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VTE common among patients with lung cancer receiving chemotherapy
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Venous thromboembolism is common among patients with lung cancer in the ambulatory setting and is associated with increased health care utilization, according to results of a recently published study.
Previous studies based on data from large population-based epidemiologic studies of hospital discharge databases and cancer registries indicated that the incidence of VTE in patients with lung cancer ranges from 1.4% to 7%.
However, these registry studies could underestimate the incidence of VTE in patients with lung cancer because these events often occur in the outpatient setting and are not captured by these registries.
“VTE in lung cancer patients is associated with significant morbidity and mortality,” Alok A. Khorana, MD, vice-chief of the division of hematology/oncology at the James P. Wilmot Cancer Center at the University of Rochester in New York, and colleagues wrote. “In two separate prospective studies looking at VTE recurrence in pooled cohorts of cancer patients, patients with lung cancer had the highest rate of recurrence in the first few months after VTE diagnosis.”
To examine the rate of VTE in a contemporary database of lung cancer patients initiating chemotherapy in the ambulatory setting, Khorana and colleagues extracted data on 6,732 patients with lung cancer from a large health care claims database of commercially insured patients from 2004 to 2009.
The researchers recorded VTE incidence during a 3-month to 12-month follow-up period after the initiation of chemotherapy. In addition, they evaluated demographic and clinical characteristics of the cancer cohort (n=17,284) and an age/sex-matched, noncancer control cohort. They performed multivariate analyses to determine independent predictors of VTE and bleeding.
VTE incidence among patients with lung cancer was 13.9%, according to study results. Additionally, multiple clinical factors — including increased medical comorbidities, congestive heart failure and the use of erythropoiesis-stimulating agents — were associated with increased risk for VTE in this cohort.
The researchers also reported that VTE was associated with significantly higher economic costs in patients with lung cancer, as well as a significantly higher bleeding rate.
“This large contemporary cohort study shows that VTE occurs at a relatively high rate in lung cancer patients in the ambulatory setting, and it identifies several risk factors for lung cancer-associated VTE and bleeding,” Khorana and colleagues wrote. “It also demonstrates that VTE is associated with significantly higher resource utilization.”
The lung cancer cohort also exhibited significantly higher prevalence of several other medical comorbidities, including hypertension (52% vs. 38%), stroke (9% vs. 3.9%), diabetes mellitus (18.5% vs. 14.8%), congestive heart failure (7.7% vs. 3.7%), pulmonary disease (42.2% vs. 5.8%), liver disease (14.2% vs. 1.7%) and atrial fibrillation (7.2% vs. 4.2%).
“VTE prophylaxis is common in the inpatient setting based on several randomized studies demonstrating a benefit to inpatient prophylaxis in medical patients,” Khorana and colleagues wrote. “The current study suggests that the burden of VTE in lung cancer patients may be more pronounced in the outpatient setting, where prophylaxis is much less common. Recent studies suggest there is likely clinical benefit, and further research is needed to better risk stratify lung cancer patients and examine the effect of VTE prophylaxis strategies in this cohort of ambulatory cancer patients.”
Disclosure: The researchers report funding from, as well as employment and consulting relationships with, Sanofi-Aventis.
Perspective
Back to TopEric H. Kraut, MD
The article by Khorana and colleagues deals with an extremely important problem in medical oncology, the development of venous thromboembolic disease. It has been recognized for many years that the presence of cancer dramatically increases the risk of VTE and that many of the effective new chemotherapy drugs may further amplify this risk. This article continues the important work of Dr. Khorana’s group establishing which patients are at high risk and who might benefit from anticoagulation prophylaxis.
For the practicing lung cancer specialist, understanding that VTE may occur in up to 1 of 8 outpatients — and that it frequently occurs during the first 6 months of therapy — suggests incorporating an evaluation for this in the treatment paradigm. One might also consider a randomized study with and without low-molecular–weight heparin in this patient group. Yogi Berra, the American folk philosopher, once said, “You can observe a lot by just watching.” By watching a large group of lung cancer outpatients in this article, we have observed a lot.
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