Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer

Abstract

Objectives Lung cancer is strongly associated with venous thromboembolism (VTE), but primary prevention against VTE is not a validated management strategy. Risk assessment models will be necessary for efficient implementation of preventative strategies. Materials and methods Utilizing a prospectively collected lung cancer database, we aimed to validate the Khorana Risk Score (KRS) in the prediction of VTE among patients with lung cancer. VTE events were retrospectively identified by reviewers unaware of the clinical prediction score calculation. The association between KRS and the risk of VTE was examined using cumulative incidence function with competing risks models. Mortality prediction was evaluated as secondary outcome. Results We included 719 patients in our review. The patients were predominantly older males with NSCLC and 40% had metastatic disease at inception. The median follow up was 15.2 months. There were 83 VTEs (11.5%) and 568 (78.8%) patients died. A high KRS (Cumulative Incidence 12.4%, 95% Confidence Interval 6.4-20.5%) was not associated with VTE compared to an intermediate score (Cumulative Incidence 12.1%, 95% Confidence Interval 9.5-15.0%)) in both univariate and multivariable analyses. However, a high KRS was a predictor of mortality (HR 1.7 95% CI 1.4 - 2.2). Conclusions Among patients with lung cancer the KRS did not stratify the patients at the highest risk of VTE. Improved risk stratification methods are needed for this group of patients prior to implementing a primary prevention strategy.

Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer: comment

“…The findings of Mansfield et al [1] are consistent with the results from a subgroup analysis of patients receiving chemotherapy in the FRAGMATIC study, which were presented at the XXV ISTH Congress [3]. In brief, patients with primary bronchial carcinoma, non-small-cell lung cancer or small-cell lung cancer within 6 weeks of diagnosis and prior to definitive anticancer treatment were enrolled in the FRAGMATIC study: a phase III trial investigating the impact on overall survival of adding low molecular weight heparin to usual care in patients with lung cancer [4].…”

“…We read with interest the article by Mansfield et al [1] in which the authors report their attempt to validate the Khorana Risk Score (KRS) [2] in the prediction of venous thromboembolism (VTE) among ambulant patients with lung cancer receiving chemotherapy. In their prospectively collected lung cancer database of 719 patients, there were 83 (11.5%) episodes of VTE.…”

Evaluation of the ThroLy score for the prediction of venous thromboembolism in newly diagnosed patients treated for lymphoid malignancies in clinical practice

“…[8][9][10][11][12] Recently research shows that the KRS failed to discriminate between high-and low-risk patients with cancer for VTE development, including patients with lymphoma. [13][14][15][16]36,37 This is further supported by our study in which the KRS did not adequately predict VTE events in patients at a higher risk of VTE in a cohort of patients with lymphoid malignancies. 37 Therefore, Antic et al developed the prognostic Thrombosis Lymphoma (ThroLy) score which is more specific for lymphoma patients than any other available scores targeting thrombosis in cancer patients.…”

“…Due to poor discriminatory performance, most of the recently established VTE-assessment models have proven to be of limited clinical utility because of the low predictive value of VTE events in subsequent studies, particularly in studies based on a single cancer cohort. [13][14][15][16] It is believed that the risk to patients with lymphoma, undergoing ambulatory chemotherapy, of developing VTE is similar to that of patients with solid tumours with the incidence reaching 14.6%. 17,18 Lymphoma is considered to constitute a high risk of VTE development in the best-validated model to stratify outpatients with cancer, which was developed by Khorana and is known as the Khorana risk score (KRS).…”

Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer: reply

“…We appreciate the thoughtful response to our article ‘Predictors of active cancer thromboembolic outcomes: validation of the Khorana score among patients with lung cancer’ from Noble et al . .…”