Cancer is associated with inferior outcome in patients with ischemic stroke

Abstract

Background Whether patients with stroke and cancer exhibit specific characteristics has remained controversial. Methods Medical records of patients with ischemic stroke in 2014 or 2015 registered in the Swiss Stroke Registry of Zurich were retrospectively analyzed and integrated with regional cancer registry data. Associations of clinical and outcome parameters with cancer diagnosed up to 5 years prior to stroke were tested. Results Of 753 patients with ischemic stroke, 59 patients with cancer were identified. History of venous thromboembolism (p < 0.001) was associated with cancer while age and cardiovascular risk factors were not. Higher levels of D-dimers (p = 0.001), erythrocyte sedimentation rate (p = 0.003), C-reactive protein (CRP) (p < 0.001), and lower levels of hemoglobin (p = 0.003) were associated with cancer. For platelets, pathologically low (p = 0.034) or high levels (p < 0.001) were linked to cancer. Modified Rankin scale (mRS) scores ≥ 4 on admission and at follow-up were more frequent in cancer patients (p = 0.038 and p = 0.001). Poor post-stroke survival was associated with cancer (HR 2.2, p < 0.001). Multivariable analysis identified venous thromboembolism (OR 5.1), pathologic platelet count (OR = 2.9), low hemoglobin (OR 2.5) and elevated CRP (OR 1.8) as independently associated with cancer. In multivariable Cox regression, risk for death was associated with cancer (HR 1.7), low hemoglobin (HR 2.6), mRS on admission ≥ 4 (HR 1.9), pathologic platelet count (HR 1.6), female sex (HR 1.7), and elevated CRP (HR 1.4). Conclusions Considering cancer as a cofactor for post-stroke outcome may impact clinical decision making.

A risk model for prediction of diagnosis of cancer after ischemic stroke

“…The novelty and strength of our methodological approach represents the integration of risk of death as competing risk of cancer diagnosis after stroke respecting age as risk factor for stroke, cancer and death as well as higher post-stroke mortality for patients with preexisting cancer and stroke 5 , 8 , 9 , 22 . It remains uncertain whether intraarterial therapeutic interventions may be beneficial for outcome of patients with cancer and acute ischemic stroke with two studies showing no differences in post-stroke mortality associated with cancer 23 , 24 , while others suggested higher mortality of cancer patients 22 .…”

“…Incidence and characteristics of cancer and date of follow-up was retrieved as available in the medical records for all patients and matched with the data of the Cancer Registry of the Cantons of Zurich, Zug, Schaffhausen and Schwyz in Switzerland, where applicable. Subsets of patients with ischemic stroke have been previously described 8,10 .…”

“…Most studies represent single institution retrospective analyses focusing on the early post-stroke phase and methodologically do not consider death as competing risk for cancer diagnosis after stroke. The latter is especially important since higher in-hospital mortality and inferior post-stroke survival is associated with cancer in patients with acute ischemic stroke 5 , 8 , 9 .…”

“…Several risk factors associated with occult cancer have been suggested, among them older age, smoking, involvement of multiple vascular territories, elevated levels of C-reactive protein (CRP), d-dimers, and lower levels of hemoglobin 3,6,7 .Most studies represent single institution retrospective analyses focusing on the early post-stroke phase and methodologically do not consider death as competing risk for cancer diagnosis after stroke. The latter is especially important since higher in-hospital mortality and inferior post-stroke survival is associated with cancer in patients with acute ischemic stroke 5,8,9 .The present study represents an exploratory analysis of potential predictive factors associated with risk of cancer diagnosis after acute ischemic stroke without and with consideration of death as a competing risk for a diagnosis of cancer. To consider uncertainties regarding a potential temporal relationship between the diagnosis…”

Predictors of survival in patients with ischemic stroke and active cancer: A prospective, multicenter, observational study

“…8 Other studies compared ischemic stroke outcomes in patients with and without active cancer, suggesting that patients with ischemic stroke and with active cancer have poorer outcomes than those without ischemic stroke. [9][10][11][12][13] Overall, patients with ischemic stroke and active cancer are known to have poor survival outcomes. However, most of these studies are retrospective, [7][8][9][10][11][12] and limited data are available about prospective studies.…”