ABSTRACT

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.

PMID:37832588 | DOI:10.1055/a-2191-7510

08:20

PubMed articles on: Cancer & VTE/PE

Implementation of routine venous thromboembolism prophylaxis during neoadjuvant chemotherapy for patients with ovarian cancer

Gynecol Oncol. 2023 Oct 11;178:89-95. doi: 10.1016/j.ygyno.2023.10.001. Online ahead of print.

ABSTRACT

OBJECTIVE: To compare the venous thromboembolism (VTE) rate in patients with ovarian cancer undergoing neoadjuvant chemotherapy before and after implementing routine thromboprophylaxis.

METHODS: This is a quasi-experimental pre-post study evaluating the VTE rate in patients with ovarian cancer who received neoadjuvant chemotherapy following a quality improvement initiative of routine thromboprophylaxis within a single healthcare system that started in January 2017. Patients were excluded if VTE was diagnosed before initiating chemotherapy. Patient factors and perioperative variables of interest were investigated for their association with VTE through univariate and multivariate models.

RESULTS: Of the 136 patients in the pre-implementation group, 3.7% (n = 5) received thromboprophylaxis. Of the 154 patients in the post-implementation group, 65.6% (n = 101) received thromboprophylaxis. Provider compliance varied from 51% in 2019 to 79.3% in 2021. The overall rate of VTE, from the start of chemotherapy to the end of treatment, was 21.3% (n = 29) pre- and 8.4% (n = 13) in the post-implementation group (p < 0.01). There was no difference in major bleeding events between groups (0% vs. 0.68%, p = 0.63). On univariate analysis, thromboprophylaxis (OR 0.19; 95% CI 0.07-0.52) and post-implementation period (OR 0.34; 95% CI 0.17-0.69) were associated with a decreased risk of any VTE during primary treatment. On multivariate analysis, only thromboprophylaxis remained significantly associated with reduced VTE rates (aOR 0.19; 95% CI 0.07-0.53).

CONCLUSION: Routine thromboprophylaxis during neoadjuvant chemotherapy is associated with reduced risk of VTE throughout primary treatment and is not associated with increased bleeding events.

PMID:37832182 | DOI:10.1016/j.ygyno.2023.10.001

08:20

PubMed articles on: Cancer & VTE/PE

Risk of Thrombosis and Bleeding in Gynecologic Cancer Surgery: Systematic Review and Meta-Analysis

Am J Obstet Gynecol. 2023 Oct 10:S0002-9378(23)00735-4. doi: 10.1016/j.ajog.2023.10.006. Online ahead of print.

ABSTRACT

OBJECTIVE: To provide procedure-specific estimates of the risk of symptomatic venous thromboembolism (VTE) and major bleeding, in the absence of thromboprophylaxis, following gynecologic cancer surgery.

DATA SOURCES: We conducted comprehensive searches on Embase, MEDLINE, Web of Science, and Google Scholar for observational studies. We also reviewed reference lists of eligible studies and review articles. We performed separate searches for randomized trials addressing effects of thromboprophylaxis and conducted a web-based survey on thromboprophylaxis practice.

STUDY ELIGIBILITY CRITERIA: Observational studies enrolling ≥50 adult patients undergoing gynecologic cancer surgery procedures reporting absolute incidence for at least one of the following: symptomatic pulmonary embolism, symptomatic deep vein thrombosis, symptomatic VTE, bleeding requiring reintervention (including re-exploration and angioembolization), bleeding leading to transfusion or post-operative hemoglobin <70

STUDY APPRAISAL AND SYNTHESIS METHODS: Two reviewers independently assessed eligibility, performed data extraction, and evaluated risk of bias of eligible articles. We adjusted the reported estimates for thromboprophylaxis and length of follow-up and used the median value from studies to determine cumulative incidence at 4 weeks post-surgery stratified by patient VTE risk factors, and used the GRADE approach to rate evidence certainty.

RESULTS: We included 188 studies (398,167 patients) reporting on 37 gynecologic cancer surgery procedures. The evidence certainty was generally low to very low. Median symptomatic VTE risk (in the absence of prophylaxis) was <1%2.0% in 13 of 37 (35%). The risks of VTE varied from 0.1% in low VTE risk patients undergoing cervical conization to 33.5% in high VTE risk patients undergoing pelvic exenteration. Estimates of bleeding requiring reintervention varied from <0.1%<1%

CONCLUSIONS: VTE reduction with thromboprophylaxis likely outweighs increase in bleeding requiring reintervention in many gynecologic cancer procedures (e.g., open surgery for ovarian cancer and pelvic exenteration). In some procedures (e.g., laparoscopic total hysterectomy without lymphadenectomy), thromboembolism and bleeding risks are similar, and decisions depend on individual risk prediction and values and preferences regarding VTE and bleeding.

PMID:37827272 | DOI:10.1016/j.ajog.2023.10.006

08:20

PubMed articles on: Cancer & VTE/PE

Accuracy of the ACS NSQIP Surgical Risk Calculator for Predicting Postoperative Complications in Gastric Cancer Following Open Gastrectomy

Am Surg. 2023 Oct 12:31348231206581. doi: 10.1177/00031348231206581. Online ahead of print.

ABSTRACT

INTRODUCTION: The prediction of complications before gastric surgery is of utmost importance in shared decision making and proper counseling of the patient in order to minimize postoperative complications. Our aim was to evaluate the predictive validity of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) risk calculator in gastric cancer patients who underwent gastrectomy.

METHODS: Preoperative assessment data of 432 patients were retrospectively reviewed and manually entered into the calculator. The accuracy of the calculator was evaluated using Pearson's chi-squared test, C-statistic, Brier score, and Hosmer-Lemeshow test.

RESULTS: The lowest Brier scores were observed in urinary tract infection, renal failure, venous thromboembolism, pneumonia, and cardiac complications. Best results were obtained for predicting sepsis, discharge to rehabilitation facility, and death (low Brier scores, C-statistic >.7, and Hosmer-Lemeshow P > .05).

CONCLUSION: The calculator had a strong performance in predicting sepsis, discharge to the rehabilitation facility, and death. However, it performed poor in predicting the most commonly observed events (any or serious complication and surgical site infection).

PMID:37823864 | DOI:10.1177/00031348231206581

08:20

PubMed articles on: Cancer & VTE/PE

Venous thromboembolism prevention in cancer care: implementation strategies to address underuse

Res Pract Thromb Haemost. 2023 Aug 20;7(7):102173. doi: 10.1016/j.rpth.2023.102173. eCollection 2023 Oct.