Venous thromboembolism in cancer patients receiving neoadjuvant chemotherapy: a systematic review and meta‐analysis

Abstract

Background Venous thromboembolism (VTE) is a frequent complication in cancer patients receiving adjuvant treatment. The risk of VTE during neoadjuvant chemo-radiotherapy remains unclear. Objectives This systematic review evaluated the incidence of VTE in patients with cancer receiving neoadjuvant treatment. Methods MEDLINE and EMBASE databases were searched from inception to October 2017. Search results were supplemented with screening of conference proceedings of the American Society of Clinical Oncology (2009-2016) and the International Society of Thrombosis and Haemostasis (2003-2016). Two review authors independently screened titles and abstracts, and extracted data onto standardized forms. Results Twenty-eight cohort studies (7827 cancer patients, range 11 to 1398) were included. Twenty-five had a retrospective design. Eighteen cohorts included patients with gastrointestinal cancer, representing over two-thirds of the whole study population (n = 6002, 78%). In total, 508 of 7768 patients were diagnosed with at least one VTE during neoadjuvant treatment, for a pooled VTE incidence of 7% (95% CI, 5% to 10%) in the absence of substantial between-study heterogeneity. Heterogeneity was not explained by site of cancer or study design characteristics. VTE presented as pulmonary embolism in 22% to 96% of cases (16 cohorts), and it was symptomatic in 22% to 100% of patients (11 cohorts). The highest VTE rates were observed in patients with bladder (10.6%) or esophageal (8.4%) cancer. Conclusions This review found a relatively high incidence of VTE in cancer patients receiving neoadjuvant therapy in the presence of some between-study variation, which deserves further evaluation in prospective studies.

Incidence of venous thromboembolism among patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer

“…Although most venous thromboembolisms were present at the time of diagnosis of the epithelial ovarian cancer, the incidence of venous thromboembolism during neoadjuvant chemotherapy for the remaining patients was high at 7.7%. This rate is comparable to the 7% described by Di Nisio et al in a 2018 systematic review of venous thromboembolism during neoadjuvant chemotherapy across all types of cancer17 but lower than the 11.6% previously reported specifically for patients receiving neoadjuvant chemotherapy for advanced epithelial ovarian cancer 16 18. Several characteristics of the latter study may help explain this difference: it was performed at a single institution with a smaller sample size, and the study period was prior to 2014, which precedes the interval described in the current investigation.…”

Thromboembolic and bleeding complications in patients with oesophageal cancer

“…A possible drawback of direct oral anticoagulants is the increased bleeding tendency in patients with gastrointestinal cancer 27 -29 . Few other studies have evaluated thromboembolic complications in patients with oesophageal cancer. A systematic review and meta-analysis 8 including six retrospective cohort studies reported a pooled incidence of symptomatic or incidental VTE of 7 per cent during neoadjuvant chemoradiation. The lower incidence of 2⋅5 per cent in the present study may be explained by differences in case mix, definitions of outcome and duration of study.…”

“…It is also unclear at which stage of treatment these patients are at highest risk of VTE. Although it has been reported that there is a considerable VTE risk during neoadjuvant chemotherapy 8 , there are no reports of the estimated risk for the interval from cancer diagnosis to initiation of chemotherapy and the period after surgery. Various types of cancer are associated with an increased risk of arterial thromboembolism 9 , but data for patients with oesophageal cancer are lacking.…”

Primary Thromboprophylaxis in Ambulatory Cancer Patients: Where Do We Stand?

“…However, the risk of cancer-associated VTE heavily depends on tumor type, ranging from 1% in patients with low-risk tumors, such as breast or prostate cancer, to up to 20% in those with high-risk tumors, such as pancreatic cancer [2]. Other important risk factors include tumor stage and chemotherapy [3,4].…”