA) or low molecular weight heparin (LMWH) is indicated for as long as the cancer is active. Although current literature suggests that LMWH is more efficacious in reducing VTE recurrence in patients with cancer when compared with oral VKA1, the need for daily injection and high drug cost are major drawbacks to the upfront use of LMWH in this setting. At our institution in Manitoba (Canada), we treat all patients with first line VKA, managed by a specialized pharmacist-run anticoagulation clinic (CCMB ACC), switching to LMWH if thrombosis recurs despite VKA. The aim of this retrospective review is to access the efficacy and safety of this approach, comparing outcomes between patients with cancer to a convenience cohort (controls) on VKA managed by the same ACC and to that of the literature. We hypothesize that appropriate anticoagulation with an oral VKA can be achieved through ACC and its use as first line therapy for extended VTE prophylaxis in cancer patients is not associated with significant increase in VTE recurrence or major bleeding episodes. Methods: We analyzed retrospectively all patients receiving oral VKA who were monitored by the CCMB ACC from July 23, 2002 to August 9, 2007, using the ACC database and CCMB electronic charts. Primary outcome is the time spent within the target INR range (%TSTR) which is defined as the proportion of patient-days for which the INR was between 2 and 3, and imputing daily values between INR tests by linear interpolation2. We limit this analysis to include only patients with at least 30 days of follow up to ensure adequate time for stabilization of INR. Secondary outcomes include rate of VTE recurrence, rate of major bleeding and rate of switching to LMWH for any reason. Multinomial logistic regression was performed to identify predictors for poor anticoagulation as well as cox regression to identify predictors of recurrence VTE or bleeding complications. Results: Although the quality of anticoagulation with oral VKA is inferior in patients with VTE and active cancer when compared to control patients (%TSTR 54% versus 64%, p<0.001), the rate of VTE recurrence and bleeding is similar. The TSTR in this cohort compared favourably with those obtained from the literature (%TSTR 54% vs 46% in the CLOT trial3) and the risk of VTE recurrence and bleeding is not excessive (10% and 5.3% respectively). However, patients with cancer are more likely to experience VKA failure (OR 7.22; 95% CI 1.47–35.5) and risk of death (OR 4.48; 95% CI 2.72–7.34) compared to control. No significant predictors were identified for recurrent VTE but those with poor INR control were more likely to suffer from bleeding complications. Conclusions: Oral VKA remains an effective option for anticoagulation for most patients and LMWH can be reserved for patients with additional risks for VKA failure and those with poor INR control due to increased risk of bleeding.
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