Management of Cancer-Associated Thrombosis: An Evolving Area

Frère, Corinne; Connors, Jean M.; Farge, Dominique

doi:10.3390/cancers12102999

Cited by 3 publications

(2 citation statements)

References 32 publications

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“…Specific recommendations regarding the benefit and risk of anticoagulants for the treatment or prevention of VTE in patients with cancer and COVID-19 are not available. 35 Using novel data from the CCC19 registry, we conclude that patients with cancer and COVID-19 who require hospitalization and have recently received TOIs are at a relatively high risk of VTEs; those patients who experience a TEE are at very high risk of death (approximately 20%-25%). Although not designed to prove causality between systemic therapy exposure and TEEs, our study highlights a potential association, and further investigation with prospective studies and randomized clinical trials is recommended to address riskmitigation strategies.…”

Section: Discussionmentioning

confidence: 93%

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Gulati,

Hsu,

Shah

et al. 2023

JAMA Oncol

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ImportanceSystematic data on the association between anticancer therapies and thromboembolic events (TEEs) in patients with COVID-19 are lacking.ObjectiveTo assess the association between anticancer therapy exposure within 3 months prior to COVID-19 and TEEs following COVID-19 diagnosis in patients with cancer.Design, Setting, and ParticipantsThis registry-based retrospective cohort study included patients who were hospitalized and had active cancer and laboratory-confirmed SARS-CoV-2 infection. Data were accrued from March 2020 to December 2021 and analyzed from December 2021 to October 2022.ExposureTreatments of interest (TOIs) (endocrine therapy, vascular endothelial growth factor inhibitors/tyrosine kinase inhibitors [VEGFis/TKIs], immunomodulators [IMiDs], immune checkpoint inhibitors [ICIs], chemotherapy) vs reference (no systemic therapy) in 3 months prior to COVID-19.Main Outcomes and MeasuresMain outcomes were (1) venous thromboembolism (VTE) and (2) arterial thromboembolism (ATE). Secondary outcome was severity of COVID-19 (rates of intensive care unit admission, mechanical ventilation, 30-day all-cause mortality following TEEs in TOI vs reference group) at 30-day follow-up.ResultsOf 4988 hospitalized patients with cancer (median [IQR] age, 69 [59-78] years; 2608 [52%] male), 1869 had received 1 or more TOIs. Incidence of VTE was higher in all TOI groups: endocrine therapy, 7%; VEGFis/TKIs, 10%; IMiDs, 8%; ICIs, 12%; and chemotherapy, 10%, compared with patients not receiving systemic therapies (6%). In multivariable log-binomial regression analyses, relative risk of VTE (adjusted risk ratio [aRR], 1.33; 95% CI, 1.04-1.69) but not ATE (aRR, 0.81; 95% CI, 0.56-1.16) was significantly higher in those exposed to all TOIs pooled together vs those with no exposure. Among individual drugs, ICIs were significantly associated with VTE (aRR, 1.45; 95% CI, 1.01-2.07). Also noted were significant associations between VTE and active and progressing cancer (aRR, 1.43; 95% CI, 1.01-2.03), history of VTE (aRR, 3.10; 95% CI, 2.38-4.04), and high-risk site of cancer (aRR, 1.42; 95% CI, 1.14-1.75). Black patients had a higher risk of TEEs (aRR, 1.24; 95% CI, 1.03-1.50) than White patients. Patients with TEEs had high intensive care unit admission (46%) and mechanical ventilation (31%) rates. Relative risk of death in patients with TEEs was higher in those exposed to TOIs vs not (aRR, 1.12; 95% CI, 0.91-1.38) and was significantly associated with poor performance status (aRR, 1.77; 95% CI, 1.30-2.40) and active/progressing cancer (aRR, 1.55; 95% CI, 1.13-2.13).Conclusions and RelevanceIn this cohort study, relative risk of developing VTE was high among patients receiving TOIs and varied by the type of therapy, underlying risk factors, and demographics, such as race and ethnicity. These findings highlight the need for close monitoring and perhaps personalized thromboprophylaxis to prevent morbidity and mortality associated with COVID-19–related thromboembolism in patients with cancer.

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Section: Discussionmentioning

confidence: 93%

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Gulati,

Hsu,

Shah

et al. 2023

JAMA Oncol

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“…molecular-weight heparin (LMWH) over the direct oral anticoagulants for the initialand long-term therapy of VTE in patients with cancer at high-risk for bleeding. [1][2][3][4] However, there is scarce evidence in the literature on the use of LMWH for the initialand long-term therapy of VTE in patients with cancer and RI with regards to dose adjustment and safety. Randomized trials investigating the treatment of VTE often exclude patients with severe RI.…”

Section: Accepted Manuscriptmentioning

confidence: 99%

Enoxaparin for Long-Term Therapy of Venous Thromboembolism in Patients with Cancer and Renal Insufficiency

Sigüenza,

López-Núñez,

Falgá

et al. 2023

Thromb Haemost

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Background: The optimal therapy of venous thromboembolism (VTE) in cancer patients with renal insufficiency (RI) is unknown. Current guidelines recommend to use low-molecular-weight heparin over direct oral anticoagulants to treat VTE in cancer patients at high-risk for bleeding. Methods: We used the RIETE registry to compare the 6-month incidence rates of: 1) VTE recurrences vs. major bleeding; and 2) fatal pulmonary embolism (PE) vs. fatal bleeding in 3 subgroups (those with mild, moderate, or severe RI) of cancer patients receiving enoxaparin monotherapy. Results: From January 2009 through June 2022, 2,844 patients with RI received enoxaparin for ≥6 months: 1,432 (50%) had mild, 1,168 (41%) moderate, and 244 (8.6%) had severe RI. Overall, 68%, 62% and 12% respectively, received the recommended doses. Among patients with mild RI, the rates of VTE recurrences vs. major bleeding (4.6% vs. 5.4%) and fatal PE vs. fatal bleeding (1.3% vs. 1.2%) were similar. Among patients with moderate RI, VTE recurrences were half as common as major bleeding (3.1% vs. 6.3%), but fatal PE and fatal bleeding were close (1.8% vs. 1.2%). Among patients with severe RI, VTE recurrences were 3-fold less common than major bleeding (4.1% vs. 13%), but fatal PE was 3-fold more frequent than fatal bleeding (2.5% vs. 0.8%). During the first 10 days, fatal PE was 5-fold more common than fatal bleeding (2.1% vs. 0.4%). Conclusions: Among cancer patients with severe RI, fatal PE was 5-fold more common than fatal bleeding. The recommended doses of enoxaparin in these patients should be revisited.

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Direct oral anticoagulants in the treatment of venous thromboembolic disease associated with cancer. Evidence and recommendations

Sánchez¹,

Hernández²,

Castillo³

et al. 2021

Angiologia

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Losanticoagulantes orales directos en el tratamiento de la enfermedad tromboembólica venosa asociada a cáncer. Evidencias y recomendaciones Direct oral anticoagulants in the treatment of venous thromboembolic disease associated with cancer. Evidence and recommendations 10.20960/angiologia.00313 11/30/2021 Los anticoagulantes orales directos en el tratamiento de la enfermedad tromboembólica venosa asociada a cáncer. Evidencias y recomendaciones Direct oral anticoagulants in the treatment of venous thromboembolic disease associated with cancer. Evidence and recommendations

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Management of Cancer-Associated Thrombosis: An Evolving Area

Cited by 3 publications

References 32 publications

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Systemic Anticancer Therapy and Thromboembolic Outcomes in Hospitalized Patients With Cancer and COVID-19

Enoxaparin for Long-Term Therapy of Venous Thromboembolism in Patients with Cancer and Renal Insufficiency

Direct oral anticoagulants in the treatment of venous thromboembolic disease associated with cancer. Evidence and recommendations

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