Venous thromboembolism in cancer patients: a population-based cohort study.

The incidence of venous thromboembolism (VTE) in cancer patients may have changed in the past decade, possibly due to novel cancer therapies, improved survival, and high-resolution imaging. Danish medical registries were used to identify 499 092 patients with a first-time cancer diagnosis between 1997 and 2017, who were matched to 1 497 276 comparison individuals without cancer from the general population. We computed cumulative incidences of VTE 6 and 12 months after the diagnosis/index date. Hazard ratios (HRs) were calculated using Cox regression. Risk factors were examined by computing subdistribution hazard ratios (SHRs) in a competing-risk analysis. Cumulative incidence of VTE 12 months after the cancer diagnosis/index date was 2.3% (95% confidence interval [CI], 2.2% to 2.3%) in the cancer cohort and 0.35% (95% CI, 0.34% to 0.36%) in the comparison cohort (HR, 8.5; 95% CI, 8.2-8.8). Important risk factors for cancer patients were prior VTE (SHR, 7.6; 95% CI, 7.2-8.0), distant metastasis (SHR, 3.2; 95% CI, 2.9-3.4), and use of chemotherapy (SHR, 3.4; 95% CI, 3.1-3.7), protein kinase inhibitors (SHR, 4.1; 95% CI, 3.4-4.9), antiangiogenic therapy (SHR, 4.4; 95% CI, 3.8-5.2), and immunotherapy (SHR, 3.6; 2.8-4.6). Twelve-month incidence in the cancer cohort increased from 1.0% (95% CI, 0.9% to 1.2%) in 1997 to 3.4% (95% CI, 2.9% to 4.0%) in 2017, which was paralleled by improved 12-month survival and increased use of computed tomography scans, chemotherapy, and targeted therapies. In conclusion, the risk of VTE in cancer patients is increasing steadily and is ninefold higher than in the general population.

Thromboembolic and bleeding complications in patients with oesophageal cancer.

BACKGROUND: In patients who undergo curative treatment for oesophageal cancer, risk estimates of venous thromboembolism (VTE), arterial thromboembolism and bleeding are needed to guide decisions about thromboprophylaxis. METHODS: This was a single-centre, retrospective cohort study of patients with stage I-III oesophageal cancer who received neoadjuvant chemoradiation followed by oesophagectomy. The outcomes VTE, arterial thromboembolism, major bleeding, clinically relevant non-major bleeding and mortality were analysed for four consecutive cancer treatment stages (from diagnosis to neoadjuvant chemoradiotherapy, during neoadjuvant treatment, 30-day postoperative period, and up to 6 months after postoperative period). RESULTS: Some 511 patients were included. The 2-year survival rate was 67·3 (95 per cent c.i. 63·2 to 71·7) per cent. During the 2-year follow-up, 50 patients (9·8 per cent) developed VTE, 20 (3·9 per cent) arterial thromboembolism, 21 (4·1 per cent) major bleeding and 30 (5·9 per cent) clinically relevant non-major bleeding. The risk of these events was substantial at all treatment stages. Despite 30-day postoperative thromboprophylaxis, 17 patients (3·3 per cent) developed VTE after surgery. Patients with VTE had worse survival (time-varying hazard ratio 1·81, 95 per cent c.i. 1·25 to 2·64). Most bleeding events occurred around the time of medical intervention, and approximately one-half during concomitant use of prophylactic or therapeutic anticoagulation. CONCLUSION: Patients with oesophageal cancer undergoing neoadjuvant chemoradiotherapy and surgery are at substantial risk of thromboembolic and bleeding events throughout all stages of treatment. Survival is worse in patients with thromboembolic events during follow-up.

ANTECEDENTES: Para tomar decisiones en cuanto a la profilaxis tromboembólica, es preciso estimar el riesgo de tromboembolismo venoso (venous thromboembolism, VTE), de tromboembolismo arterial y de hemorragia en pacientes a los que se vaya a realizar un tratamiento curativo para el cáncer de esófago. MÉTODOS: Se realizó un estudio de cohortes retrospectivo de un solo centro, de pacientes con cáncer de esófago en estadios I-III que fueron tratados con quimiorradioterapia neoadyuvante y esofagectomía. Se analizaron, en cuatro momentos del tratamiento (desde el momento del diagnóstico hasta la quimiorradioterapia neoadyuvante, durante el tratamiento neoadyuvante, en los 30 días del período postoperatorio y a los 6 meses de la cirugía) las siguientes variables: VTE, tromboembolismo arterial, hemorragia grave, hemorragia no grave clínicamente relevante y mortalidad. RESULTADOS: Se incluyeron 511 pacientes. La supervivencia a los 2 años fue del 67,3% (ic. del 95%, 63,2-71,7). Durante el seguimiento de 2 años, 50 pacientes desarrollaron un VTE (9,8%), 20 un tromboembolismo arterial (3,9%), 21 hemorragias graves (4,1%) y 30 hemorragias no graves clínicamente relevantes (5,9%). El riesgo de estos accidentes fue notable en todas las etapas del tratamiento. A pesar de la profilaxis tromboembólica posquirúrgica, a los 30 días, 17 pacientes (3,3%) desarrollaron un VTE después de la operación. Los pacientes con VTE tuvieron una supervivencia menor (cociente de riesgos instantáneos, hazard ratio en función del tiempo 1,81; i.c. del 95%, 1,25-2,64). La mayoría de los accidentes hemorrágicos ocurrieron en el contexto de una intervención médica y el 48% durante el uso concomitante de anticoagulación profiláctica o terapéutica. CONCLUSIÓN: Los pacientes con cáncer de esófago tratados con quimiorradioterapia neoadyuvante y cirugía tienen un riesgo sustancial de sufrir accidentes tromboembólicos y hemorrágicos en todas las fases del tratamiento. La supervivencia es peor en aquellos pacientes que presentan accidentes tromboembólicos durante el seguimiento.

Edoxaban for treatment of venous thromboembolism in patient groups with different types of cancer: Results from the Hokusai VTE Cancer study.

BACKGROUND: The safety and efficacy of edoxaban and dalteparin is unclear for several cancer groups. METHODS: We evaluated the occurrence of the primary outcome in large cancer groups. The primary outcome was the composite of recurrent VTE or major bleeding over 12 months. RESULTS: In patients with gastrointestinal cancer, the primary outcome occurred in 19.4% patients given edoxaban and in 15.0% given dalteparin (risk difference [RD], 4.4%; 95%-CI, -4.1% to 12.8%). The corresponding rates for edoxaban and dalteparin were 10.4% and 10.7% for lung cancer (RD, -0.3%; 95%-CI, -10.0% to 9.5%), 13.6% and 12.5% for urogenital cancer (RD, 1.1; 95%-CI, -10.1-12.4), 3.1% and 11.7% for breast cancer (RD, -8.6; 95%-CI, -19.3-2.2), 8.9% and 10.9% for hematological malignancies (RD, -2.0; 95%-CI, -13.1-9.1), and 10.4% and 17.4% for gynecological cancer (RD, -7.0; 95%-CI, -19.8-5.7). In the subgroup of gastrointestinal cancer, edoxaban was associated with a 3.5% lower absolute risk of recurrent VTE and a 7.9% higher risk of major bleeding. CONCLUSION: Edoxaban has a similar risk-benefit ratio to dalteparin in most cancer groups. In those with gastrointestinal cancer, the lower risk of recurrent VTE and the advantages of oral therapy need to be balanced against the increased risk of major bleeding.