Deep Venous Thrombosis In Cancer Patients Research Articles

Apixaban versus rivaroxaban for treatment of acute deep venous thrombosis in patients with cancer.

12113 Background: Direct oral anticoagulants (DOAC) such as Apixaban and Rivaroxaban are increasingly used for the treatment of acute venous thromboembolism (VTE) over traditional vitamin K antagonists. Malignant neoplasms predispose to acute VTE and clinical management necessitates anticoagulation to prevent further complications. We compare Apixaban to Rivaroxaban for the treatment of acute VTE in the setting of malignancy with the endpoint of chronic deep venous thrombosis (DVT) development after 2 years. Methods: The TriNetX Research network was used for this study. TriNetX provides access to anonymized medical record information on more than 107 million patients in 76 large healthcare organizations. Two cohorts were created for this study using the International Classification of Disease-10 (ICD-10) codes. All patients were required to have a diagnosis of breast (C50), lung (C34), colon (C18), or prostate cancer (C61). All were diagnosed with acute deep venous thrombosis (DVT) of the lower extremities (I82.409). One cohort was treated with rivaroxaban while the other was treated with apixaban within 3 days of DVT diagnosis. Each cohort was excluded from being treated with the other anticoagulant. The cohorts were balanced for age, race, gender, and ethnicity, then evaluated for the development of chronic DVT (I82.509) within the subsequent twelve months. Results: The development of chronic DVT was significantly more common in the apixaban cohort, with a risk ratio of 1.36 (95% CI (1.12,1.65), p-value 0.0015). See table. Conclusions: Patients with acute VTE in the setting of malignancy were at a significantly higher risk of developing chronic DVT following treatment with Apixaban compared to those who received Rivaroxaban at 2 years post-treatment. These results may contribute to increased discussion between physicians and patients when deciding between these two direct oral anticoagulants for the management of acute VTE. Diagnosis of chronic DVT in cancer patients treated with apixaban and rivaroxaban. [Table: see text]

Cancer-Associated Venous Thromboembolism in Ambulatory Solid Organ Malignancy Patients: Experience from a Cancer Research Institute.

Cancer-associated deep venous thrombosis (DVT) and venous thromboembolism (VTE) are exceedingly common in patients with cancer. One-fifth of DVT events occur in patients with cancer and it is the second leading cause of death in patients with cancer after cancer itself. Data on DVT in cancer patients on medical therapy, especially from Indian experiences, are sparse. Here, we present our experience in ambulatory patients with solid organ cancer. The purpose of the study was to study the incidence of DVT in cancer patients on medical therapy and to analyze probable DVT risk factors. This study was a hospital-based single-arm retrospective collection and analysis of hospital records from patients receiving medical therapy on an outpatient and short-stay basis. From January 2016 to February 2017, adult solid organ cancer patients attending the medical oncology outpatient department (OPD), receiving active anticancer treatment, either oral or injectable, were included. The data was retrieved from the medical records department and the department of radiology. Descriptive statistics were used to analyze the data. Twenty-nine out of 1190 patients were documented to have developed DVT during the study period. The incidence of DVT in the outpatient settings was 2.4%, and DVT associated with venous access device in situ was seen in 4.05% (20/493) of the patients. Gynecological, breast, and hepatobiliary malignancies comprised most of the cases. Cancer patients are clearly at increased risk for DVT, but this risk is highly variable. It differs between subgroups of cancer patients. Five points Khorana risk model can predict risk for DVT in the ambulatory cancer patients receiving chemotherapy; however, the routine use of thromboprophylaxis in all cancer patients is not recommended. High-risk patients especially those with venous access devices need careful evaluation and counseling for prompt reporting and recognition of venous thrombosis.

Daily low-dose aspirin in cancer patients with central venous catheter: new role for an old drug

Central venous catheters (CVC) placement increases the risk of blood clots in cancer patients [1–2]. Several randomized trials have evaluated antithrombotic prophylaxis in cancer patients with CVCs with oral anticoagulant or low-molecular-weight heparins (LMWHs) [3–13]. We agree with concerns and questions raised by Dr. Tassinari et al. We can argue that, based on interpretation of the results of contemporary trials, we could not recommend for all patients routine prophylaxis with anticoagulants or LMWH. Cancer patients are receiving increasingly complex chemotherapy regimens in combination with biologic therapies, such as bevacizumab, that can also increase incidence of deep venous thrombosis (DVT) [14]. We believe in the potential efficacy of LMWH but trials with much larger power, with a longer duration of treatment or higher dose would be required. Aspirin can be considered an attractive and safe drug for primary prevention of thrombosis in cancer patients with CVCs. Several trials assessed its efficacy in primary prevention of DVT in normal subjects. A comparison trial designed for high-risk subject (>10 h flight) evaluated impact of prevention with one dose of LMWH (equivalent to 0.1 mL per 10 kg of body weight) versus aspirin (400 mg one dose daily for 3 days, starting 12 h before the beginning of the flight) versus control [15]. Investigators reported 4.8% of subjects with DVT in the control arm, 3.6% in the aspirin arm and no DVT in the LMWH group [15]. Another recent trial investigated the efficacy of long-term aspirin therapy for preventing venous thromboembolism (VTE) in female health care professionals in the Women's Health Study. In this large study, subjects were randomized to aspirin, 100 mg, or placebo on alternate days. The incidence of VTE (per 1,000 person-years) was 1.18 among women randomly assigned to active aspirin, compared with 1.25 among women randomly assigned to placebo. Subgroup analysis for subjects with factor V Leiden, G20210A prothrombin, and MTHFR 677C>T polymorphisms showed a trend versus a beneficial effect from aspirin treatment in this subpopulation [16]. Translating these data into a cancer population, no current studies are so robust to support use of aspirin in the primary prevention of DVT in cancer patients with CVCs. A recent non randomized study in elderly patients with myeloma treated with melphalan, prednisone and lenalidomide demonstrated the efficacy of aspirin in preventing DVT [17]. Another recent meta-analysis evaluated the efficacy and safety of anticoagulation in reducing VTE events in cancer patients with CVCs [18]. Nine randomized controlled trials (RCTs) were included in the meta-analysis. The use of LMWHs in cancer patients with CVC was associated with a trend towards a reduction in symptomatic DVT, but the data did not show any statistically significant effect on mortality, major bleeding or thrombocytopenia. When studies assessing different types of anticoagulants were pooled, symptomatic DVT rates were significantly Support Care Cancer (2008) 16:313–314 DOI 10.1007/s00520-007-0387-8

Combined use of clinical pre-test probability and D-dimer test in the diagnosis of preoperative deep venous thrombosis in colorectal cancer patients

The preoperative prevalence of deep venous thrombosis (DVT) in patients with colorectal cancer may be as high as 8%. In order to minimize the risk of pulmonary embolism, it is important to rule out preoperative DVT. A large study has confirmed that a negative D-dimer test in combination with a low clinical pre-test probability (PTP) can be safely used to rule out the tentative diagnosis of DVT in cancer patients. However, the accuracy in colorectal cancer patients is uncertain. This study assessed the diagnostic accuracy of a quantitative D-dimer assay in combination with the PTP score in ruling out preoperative DVT in colorectal cancer patients admitted for surgery. Preoperative D-dimer test and compression ultrasonography for DVT were performed in 193 consecutive patients with newly diagnosed colorectal cancer. Diagnostic accuracy indices of the D-dimer test were assessed according to the PTP score. The negative predictive value, positive predictive value, sensitivity and specificity were 99% (95% confidence interval (CI), 95-100%), 17% (95% CI, 9-26), 93% (95% CI, 68-100%) and 61% (95% CI, 53-68%), respectively. In conclusion, the combined use of pre-test probability and D-dimer test may be useful in ruling out preoperative DVT in colorectal cancer patients admitted for surgery.

Outcomes and cost of deep venous thrombosis among patients with cancer

Study Question: What are the outcomes of patients with cancer complicated by deep venous thrombosis (DVT)? Methods: The initial medical records and outcome of 529 consecutive cancer patients in whom DVT developed from January 1, 1994, through December 31, 1997, were tracked until December 31, 2000. The study was conducted in a major cancer center, and the cost of hospitalization was obtained from the hospital’s cost-accounting system and inflated to 2002 US dollars using the Consumer Price Index for Medical Care. Logistic regression was used to identify factors associated with a high risk of poor outcomes. Results: The mean age was 55 years, and 52% were women. Seventy-seven percent of DVT cases presented as outpatients, 15% had a previous bout of DVT, and 13% developed within 30 days of a surgical procedure. Over 70% had the diagnosis established within 24 h of symptoms onset, although 20% had symptoms for at least 2 weeks; 50% were lower extremity and 40% were a major central vein alone or with an extremity. The latter were more often associated with central venous catheters (51% with vs. 35% without, p<0.001). Ninety-three percent received anticoagulants (95% received heparin). The most common complication of DVT was bleeding, which occurred in 13% of patients. Pulmonary embolus occurred in 4%. Five patients (1%) died of complications of DVT and 5 (1%) of complications of anticoagulation. Recurrence of DVT was common (17% overall), particularly among those who had inferior vena cava filters (32%, p<0.001) or a previous episode of DVT (p=0.03). All but 4 patients were hospitalized for initial anticoagulation therapy, for a mean of 11 days. The mean cost of hospitalization was 2002 US $20,065. Conclusions: Among patients with cancer, DVT frequently is associated with serious clinical outcomes. Its treatment is resource intensive and costly. More effective agents and less costly management strategies could have a significant impact on the outcomes and cost of DVT in this population. Perspective: This study demonstrates the very high rate of recurrence of DVT in cancer patients, and as with other studies that question the efficacy of IVC filters. The latter may be selection bias, but also could infer that the presence of the filter increases the risk of distant thrombosis. Unfortunately, the data cannot be used to draw any specific therapeutic conclusions. MR