Competing events in patients with malignant disease who are at risk for recurrent venous thromboembolism

Parpia, Sameer; Julian, Jim A.; Thabane, Lehana; Lee, A.Y.Y.; Rickles, Frederick R.; Levine, Mark

doi:10.1016/j.cct.2011.07.005

Cited by 26 publications

(26 citation statements)

References 12 publications

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“…Since death is a frequent competing risk in patients with cancer, we used competing risk survival statistics to calculate the cumulative incidence of stroke and the associated 95% confidence intervals (CI). 23 We specifically chose this technique over standard survival statistics (e.g., Kaplan-Meier method) because the occurrence of death (i.e., frequent competing event) may prevent stroke (i.e., outcome of interest) from being observed and standard survival statistics ignore competing risks, which can produce bias and invalid results. In contrast, the competing risk method estimates the hazard of stroke in the presence of death and unlike the Kaplan-Meier method doesn’t censor patients at the time of their death, but instead considers them as failures in the event-free survival portion of its calculation.…”

Section: Methodsmentioning

confidence: 99%

Association between incident cancer and subsequent stroke

Navi

Reiner

Kamel

et al. 2015

Annals of Neurology

200

197

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Objective To examine the association between incident cancer and the subsequent risk of stroke. Methods Using the Surveillance Epidemiology and End Results-Medicare linked database, we identified patients with a new primary diagnosis of breast, colorectal, lung, pancreatic, or prostate cancer from 2001 through 2007. These patients were individually matched by age, sex, race, registry, and medical comorbidities to a group of Medicare enrollees without cancer, and each pair was followed through 2009. Validated diagnosis codes were used to identify a primary outcome of stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Results Among 327,389 pairs of cancer patients and matched controls, the 3-month cumulative incidence of stroke was generally higher in patients with cancer. Cumulative incidence rates were 5.1% (95% confidence interval [CI], 4.9–5.2%) in patients with lung cancer compared to 1.2% (95% CI, 1.2–1.3%) in controls (p<0.001), 3.4% (95% CI, 3.1–3.6%) in patients with pancreatic cancer compared to 1.3% (95% CI, 1.1–1.5%) in controls (p<0.001), 3.3% (95% CI, 3.2–3.4%) in patients with colorectal cancer compared to 1.3% (95% CI, 1.2–1.4%) in controls (p<0.001), 1.5% (95% CI, 1.4–1.6%) in patients with breast cancer compared to 1.1% (95% CI, 1.0–1.2%) in controls (p<0.001), and 1.2% (95% CI, 1.1–1.3%) in patients with prostate cancer compared to 1.1% (95% CI, 1.0–1.2%) in controls (p=0.085). Excess risks attenuated over time and were generally no longer present beyond 1 year. Interpretation Incident cancer is associated with an increased short-term risk of stroke. This risk appears highest with lung, pancreatic, and colorectal cancers.

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Section: Methodsmentioning

confidence: 99%

Association between incident cancer and subsequent stroke

Navi

Reiner

Kamel

et al. 2015

Annals of Neurology

200

197

View full text Add to dashboard Cite

show abstract

“…As death is a frequent competing risk in patients with cancer and can prevent arterial thromboembolic events from being observed, competing risk survival statistics accounting for death were used to calculate the cumulative incidence of arterial thromboembolism (32). Visual inspection of the cumulative incidence curves, as well as formal statistical testing, demonstrated that the risks of arterial thromboembolism in the cancer groups varied over time, meaning that the proportional hazard assumption was violated.…”

Section: Control Study Groupmentioning

confidence: 99%

Risk of Arterial Thromboembolism in Patients With Cancer

Navi

Reiner

Kamel

et al. 2017

Journal of the American College of Cardiology

507

439

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Background The risk of arterial thromboembolism in patients with cancer is incompletely understood. Objectives The authors aimed to better define this epidemiological relationship, including the effects of cancer stage. Methods Using the Surveillance Epidemiology and End Results-Medicare linked database, we identified patients with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, pancreatic, or gastric cancer or non-Hodgkin lymphoma from 2002 through 2011. They were individually matched by demographics and comorbidities to a Medicare enrollee without cancer, and each pair was followed through 2012. Validated diagnosis codes were used to identify arterial thromboembolism, defined as myocardial infarction or ischemic stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Cox hazards analysis was used to compare rates between groups at discrete time points. Results We identified 279,719 pairs of patients with cancer and matched controls. The 6-month cumulative incidence of arterial thromboembolism was 4.7% (95% confidence interval [CI]: 4.6% to 4.8%) in patients with cancer compared to 2.2% (95% CI: 2.1% to 2.2%) in controls (HR: 2.2; 95% CI: 2.1 to 2.3). The 6-month cumulative incidence of myocardial infarction was 2.0% (95% CI: 1.9% to 2.0%) in patients with cancer compared with 0.7% (95% CI: 0.6% to 0.7%) in controls (HR: 2.9; 95% CI: 2.8 to 3.1). The 6-month cumulative incidence of ischemic stroke was 3.0% (95% CI: 2.9% to 3.1%) in patients with cancer compared to 1.6% (95% CI: 1.6% to 1.7%) in controls (HR: 1.9; 95% CI: 1.8 to 2.0). Excess risk varied by cancer type (greatest for lung), correlated with cancer stage, and generally had resolved by 1 year. Conclusions Patients with incident cancer face a substantially increased short-term risk of arterial thromboembolism.

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“…Those treated with LMWH still had a significantly lower risk of recurrent clot than those treated with a vitamin K antagonist, but the magnitude of effect was not as large. 16,17 …”

Section: Discussion/conclusionmentioning

confidence: 99%

Recurrence of Venous Thromboembolism in Patients With Cancer Treated With Warfarin

Marshall

Campigotto

Neuberg

et al. 2015

Clin Appl Thromb Hemost

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Venous thromboembolism (VTE) is a common complication in patients with cancer. Previous randomized studies have demonstrated that rates of recurrent VTE are lower in patients treated with low-molecular-weight heparin compared to warfarin. We performed a retrospective analysis of 236 patients with cancer managed by a dedicated oncology anticoagulation management service to compare “real-world” rates of recurrent VTE and bleeding in patients treated with warfarin versus parenteral anticoagulants. Initial anticoagulant regimen included a parenteral agent with transition to warfarin in 132 (55.9%) patients, enoxaparin in 53 (22.5%), dalteparin in 37 (15.7%), and fondaparinux in 14 (5.9%). Taking into account the competing risk of death, cumulative incidence of VTE recurrence at 6 months was 4.0% with warfarin, 10.3% with enoxaparin, 3.0% with dalteparin, and 7.7% with fondaparinux (P = .004). Bleeding complications occurred in 10.6% of patients on warfarin, 17.0% on enoxaprin, 27.0% on dalteparin, and 14.3% on fondaparinux (P = .089). In a dedicated anticoagulation clinic, specific for patients with cancer, warfarin may be an acceptable treatment for first thrombotic events in patients with cancer.

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Competing events in patients with malignant disease who are at risk for recurrent venous thromboembolism

Cited by 26 publications

References 12 publications

Association between incident cancer and subsequent stroke

Association between incident cancer and subsequent stroke

Risk of Arterial Thromboembolism in Patients With Cancer

Recurrence of Venous Thromboembolism in Patients With Cancer Treated With Warfarin

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