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VTE and Active Cancer: Impact, Treatment, and Costs

Learn about the connection between VTE and active cancer, the impact on treatment outcomes, and the added costs for patients. Explore the complexity of managing VTE in cancer patients and the need for improved strategies.

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VTE and Active Cancer: Impact, Treatment, and Costs

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  1. References: • What is the connection between VTE and active cancer? • 1. Khorana AA, Francis CW, Culakova E et al. Thromboembolismis a leading cause ofdeath in cancerpatientsreceivingoutpatientchemotherapy. Journalof Thrombosis and Haemostasis. 2007 Mar 1;5(3):632-4. • 2. Levitan N, Dowlati A, Remick SC et al. Rates ofinitial and recurrentthromboembolicdiseaseamongpatientswithmalignancy versus thosewithoutmalignancy. Riskanalysisusing Medicare claims data. Medicine (Baltimore) 1999;78:285-291. • 3. Heit JA. Cancer Control 2005;12(Suppl 1):5–10. • 4. Lipp R, Feuerbach M, Freigang F et al. Economicburdenofcancerassociatedthrombosis in Germany - Findings and extrapolations (1037P). EuropeanSocietyof Medical Oncology. Copenhagen, Denmark, 2016. • 5. Prandoni P. TheTreatmentofVenousThromboembolism in Patientswith Cancer. AdvExpMedBiol - Advances in Internal Medicine (2017) 1: 123-135. • 6. Prandoni P, Lensing AW, Piccioli A, et al. Blood. 2002 Nov 15;100(10):3484-8. • Active Cancer: • 1. National Institute for Health and Care Excellence. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing 2012; NICE guideline CG144. • Thrombosis together with infections is the second-leading cause of death in cancer patients: • 1. Khorana AA, Francis CW, Culakova E et al. Thromboembolismis a leading cause ofdeath in cancerpatientsreceivingoutpatientchemotherapy. Journalof Thrombosis and Haemostasis. 2007 Mar 1;5(3):632-4. • 2. Trujillo-Santos J, Martos FM, Font C, et al. Analysis of clinical factors affecting the rates of fatal pulmonary embolism and bleeding in cancer patients with venous thromboembolism. Heliyon. 2017 Jan 1;3(1):e00229. • 3. Cancer-Associated Thrombosis (CAT ), a neglected cause of Cancer Death: actions needed to increase health outcomes and reduce mortality. Report summarising the findings of an Expert Steering Group meeting in Belgium. • Most frequent causes of death in patients initially presenting with PE: • 1. Trujillo-Santos J, Martos FM, Font C et al. Analysisofclinicalfactorsaffectingtheratesof fatal pulmonaryembolism and bleeding in cancerpatientswithvenousthromboembolism. Heliyon 2017 Jan 1;3(1):e00229.

  2. References: How does advanced cancer affect CAT treatment outcomes? 1. Levitan N, Dowlati A, Remick SC et al. Rates ofinitial and recurrentthromboembolicdiseaseamongpatientswithmalignancy versus thosewithoutmalignancy. Riskanalysisusing Medicare claims data. Medicine (Baltimore) 1999;78:285-291. 2. Diez de los Rios de la Serna C, Richardson A, Lennan E (2017) Adherencetolow molecular weightheparintreatmentbypatientswithcancerwhodevelop VTE. Cancer NursingPractice. 16, 4, 21-26. Date ofsubmission: 17 November 2016; date ofacceptance: 10 March 2017. Survival rate is lower when cancer patients also experience VTE: 1. Levitan N, Dowlati A, Remick SC et al. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore) 1999;78:285-291. Cancer biology: Extrinsic factors 1. Heit JA. Cancer Control 2005;12(Suppl 1):5–10. 2. Young A, Chapman O, Connor C, et al. Thrombosis and cancer. Nature reviews Clinical oncology. 2012 Aug;9(8):437. What is the added cost of CAT per patient, on top of cancer? 1. Lipp R, Feuerbach M, Freigang F, et al. Economic burden of cancer associated thrombosis in Germany - Findings and extrapolations (1037P). European Society of Medical Oncology. Copenhagen, Denmark, 2016 VTE adds complexity to cancer patient management 1. P. Prandoni. The Treatment of Venous Thromboembolism in Patients with Cancer. Adv Exp Med Biol - Advances in Internal Medicine (2017) 1: 123–135 2. Voigtlaender M, Langer F. Direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism. Hämostaseologie 2017; 37: 241-55 CAT management is different from classic VTE management 1. Prandoni P, Lensing AW, Piccioli A, et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood. 2002 Nov 15;100(10):3484-8.

  3. References: Thanks to improved treatment strategies, patients with cancer are surviving longer and undergoing more cancer treatments. In the future, this will increase the incidence of VTE for cancer patients: 1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2013 Sep 5;122(10):1712-23. 2. Lyman GH. Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis. Cancer 2011;117:1334–1349. 3. Cronin-Fenton DP, Søndergaard F, Pedersen LA, et al. Hospitalisation for venous thromboembolism in cancer patients and the general population: a population-based cohort study in Denmark, 1997–2006. British journal of cancer. 2010 Sep;103(7):947. 4. Stein PD, Beemath A, Meyers FA, et al. Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med. 2006 Jan;119(1):60-8. 5. Cohen AT, Katholing A, Rietbrock S, Bamber L, Martinez C. Epidemiology of first and recurrent venous thromboembolism in patients with active cancer. Thrombosis and haemostasis. 2017 Jan;117(01):57-65. Risk of VTE is higher in the first 3 months of cancer after diagnosis: 1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiology of cancer-associated venous thrombosis. Blood. 2013 Sep 5;122(10):1712-23 2. Lyman GH. Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis. Cancer 2011;117:1334-1349. VTE risk is 20 times higher for distant metastatic disease compared to localised cancer: 1. Fuentes HE, Tafur AJ, Caprini JA. Cancer-associated thrombosis. Dis Mon 2016;62(5):121-58. 2. Cronin-Fenton DP, Søndergaard F, Pedersen LA, et al. Hospitalisation for venous thromboembolism in cancer patients and the general population: a population-based cohort study in Denmark, 1997–2006. British journal of cancer. 2010 Sep;103(7):947. VTE incidence by cancer type: 1. Stein PD, Beemath A, Meyers FA, et al. Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med. 2006 Jan;119(1):60-8 Incidence of a first venous thromboembolic event was highest in the elderly population: 1. Cohen AT, Katholing A, Rietbrock S, et al. Epidemiology of first and recurrent venous thromboembolism in patients with active cancer. Thrombosis and haemostasis. 2017 Jan;117(01):57-65.

  4. References: A number of factors among cancer patients further increase the VTE risk: 1. Timp JF, Braekkan SK, Versteeg HH, Cannegieter SC. Epidemiologyofcancer-associatedvenousthrombosis. Blood. 2013 Sep 5;122(10):1712-23. Chemotherapy: 1. Fuentes HE, Tafur AJ, Caprini JA. Cancer-associatedthrombosis. DisMon 2016;62(5):121-58. 2. Oppelt P, Betbadal A, Nayak L. Approachtochemotherapy-associatedthrombosis. Vascular Medicine. 2015 Apr;20(2):153-61. Comorbidities: 1. Donnellan E, Khorana AA. Cancer and Venous Thromboembolic Disease: A Review. Oncologist. 2017 Feb 1;22(2). Age & gender: 1. Cohen AT, Katholing A, Rietbrock S, Bamber L, Martinez C. Epidemiology of first and recurrent venous thromboembolism in patients with active cancer. Thrombosis and haemostasis. 2017 Jan;117(01):57-65 Surgery: 1. Trinh VQ, Karakiewicz PI, Sammon J, Sun M, Sukumar S, Gervais MK, Shariat SF, Tian Z, Kim SP, Kowalczyk KJ, Hu JC. Venousthromboembolism after majorcancersurgery: temporal trends and patternsofcare. JAMA surgery. 2014 Jan 1;149(1):43-9 2. Tikkinen KA, Agarwal A, Craigie S, Cartwright R, Gould MK, Haukka J, Naspro R, Novara G, Sandset PM, Siemieniuk RA, Violette PD. Systematicreviewsofobservationalstudiesofriskofthrombosis and bleeding in urologicalsurgery (ROTBUS): introduction and methodology. Systematicreviews. 2014 Dec;3(1):150 Immobility: 1. Fuentes HE, Tafur AJ, Caprini JA. Cancer-associatedthrombosis. DisMon 2016;62(5):121-58 Metastasis: 1. Fuentes HE, Tafur AJ, Caprini JA. Cancer-associatedthrombosis. DisMon 2016;62(5):121-58. Obesity: 1. Farge D, Bounameaux H, Bauersachs RM, Brenner B. Women, thrombosis, and cancer: A gender-specific analysis. Thrombosis research. 2017 Mar 1;151:S21-9

  5. References: Despite the well-known association of VTE and cancer, patients are woefully unaware of that risk and of warning signs and symptoms: 1. Lyman GH, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. Journal of Clinical Oncology. 2013 May 13;31(17):2189-204. 2. Noble S, Matzdorff A, Maraveyaspatients' anticoagulation preferences for the treatment of cancer-associated thrombosis using conjoint methodology. Haematologica 2015; 100(11): 1486-92 VTE can be detected on imaging studies conducted for other indications, typically while staging cancer: 1. Khorana A. et al, Incidental VenousThromboembolism in OncologyPatients. JTH 2012; Dec; 10(12): 2602-4 2. O’Connell C.L, et al. UnsespectedPulmonaryEmboli in Cancer Patients: ClinicalCorrelates and Relevance. JCO 2006; 24;4928-4932 3. Stein PD, et al. Chest 1995;110:978–81 4. Sander DA, et al. Autopsyprovenpulmonaryembolism in hospital patients: are wedetectingenoughdeepveinthrombosis? J R SocMed 1969;82:203–5. 5. Nicolaides AN, Fareed J, Kakkar AK, Breddin HK. Prevention and treatmentofvenousthromboembolism International ConsensusStatement (guidelinesaccordingtoscientificevidence). International Angiology. 2006 Jun 1;25(2):101 High rates of incidental VTE: 1. Moore RA, Adel N, Riedel E, Bhutani M, Feldman DR, Tabbara NE, Soff G, Parameswaran R, Hassoun H. High incidenceofthromboembolicevents in patientstreatedwithcisplatin-basedchemotherapy: a largeretrospectiveanalysis. JournalofClinicalOncology. 2011 Aug 1;29(25):3466-73. 2. Menapace LA, Peterson DR, Berry A et al. Symptomatic and incidental thromboembolism are bothassociatedwithmortality in pancreaticcancer. ThrombHaemost 2011;106:371–378 Similar outcomes for cancer patients with incidental & symptomatic PE: 1. Den Exter PL, Hooijer J, Dekkers OM, Huisman MV. Riskofrecurrentvenousthromboembolism and mortality in patientswithcancerincidentallydiagnosedwithpulmonaryembolism: a comparisonwithsymptomaticpatients. JournalofClinicalOncology. 2011 May 9;29(17):2405-9.

  6. References: Anticoagulation should be continued 3-6 months for the treatment of VTE in cancer patients: 1. ASCO: Lyman GH, Bohlke K, Khorana AA, et al. VenousThromboembolismProphylaxis and Treatment in Patientswith Cancer: American SocietyofClinicalOncologyClinicalPracticeGuidelineUpdate 2014. J Clin Oncol 2015; 33(6): 654-6. 2. ESMO: Mandalà M, Falanga A, Roila F. Management ofVenousThromboembolism (VTE) in Cancer Patients: ESMO ClinicalPracticeGuidelines. Ann Oncol 2011; 22 (Suppl 6): vi85-vi92. 3. NCCN: Streiff MB, Holmstrom B, Bockenstedt PL, et al. NCCN ClinicalPracticeGuidelines in Oncology (NCCN Guidelines™). Cancer-AssociatedVenousThromboembolicDisease, Version 1, 2017. 4. ISTH: Farge D, Debourdeau P, Beckers M, et al. International clinicalpracticeguidelinesforthetreatment and prophylaxisofvenousthromboembolism in patientswithcancer. Journalof Thrombosis and Haemostasis. 2013 Jan 1;11(1):56-70. 5. ACCP: Kearon C, Akl EA, Ornelas J, et al. AntithromboticTherapyfor VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149(2): 315-52.

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