Venous thromboembolism (VTE) represents a significant cause of morbidity and mortality in cancer patients. The risk of VTE is increased by certain cancer types, advanced or metastatic disease, surgery, chemotherapy, targeted therapy, and hospitalization. Prophylaxis is recommended for cancer patients undergoing surgery, hospitalized with medical conditions, and those receiving chemotherapy or targeted therapy who are at high risk. Prophylaxis involves pharmacological methods like low molecular weight heparins or mechanical methods. Guidelines provide recommendations on assessing risk factors, initiating prophylaxis, and duration of treatment and prophylaxis to balance preventing VTE events and risks of bleeding in cancer patients.
1) Armand Trousseau was the first to associate thrombosis and malignancy in the 19th century and suggest screening cancer patients for thrombosis.
2) Cancer patients have a highly elevated risk of developing venous thromboembolism (VTE), which can occur in up to 20% and is a common cause of death.
3) The presence of VTE at cancer diagnosis is associated with worse prognosis and survival rates. Tissue factor expression by tumor cells contributes to increased coagulation and thrombosis.
Venous Thromboembolism in the Cancer Patientlarriva
Cancer patients are at an increased risk of venous thromboembolism. There have been several guidelines published on the topic from the American College of Chest Physicians (ACCP), the American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN). Although they agree on some issues regarding prophylaxis and treatment there are several areas that vary. This presentation covers the varying recommendations and the areas of consensus (yellow boxes) among the guidelines while using a patient case to guide their interpretation.
Cancer-Associated Thrombosis.From LMWH to DOACsmagdy elmasry
This document summarizes a presentation on cancer-associated thrombosis (CAT). It discusses that up to 20% of cancer patients experience venous thromboembolism (VTE) and cancer patients have a 5 times higher risk of VTE than the general population. The presentation reviews risk factors for CAT, mechanisms of cancer-related VTE, treatment options including low molecular weight heparins (LMWH), vitamin K antagonists (VKA), and direct oral anticoagulants (DOACs). It summarizes evidence from clinical trials comparing these treatments and guidelines recommending LMWH for at least 6 months. Considerations for optimal use of each treatment class and avoiding certain options are also outlined.
Venous thromboembolism (VTE) is common in patients with malignancy and carries a high risk of morbidity and mortality. Approximately 15% of cancer patients will develop symptomatic VTE, and VTE is the second leading cause of death among hospitalized cancer patients. The risk of VTE is increased by certain tumor types, advanced stage, chemotherapy, and surgery. The pathophysiology involves stasis, endothelial injury, and a hypercoagulable state induced by tumor-derived procoagulants and cytokines. Prevention includes pharmacological prophylaxis with low molecular weight heparin for high-risk patients. Treatment of VTE involves initial parenteral anticoagulation followed by long-term therapy typically
VTE and Cancer Healthcare Professional Educationvtesimplified
Cancer patients are at increased risk of developing blood clots (venous thromboembolism or VTE) due to factors such as tumour infiltration of blood vessels, immobility, and cancer treatments. VTE is a leading cause of death in cancer patients and the risk is highest in the first months after diagnosis. Guidelines recommend thromboprophylaxis for hospitalized cancer patients without bleeding risk, but evidence for routine outpatient prophylaxis is limited to certain high risk groups. Risk assessment tools can help identify those at highest risk who may benefit most from prophylaxis.
This document discusses cancer-associated thrombosis, including its high prevalence and mortality risk. Venous thromboembolism (VTE) is common in cancer patients due to patient-related, cancer-related, and treatment-related risk factors. VTE prophylaxis and treatment are important, with low molecular weight heparins and direct oral anticoagulants playing a major role. Treatment decisions require weighing risks and benefits on a case-by-case basis, with at least 6 months of anticoagulation often recommended for cancer-associated VTE. Special populations like those with renal or liver impairment require modified approaches.
Management Of Recurrent Ovarian Ca (ROC)
The document discusses the management of recurrent ovarian cancer. It provides details on the incidence and patterns of recurrence for ovarian cancer. For patients with platinum-sensitive recurrent ovarian cancer, the standard treatment is second line chemotherapy. Several chemotherapy regimens are discussed including carboplatin with paclitaxel, gemcitabine, or pegylated liposomal doxorubicin. For partially platinum-sensitive recurrent ovarian cancer, the OVA-301 trial showed improved overall survival with the combination of carboplatin and pegylated liposomal doxorubicin compared to carboplatin alone. Management of recurrent ovarian cancer aims to prolong survival, delay progression,
1) Armand Trousseau was the first to associate thrombosis and malignancy in the 19th century and suggest screening cancer patients for thrombosis.
2) Cancer patients have a highly elevated risk of developing venous thromboembolism (VTE), which can occur in up to 20% and is a common cause of death.
3) The presence of VTE at cancer diagnosis is associated with worse prognosis and survival rates. Tissue factor expression by tumor cells contributes to increased coagulation and thrombosis.
Venous Thromboembolism in the Cancer Patientlarriva
Cancer patients are at an increased risk of venous thromboembolism. There have been several guidelines published on the topic from the American College of Chest Physicians (ACCP), the American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN). Although they agree on some issues regarding prophylaxis and treatment there are several areas that vary. This presentation covers the varying recommendations and the areas of consensus (yellow boxes) among the guidelines while using a patient case to guide their interpretation.
Cancer-Associated Thrombosis.From LMWH to DOACsmagdy elmasry
This document summarizes a presentation on cancer-associated thrombosis (CAT). It discusses that up to 20% of cancer patients experience venous thromboembolism (VTE) and cancer patients have a 5 times higher risk of VTE than the general population. The presentation reviews risk factors for CAT, mechanisms of cancer-related VTE, treatment options including low molecular weight heparins (LMWH), vitamin K antagonists (VKA), and direct oral anticoagulants (DOACs). It summarizes evidence from clinical trials comparing these treatments and guidelines recommending LMWH for at least 6 months. Considerations for optimal use of each treatment class and avoiding certain options are also outlined.
Venous thromboembolism (VTE) is common in patients with malignancy and carries a high risk of morbidity and mortality. Approximately 15% of cancer patients will develop symptomatic VTE, and VTE is the second leading cause of death among hospitalized cancer patients. The risk of VTE is increased by certain tumor types, advanced stage, chemotherapy, and surgery. The pathophysiology involves stasis, endothelial injury, and a hypercoagulable state induced by tumor-derived procoagulants and cytokines. Prevention includes pharmacological prophylaxis with low molecular weight heparin for high-risk patients. Treatment of VTE involves initial parenteral anticoagulation followed by long-term therapy typically
VTE and Cancer Healthcare Professional Educationvtesimplified
Cancer patients are at increased risk of developing blood clots (venous thromboembolism or VTE) due to factors such as tumour infiltration of blood vessels, immobility, and cancer treatments. VTE is a leading cause of death in cancer patients and the risk is highest in the first months after diagnosis. Guidelines recommend thromboprophylaxis for hospitalized cancer patients without bleeding risk, but evidence for routine outpatient prophylaxis is limited to certain high risk groups. Risk assessment tools can help identify those at highest risk who may benefit most from prophylaxis.
This document discusses cancer-associated thrombosis, including its high prevalence and mortality risk. Venous thromboembolism (VTE) is common in cancer patients due to patient-related, cancer-related, and treatment-related risk factors. VTE prophylaxis and treatment are important, with low molecular weight heparins and direct oral anticoagulants playing a major role. Treatment decisions require weighing risks and benefits on a case-by-case basis, with at least 6 months of anticoagulation often recommended for cancer-associated VTE. Special populations like those with renal or liver impairment require modified approaches.
Management Of Recurrent Ovarian Ca (ROC)
The document discusses the management of recurrent ovarian cancer. It provides details on the incidence and patterns of recurrence for ovarian cancer. For patients with platinum-sensitive recurrent ovarian cancer, the standard treatment is second line chemotherapy. Several chemotherapy regimens are discussed including carboplatin with paclitaxel, gemcitabine, or pegylated liposomal doxorubicin. For partially platinum-sensitive recurrent ovarian cancer, the OVA-301 trial showed improved overall survival with the combination of carboplatin and pegylated liposomal doxorubicin compared to carboplatin alone. Management of recurrent ovarian cancer aims to prolong survival, delay progression,
DAPT trial evaluated whether 30 months of dual antiplatelet therapy (DAPT) was superior to 12 months in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent placement. The trial found that prolonged DAPT reduced stent thrombosis and major adverse cardiac and cerebrovascular events compared to aspirin alone, but increased bleeding risk. An analysis of the trial developed the DAPT score to predict ischemic and bleeding risks and help determine optimal DAPT duration for individual patients. Newer PRECISE-DAPT and other scores further refine risk stratification to personalize DAPT duration based on balancing ischemic benefit versus bleeding risk.
Update on Management of Triple Negative Breast Cancerspa718
This document provides an update on the management of triple negative breast cancer from Dr. Banu Arun at MD Anderson Cancer Center. It discusses that triple negative breast cancer is a heterogeneous disease comprised of several molecular subtypes with different characteristics and potential treatment targets. Clinical trials exploring chemotherapy regimens, platinum agents, PARP inhibitors, anti-angiogenic drugs, and immunotherapies are summarized. Ongoing research aims to better define the subtypes in order to personalize treatment for triple negative breast cancer patients.
Targeted therapies such as tyrosine kinase inhibitors (TKIs), monoclonal antibodies (MABs), and other small molecules are used to treat various cancers. TKIs like gefitinib, erlotinib, sorafenib, sunitinib, and imatinib are indicated for lung cancer, gastrointestinal stromal tumor, kidney cancer, and chronic myeloid leukemia. They can cause diarrhea, rash, hypertension, and myelosuppression. MABs including trastuzumab, rituximab, cetuximab, and bevacizumab are used for breast cancer, lymphoma, colorectal cancer, and lung cancer. Potential toxicities are cardiomyopathy, hypersensitivity
The document summarizes several international guidelines for treating breast cancer, including the St. Gallen, ASCO, NCCN, and AGO guidelines. The St. Gallen guidelines classify risk based on endocrine responsiveness. The NCCN guidelines recommend aromatase inhibitors for 5 years or switching from tamoxifen to an AI after 2-3 years. The ASCO guidelines also recommend aromatase inhibitors for 5 years or switching from tamoxifen to an AI after 2-5 years for no more than 5 years total on the AI.
Opportunities for Immune Therapy and Preventionbkling
This document summarizes a presentation on opportunities for immunotherapy in breast cancer. It discusses how the immune system fights cancer, types of immunotherapy including checkpoint inhibitors and CAR T-cell therapy. Experience with immunotherapy in breast cancer has been underwhelming due to breast cancer typically having low numbers of immune cells, but responses have been seen in triple negative and HER2+ breast cancers. Future opportunities include increasing immune cells prior to standard treatments and engaging the immune system in the adjuvant setting to reduce recurrence risks.
This document discusses cardiotoxicity from chemotherapy, specifically anthracyclines, and its management. It provides a case study of a breast cancer patient with pre-existing cardiac disease receiving chemotherapy. Key points discussed include:
1. Anthracyclines are effective chemotherapy but can cause dose-dependent cardiotoxicity and heart failure.
2. Various modalities can help detect cardiotoxicity early, including echocardiography, tissue Doppler imaging, and cardiac biomarkers.
3. While chemotherapy may cause cardiac damage, optimal heart failure therapy can significantly improve cardiac function for many patients.
4. Careful consideration of cardiac risk factors and function is important when choosing chemotherapy regimens and monitoring for toxicity
This document summarizes recent advances in treating triple negative breast cancer (TNBC). TNBC accounts for 15-20% of breast cancers and has a poorer prognosis than other subtypes. New classifications identify basal-like and other subtypes. Standard chemotherapy remains the first-line treatment for early and advanced TNBC, but adding platinum agents or nab-paclitaxel to neoadjuvant chemotherapy improves outcomes. PARP inhibitors such as olaparib and talazoparib improve progression-free survival in BRCA-mutated metastatic TNBC. Immunotherapy with atezolizumab, pembrolizumab or combinations improves progression-free and overall survival in PD-L1 positive advanced
1) The document discusses the role of targeted therapy in neuroendocrine tumors. It covers topics such as the evolution of terminology and classification of NETs, the use of biomarkers and imaging in diagnosis and monitoring, and current therapeutic approaches including somatostatin analogs.
2) Somatostatin analogs like octreotide and lanreotide are effective in controlling hormonal symptoms in NET patients by binding to somatostatin receptors that are prevalent on many NETs. They have also shown inhibitory effects on tumor proliferation.
3) A phase III study showed octreotide LAR extended time to tumor progression compared to placebo in treatment-naïve patients with well-differentiated midgut NETs
This document discusses updates in venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It describes the risk factors, signs, symptoms, and diagnostic testing for VTE including ultrasonography, CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scanning, and magnetic resonance imaging (MRI). It also discusses specific considerations for diagnosing PE during pregnancy.
Olaparib is an oral PARP inhibitor that has shown efficacy in the treatment of breast and ovarian cancers associated with BRCA mutations. In breast cancer, phase III trials OlympiA and OlympiAD demonstrated that olaparib improves invasive disease-free survival and progression-free survival, respectively, in patients with germline BRCA mutations. In ovarian cancer, phase III trials SOLO-1, PAOLA-1, and PRIMA found that olaparib improves progression-free survival when used as maintenance therapy or in combination with chemotherapy in patients with BRCA mutations. Olaparib is now approved for several indications based on these trials and provides an important targeted treatment option for cancers associated
1) Recent immunotherapy advances for advanced NSCLC include the approval of pembrolizumab as a first-line treatment for patients with PD-L1 expression ≥50% based on results from the KEYNOTE-024 trial showing improved progression-free and overall survival compared to chemotherapy.
2) The Phase III KEYNOTE-407 trial found that combining pembrolizumab with chemotherapy improved progression-free survival compared to chemotherapy alone in patients with untreated metastatic squamous NSCLC, regardless of PD-L1 expression level.
3) Combining chemotherapy with immunotherapy may enhance the immune response by increasing antigen presentation, disrupting immune evasion mechanisms, and improving outcomes compared to chemotherapy or immunotherapy alone.
This document discusses heart failure with preserved ejection fraction (HFpEF), formerly known as diastolic heart failure. It provides background on HFpEF versus systolic heart failure and explores the pathophysiology and management of HFpEF. Key points include:
1) HFpEF is a distinct clinical syndrome from heart failure with reduced ejection fraction (HFrEF), with normal ejection fraction but evidence of diastolic dysfunction.
2) Impaired systolic function can be detected in HFpEF patients using strain imaging, despite preserved global ejection fraction.
3) The pathophysiology of HFpEF is complex and multifactorial, involving microvascular inflammation, cardiomyocyte stiff
How can immunotherapy be used to treat metastatic breast cancer? Ian Krop, MD, PhD, discusses the latest research and treatment options.
This presentation was originally given as part of the 2015 Metastatic Breast Cancer Forum, held on October 17 and hosted by the Susan F. Smith Center for Women's Cancers at Dana-Farber Cancer Institute in Boston, Mass.
For more information, visit www.susanfsmith.org
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
The document discusses various antiplatelet drugs including aspirin, P2Y12 receptor antagonists like clopidogrel and prasugrel, and GPllb/llla antagonists. It provides details on the mechanisms and clinical trials of these drugs. Specifically, it summarizes that aspirin works by irreversibly inhibiting platelet COX-1 and reducing thromboxane production. Large trials showed aspirin reduces vascular events by around 25% in high risk patients. Clopidogrel and prasugrel are P2Y12 antagonists but prasugrel has faster onset and greater platelet inhibition. The TRITON trial found prasugrel more effective than clopidogrel for ACS patients
Beat the Odds: New Treatments for Pancreatic Cancer - 12.6.18Summit Health
Presenter(s): Zubin M. Bamboat, MD, FACS, Surgical Oncologist; David Gallinson, DO, Oncologist
Pancreatic cancer is often a silent killer. While surgery provides the only chance for a cure, many patients are inoperable by the time they develop symptoms. Join us to learn all about pancreatic cancer, including risk factors and symptoms. Our experts will discuss how they are combating this deadly disease by using the latest in adjuvant and neoadjuvant therapies, surgery and novel medical treatments.
This document discusses the management of triple negative breast cancer (TNBC). It begins with an overview of the three main subtypes of breast cancer and their associated treatments. It then focuses on the characteristics and treatment challenges of TNBC, including its aggressiveness, younger patient population, and lack of targeted therapies. Current treatment options for metastatic TNBC are discussed, including various chemotherapy regimens. The document also touches on neoadjuvant and adjuvant systemic therapy approaches as well as ongoing research into better understanding the biology of TNBC to revolutionize outcomes.
This document provides information about small cell lung cancer (SCLC). It discusses that tobacco consumption is the primary cause of SCLC and accounts for 80-90% of lung cancer cases. It also notes that SCLC accounts for 13% of lung cancer worldwide. The natural history of untreated SCLC is rapid progression with a median survival of 2-4 months if extensive stage disease is present at diagnosis in approximately two thirds of patients. Diagnostic workup involves imaging like CT scans and PET scans to stage the cancer as well as biopsies to confirm the diagnosis. Prognostic factors like limited versus extensive stage disease and performance status impact survival outcomes.
This downloadable slidedeck, presented in a regional grand rounds series, focuses on increasing awareness about current and emerging treatment options for patients with newly diagnosed and recurrent ovarian cancer.
The document discusses the management of venous thromboembolism (VTE) in patients with cancer. It notes that cancers of the breast, colon, and lung are most commonly associated with VTE, though cancers of the pancreas, ovary, and brain have the strongest association when adjusted for prevalence. It recommends long-term anticoagulation with low molecular weight heparin over vitamin K antagonists or heparin for VTE in cancer patients. Extensive cancer screening in patients with idiopathic VTE is not routinely warranted, as it does not improve survival outcomes.
1) Adjuvant chemotherapy is recommended for stage III colon cancer and high-risk stage II cancer to reduce the risk of recurrence. 2) For stage III, 5-FU plus folinic acid or capecitabine are standard options, while adding oxaliplatin to these regimens may provide additional benefit. 3) The value of adjuvant therapies like bevacizumab, cetuximab, and irinotecan is still unclear, with studies showing mixed results.
DAPT trial evaluated whether 30 months of dual antiplatelet therapy (DAPT) was superior to 12 months in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stent placement. The trial found that prolonged DAPT reduced stent thrombosis and major adverse cardiac and cerebrovascular events compared to aspirin alone, but increased bleeding risk. An analysis of the trial developed the DAPT score to predict ischemic and bleeding risks and help determine optimal DAPT duration for individual patients. Newer PRECISE-DAPT and other scores further refine risk stratification to personalize DAPT duration based on balancing ischemic benefit versus bleeding risk.
Update on Management of Triple Negative Breast Cancerspa718
This document provides an update on the management of triple negative breast cancer from Dr. Banu Arun at MD Anderson Cancer Center. It discusses that triple negative breast cancer is a heterogeneous disease comprised of several molecular subtypes with different characteristics and potential treatment targets. Clinical trials exploring chemotherapy regimens, platinum agents, PARP inhibitors, anti-angiogenic drugs, and immunotherapies are summarized. Ongoing research aims to better define the subtypes in order to personalize treatment for triple negative breast cancer patients.
Targeted therapies such as tyrosine kinase inhibitors (TKIs), monoclonal antibodies (MABs), and other small molecules are used to treat various cancers. TKIs like gefitinib, erlotinib, sorafenib, sunitinib, and imatinib are indicated for lung cancer, gastrointestinal stromal tumor, kidney cancer, and chronic myeloid leukemia. They can cause diarrhea, rash, hypertension, and myelosuppression. MABs including trastuzumab, rituximab, cetuximab, and bevacizumab are used for breast cancer, lymphoma, colorectal cancer, and lung cancer. Potential toxicities are cardiomyopathy, hypersensitivity
The document summarizes several international guidelines for treating breast cancer, including the St. Gallen, ASCO, NCCN, and AGO guidelines. The St. Gallen guidelines classify risk based on endocrine responsiveness. The NCCN guidelines recommend aromatase inhibitors for 5 years or switching from tamoxifen to an AI after 2-3 years. The ASCO guidelines also recommend aromatase inhibitors for 5 years or switching from tamoxifen to an AI after 2-5 years for no more than 5 years total on the AI.
Opportunities for Immune Therapy and Preventionbkling
This document summarizes a presentation on opportunities for immunotherapy in breast cancer. It discusses how the immune system fights cancer, types of immunotherapy including checkpoint inhibitors and CAR T-cell therapy. Experience with immunotherapy in breast cancer has been underwhelming due to breast cancer typically having low numbers of immune cells, but responses have been seen in triple negative and HER2+ breast cancers. Future opportunities include increasing immune cells prior to standard treatments and engaging the immune system in the adjuvant setting to reduce recurrence risks.
This document discusses cardiotoxicity from chemotherapy, specifically anthracyclines, and its management. It provides a case study of a breast cancer patient with pre-existing cardiac disease receiving chemotherapy. Key points discussed include:
1. Anthracyclines are effective chemotherapy but can cause dose-dependent cardiotoxicity and heart failure.
2. Various modalities can help detect cardiotoxicity early, including echocardiography, tissue Doppler imaging, and cardiac biomarkers.
3. While chemotherapy may cause cardiac damage, optimal heart failure therapy can significantly improve cardiac function for many patients.
4. Careful consideration of cardiac risk factors and function is important when choosing chemotherapy regimens and monitoring for toxicity
This document summarizes recent advances in treating triple negative breast cancer (TNBC). TNBC accounts for 15-20% of breast cancers and has a poorer prognosis than other subtypes. New classifications identify basal-like and other subtypes. Standard chemotherapy remains the first-line treatment for early and advanced TNBC, but adding platinum agents or nab-paclitaxel to neoadjuvant chemotherapy improves outcomes. PARP inhibitors such as olaparib and talazoparib improve progression-free survival in BRCA-mutated metastatic TNBC. Immunotherapy with atezolizumab, pembrolizumab or combinations improves progression-free and overall survival in PD-L1 positive advanced
1) The document discusses the role of targeted therapy in neuroendocrine tumors. It covers topics such as the evolution of terminology and classification of NETs, the use of biomarkers and imaging in diagnosis and monitoring, and current therapeutic approaches including somatostatin analogs.
2) Somatostatin analogs like octreotide and lanreotide are effective in controlling hormonal symptoms in NET patients by binding to somatostatin receptors that are prevalent on many NETs. They have also shown inhibitory effects on tumor proliferation.
3) A phase III study showed octreotide LAR extended time to tumor progression compared to placebo in treatment-naïve patients with well-differentiated midgut NETs
This document discusses updates in venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It describes the risk factors, signs, symptoms, and diagnostic testing for VTE including ultrasonography, CT pulmonary angiography (CTPA), ventilation-perfusion (V/Q) scanning, and magnetic resonance imaging (MRI). It also discusses specific considerations for diagnosing PE during pregnancy.
Olaparib is an oral PARP inhibitor that has shown efficacy in the treatment of breast and ovarian cancers associated with BRCA mutations. In breast cancer, phase III trials OlympiA and OlympiAD demonstrated that olaparib improves invasive disease-free survival and progression-free survival, respectively, in patients with germline BRCA mutations. In ovarian cancer, phase III trials SOLO-1, PAOLA-1, and PRIMA found that olaparib improves progression-free survival when used as maintenance therapy or in combination with chemotherapy in patients with BRCA mutations. Olaparib is now approved for several indications based on these trials and provides an important targeted treatment option for cancers associated
1) Recent immunotherapy advances for advanced NSCLC include the approval of pembrolizumab as a first-line treatment for patients with PD-L1 expression ≥50% based on results from the KEYNOTE-024 trial showing improved progression-free and overall survival compared to chemotherapy.
2) The Phase III KEYNOTE-407 trial found that combining pembrolizumab with chemotherapy improved progression-free survival compared to chemotherapy alone in patients with untreated metastatic squamous NSCLC, regardless of PD-L1 expression level.
3) Combining chemotherapy with immunotherapy may enhance the immune response by increasing antigen presentation, disrupting immune evasion mechanisms, and improving outcomes compared to chemotherapy or immunotherapy alone.
This document discusses heart failure with preserved ejection fraction (HFpEF), formerly known as diastolic heart failure. It provides background on HFpEF versus systolic heart failure and explores the pathophysiology and management of HFpEF. Key points include:
1) HFpEF is a distinct clinical syndrome from heart failure with reduced ejection fraction (HFrEF), with normal ejection fraction but evidence of diastolic dysfunction.
2) Impaired systolic function can be detected in HFpEF patients using strain imaging, despite preserved global ejection fraction.
3) The pathophysiology of HFpEF is complex and multifactorial, involving microvascular inflammation, cardiomyocyte stiff
How can immunotherapy be used to treat metastatic breast cancer? Ian Krop, MD, PhD, discusses the latest research and treatment options.
This presentation was originally given as part of the 2015 Metastatic Breast Cancer Forum, held on October 17 and hosted by the Susan F. Smith Center for Women's Cancers at Dana-Farber Cancer Institute in Boston, Mass.
For more information, visit www.susanfsmith.org
This document provides an overview of non-Hodgkin lymphomas (NHL). Key points include:
- NHL are a heterogeneous group of malignancies characterized by abnormal proliferation of B, T, or NK cells.
- The main subtypes seen in India are B-cell lymphomas (80-85%) and T-cell lymphomas (15-20%).
- Diagnostic workup involves clinical evaluation, laboratory/radiologic testing, and tissue biopsy for classification.
- Staging and risk stratification inform treatment selection which may include chemotherapy, immunotherapy, radiation, stem cell transplant, or observation depending on the NHL subtype and stage.
The document discusses various antiplatelet drugs including aspirin, P2Y12 receptor antagonists like clopidogrel and prasugrel, and GPllb/llla antagonists. It provides details on the mechanisms and clinical trials of these drugs. Specifically, it summarizes that aspirin works by irreversibly inhibiting platelet COX-1 and reducing thromboxane production. Large trials showed aspirin reduces vascular events by around 25% in high risk patients. Clopidogrel and prasugrel are P2Y12 antagonists but prasugrel has faster onset and greater platelet inhibition. The TRITON trial found prasugrel more effective than clopidogrel for ACS patients
Beat the Odds: New Treatments for Pancreatic Cancer - 12.6.18Summit Health
Presenter(s): Zubin M. Bamboat, MD, FACS, Surgical Oncologist; David Gallinson, DO, Oncologist
Pancreatic cancer is often a silent killer. While surgery provides the only chance for a cure, many patients are inoperable by the time they develop symptoms. Join us to learn all about pancreatic cancer, including risk factors and symptoms. Our experts will discuss how they are combating this deadly disease by using the latest in adjuvant and neoadjuvant therapies, surgery and novel medical treatments.
This document discusses the management of triple negative breast cancer (TNBC). It begins with an overview of the three main subtypes of breast cancer and their associated treatments. It then focuses on the characteristics and treatment challenges of TNBC, including its aggressiveness, younger patient population, and lack of targeted therapies. Current treatment options for metastatic TNBC are discussed, including various chemotherapy regimens. The document also touches on neoadjuvant and adjuvant systemic therapy approaches as well as ongoing research into better understanding the biology of TNBC to revolutionize outcomes.
This document provides information about small cell lung cancer (SCLC). It discusses that tobacco consumption is the primary cause of SCLC and accounts for 80-90% of lung cancer cases. It also notes that SCLC accounts for 13% of lung cancer worldwide. The natural history of untreated SCLC is rapid progression with a median survival of 2-4 months if extensive stage disease is present at diagnosis in approximately two thirds of patients. Diagnostic workup involves imaging like CT scans and PET scans to stage the cancer as well as biopsies to confirm the diagnosis. Prognostic factors like limited versus extensive stage disease and performance status impact survival outcomes.
This downloadable slidedeck, presented in a regional grand rounds series, focuses on increasing awareness about current and emerging treatment options for patients with newly diagnosed and recurrent ovarian cancer.
The document discusses the management of venous thromboembolism (VTE) in patients with cancer. It notes that cancers of the breast, colon, and lung are most commonly associated with VTE, though cancers of the pancreas, ovary, and brain have the strongest association when adjusted for prevalence. It recommends long-term anticoagulation with low molecular weight heparin over vitamin K antagonists or heparin for VTE in cancer patients. Extensive cancer screening in patients with idiopathic VTE is not routinely warranted, as it does not improve survival outcomes.
1) Adjuvant chemotherapy is recommended for stage III colon cancer and high-risk stage II cancer to reduce the risk of recurrence. 2) For stage III, 5-FU plus folinic acid or capecitabine are standard options, while adding oxaliplatin to these regimens may provide additional benefit. 3) The value of adjuvant therapies like bevacizumab, cetuximab, and irinotecan is still unclear, with studies showing mixed results.
Management of patients with primary colorectal cancer andYuvaraj Karthick
This document discusses the management of patients with primary colorectal cancer that has spread to the liver (synchronous liver metastasis). It notes that approximately 15% of colorectal cancer patients have synchronous liver metastasis at diagnosis. While sequential resection of the primary tumor and liver lesions is typically used, some patients may benefit from simultaneous or liver-first resection approaches. The selection of chemotherapy regimens and use of targeted therapies like monoclonal antibodies can help convert initially unresectable disease to resectable. With aggressive treatment including chemotherapy, targeted therapies, and surgical resection, long-term survival of over 30% is possible even in patients with initially extensive liver metastasis. Close postoperative surveillance is important to detect early recurrence that may be amenable to
This document discusses treatment approaches for nonmetastatic locally advanced, borderline resectable, and potentially resectable exocrine pancreatic cancer. It recommends initial chemotherapy, often with gemcitabine or FOLFIRINOX, for locally advanced unresectable disease. For those who do not progress on chemotherapy, concurrent chemoradiation using infusional 5-FU is suggested. The evidence for benefit of chemoradiation over radiation alone is reviewed, though data is limited. Oral fluoropyrimidines may substitute for infusional 5-FU as a radiation sensitizer.
Deep vein thrombosis (DVT) and Pulmonary embolism (PE)Aminul Haque
Deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively referred to as venous thromboembolism (VTE), constitute a major global burden of disease.
This document discusses deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE). It notes that VTE is a major global disease that is underdiagnosed and increasing in incidence. The document covers the etiology, risk factors, presentations, diagnosis, and management of VTE, including the use of anticoagulants like direct oral anticoagulants which have advantages over warfarin. It emphasizes the importance of appropriate diagnosis and treatment to prevent recurrence of VTE events and long-term complications.
This randomized controlled trial studied 198 patients having major cancer surgery who were assigned to either a restrictive or liberal red blood cell transfusion strategy. The restrictive strategy transfused patients when their hemoglobin was <7 g/dl, while the liberal strategy transfused at <9 g/dl. The primary outcome of death or major complications within 30 days occurred in 19.6% of the liberal group but 35.6% of the restrictive group, a statistically significant difference. A liberal transfusion strategy was associated with fewer complications. This study provides evidence that a more liberal transfusion approach may be preferable for patients having major cancer surgery.
This case study examines the use of cetuximab-based chemotherapy for the re-treatment of patients with metastatic colorectal cancer who had previously responded to cetuximab treatment but experienced disease progression after stopping treatment. The study aims to evaluate the overall response and safety of re-treating these patients with cetuximab-containing chemotherapy. It describes the study design, inclusion/exclusion criteria, experimental and control treatments, and primary/secondary outcome measures that will be assessed over a 2-year period.
This document discusses current concepts in chemotherapy for head and neck cancer. It begins by introducing head and neck squamous cell carcinoma (HNSCC) as the sixth most common cancer worldwide. It then reviews epidemiology and risk factors for HNSCC before defining different types of chemotherapy. The bulk of the document discusses evidence and standards of care for systemic therapy in previously untreated locally advanced HNSCC as well as recurrent/metastatic HNSCC. It covers the role of induction, concurrent, adjuvant and definitive chemotherapy combined with surgery or radiation. Overall survival benefits have been shown with platinum-based chemotherapy regimens and cetuximab combined with radiation or chemotherapy.
Gastric cancer remains the fourth most common cancer worldwide, with high rates in Eastern Asia and South America. While rates have declined significantly in the last century, most patients still present with advanced disease. Surgical resection with D1 or D2 lymphadenectomy offers the only chance for cure, with 5-year survival rates of 20-50% depending on stage. Adjuvant chemoradiation has been shown to improve survival after surgery in early stage disease. Ongoing studies continue to refine the use of neoadjuvant and adjuvant therapies to further improve outcomes.
Gastric cancer remains the fourth most common cancer worldwide, with high rates in Eastern Asia and South America. While rates have declined significantly in the last century, most patients still present with advanced disease. Surgical resection with D1 or D2 lymphadenectomy offers the only chance for cure, with 5-year survival rates of 20-50% depending on stage. Adjuvant chemoradiation has been shown to improve survival after surgery in some trials. Ongoing research focuses on expanding neoadjuvant approaches and personalized treatment.
Gastric cancer remains the fourth most common cancer worldwide, with high rates in Eastern Asia and South America. While rates have declined significantly in the last century, most patients still present with advanced disease. Surgical resection with D1 or D2 lymphadenectomy offers the only chance for cure, with 5-year survival rates of 20-50% depending on stage. Adjuvant chemoradiation has been shown to improve survival after surgery in some trials. Ongoing research focuses on expanding neoadjuvant approaches and personalized treatment.
gastriccancer types classified and manageShehinSalim3
Gastric cancer remains the fourth most common cancer worldwide, with high rates in Eastern Asia and South America. While rates have declined significantly in the last century, most patients still present with advanced disease. Surgical resection with D1 or D2 lymphadenectomy offers the only chance for cure, with 5-year survival rates of 20-50% depending on stage. Adjuvant chemoradiation has been shown to improve survival after surgery in some trials. Ongoing research focuses on expanding neoadjuvant approaches and personalized treatment.
This multicenter study analyzed 111 elderly patients (age 80-89) who underwent radical cystectomy for bladder cancer. The complication rate was high, with 50.4% experiencing early complications and 32% late complications. The perioperative mortality rate was 7.2% and 27.2% of patients were readmitted to the hospital. Tumor progression-free survival at 12 months was lower for patients with ≥pT3 disease (36%) compared to ≤pT1 disease (83.9%). Radical cystectomy in elderly patients carries significant risks given high complication rates, mortality, and readmission rates. Careful patient selection is important to minimize risks and balance benefits against life expectancy.
The document discusses the leading causes of death worldwide due to illnesses like heart disease, malignant neoplasms, and cerebrovascular disease. It then covers various risk factors for cancer and heart disease, including smoking and diet. The rest of the document details cancer treatment methods such as staging and surgery, as well as principles of chemotherapy, radiation therapy, hormonal therapy, immunotherapy, and molecularly targeted agents. It provides examples of cancers that may be cured through chemotherapy alone or in combination with other treatments.
The guideline addresses treatment of venous thromboembolic disease (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). For patients without cancer, non-vitamin K oral anticoagulants (NOACs) are preferred over vitamin K antagonists (VKAs) for long-term anticoagulation based on similar efficacy and lower bleeding risk with NOACs. For cancer-associated VTE, low-molecular-weight heparin is preferred over VKAs or NOACs. The guideline also addresses treatment of subsegmental PE and use of aspirin for extended treatment after stopping anticoagulants.
This document provides information about warfarin therapy for patients with mechanical heart valves, including:
1) Warfarin is the anticoagulant most commonly prescribed for patients with mechanical heart valves to reduce the risk of blood clots and thromboembolism by inhibiting vitamin K-dependent clotting factors.
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evidence regarding CRC patients at high risk of PM. Colorectal cancer is the second most common cause of cancer
death in the UK. Prompt investigation of suspicious symptoms is important, but there is increasing evidence that
screening for the disease can produce significant reductions in mortality.High quality surgery is of paramount
importance in achieving good outcomes, particularly in rectal cancer, but adjuvant radiotherapy and chemotherapy
have important parts to play. The treatment of advanced disease is still essentially palliative, although surgery for
limited hepatic metastases may be curative in a small proportion of patients.
The document discusses venous thromboembolism (VTE) risk assessment and prophylaxis for hospitalized medical patients. It provides recommendations from American Society of Hematology 2018 guidelines and Indonesian Thrombosis and Hemostasis Society 2018 national guidelines. The recommendations suggest using low molecular weight heparin or unfractionated heparin for VTE prophylaxis in acutely ill or critically ill medical patients based on their risk assessment scores. Mechanical prophylaxis alone or combined with pharmacological prophylaxis is conditionally recommended if patients cannot receive anticoagulants. Extended duration outpatient prophylaxis after hospital discharge is not routinely recommended.
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This document provides an overview of anal cancer management. It discusses the epidemiology, risk factors, pathology, spread, clinical presentation, staging, treatment including role of surgery and radiotherapy, toxicities, indications for postoperative radiotherapy, palliative care, relapse, and special circumstances like HIV patients. Radiotherapy techniques including delineation of target volumes and organs at risk are described in detail. The document is a comprehensive reference for clinicians on anal cancer management.
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Radiobiology is the study of how ionizing radiation interacts with living things. This document provides an overview of different types of ionizing radiation including electromagnetic radiation like x-rays and gamma rays, and particulate radiation like electrons, protons, alpha particles, and heavy ions. It describes the physics of how this radiation is absorbed and can cause excitation or ionization in biological materials. Specifically, it notes that x-rays and gamma rays are indirectly ionizing since they produce fast-moving electrons upon absorption, while particulate radiations can directly ionize materials. Around 10,000 to 20,000 cases of lung cancer per year in the US are attributed to alpha particles from radon gas in homes.
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
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In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
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Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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Histololgy of Female Reproductive System.pptxAyeshaZaid1
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2. Learning Objectives
Scope of the problem
VTE risk assessment for patients
Thromboprophylaxis
Management of VTE
3. Introduction
Venous thromboembolism (VTE) represents one
of the most important causes of morbidity and
mortality in cancer patients.
According to population-based case–control
studies, the 2-year cumulative incidence of VTE is
between 0.8 and 8%
4. Patients at risk
Patients with the highest 1-year incidence rate of VTE
are those with advanced disease of :
the brain,
lung,
uterus,
bladder,
pancreas,
stomach and
kidney.
For these histotypes, the rate of VTE is 4–13 times
higher among patients with metastatic disease as
compared with those with localized disease
5.
6. The increased risk of recurrent VTE in cancer
patients is greatest in the first few months
after malignancy is diagnosed and can persist
for many years after an initial episode of
symptomatic VTE.
While receiving chemotherapy, cancer
patients have a 7-fold risk of developing VTE
as compared with other patients without
cancer.
Cancer patients, once hospitalized, are at an
even higher risk of developing VTE.
7. Clinical Risk Factors
Since VTE is a multifactorial event, the absolute risk
depends on several factors including:
tumour type,
stage of disease,
the administration of chemotherapy and/or hormone
therapy,
surgical interventions, length of anaesthesia,
The presence of an indwelling central venous catheter,
age,
immobilization
and previous history of VTE
10. Chemotherapy…
One of the most important factors promoting VTE
may be the use of cytotoxic drugs.
Chemotherapy can increase the risk of VTE by at
least four mechanisms:
(i) acute damage to vessel walls;
(ii) non-acute damage of the endothelium;
(iii) a decrease in natural coagulation inhibitors
(reduced level of C and S proteins or antithrombin
III); and
(iv) platelet activation.
11. Target therapy and …
Antiangiogenic agents such as bevacizumab, thalidomide and lenalidomide
also contribute to thrombosis, through:
endothelial cell and platelet activation
and damage to the vascular endothelium.
The thrombogenic effect of antiangiogenic agents is amplified by the co-
administration of chemotherapy and steroids.
In a recent meta-analysis of clinical trials of bevacizumab administered
concomitantly with chemotherapy, the use of bevacizumab was associated
with a 33% relative increase of VTE. Among patients receiving
bevacizumab, the overall incidence of any-grade and high-grade VTE was
11.9 and 6.3%, respectively.
With regards to multiple myeloma, the highest incidence of VTE was
observed in patients treated with thalidomide- and doxorubicin-containing
chemotherapy (VTE rate of up to 34%) [9] and in patients with relapsed
myeloma treated with lenalidomide and high-dose dexamethasone [10
12.
13. Fighting VTE has two main arms
Prophylaxis
Early
detection and
management
Prevent
morbidity
and
mortality
16. When? (Indications):
Cancer patients undergoing surgeries?
Hospital admission.. (risk assessment?)
Patients on active cancer treatment?
Patients with central lines?
21. Cancer patients undergoing
surgery..
Cancer patients who undergo surgery are at high
risk of developing a VTE complication.
It has been reported that cancer patients undergoing
a surgical procedure have twice the risk of
postoperative VTE and more than three times the
risk of fatal PE than patients who undergo surgery
for benign diseases.
In addition to the cancer-associated risk, a large
group of patients presents with additional risk factors
for thrombosis, such as increasing age, prolonged
immobility, obesity and indwelling central venous
catheters.
The role of prophylaxis is unquestionable!!
22. Dosing and duration
In cancer patients undergoing major cancer
surgery, prophylaxis with LMWHs or UFH is
recommended.
Mechanical methods such as pneumatic calf
compression may be added to
pharmacological prophylaxis but should not
be used as monotherapy unless
pharmacological prophylaxis is
contraindicated because of active bleeding.
23. Dosing in the perioperative setting; In surgical
cancer patients, highdose s.c. LMWH (e.g.
enoxaparin 4000 U of anti-Xa activity, dalteparin
5000 U of anti-Xa activity) once daily, or s.c.UFH
5000 U (three times daily) are recommended
Duration; For patients having a laparotomy,
laparoscopy, thoracotomy or thoracoscopy lasting
>than 30 min, consider s.c. LMWH for at least 10
days postoperatively.
Two randomized controlled, prospective trials
have shown that, in cancer patients undergoing
elective major abdominal or pelvic surgery,
continuing prophylaxis with a LMWH up to 30
days postoperatively can reduce the risk of VTE
by 60% without increasing the risk of bleeding
24. Cancer patients on hospital
admission
Three large, high quality clinical trials, in
hospitalized ‘medical patients’, which included
cancer patients, have demonstrated that
prophylaxis leads to a lower VTE incidence
compared with placebo, without increasing
major bleeding
Prophylaxis with UFH, LMWH or fondaparinux
in hospitalized cancer patients confined to
bed with an acute medical complication is
recommended
25.
26. How to apply the
recommendations in our daily
practice???
32. Well…
Now I know my patient is AT
RISK of thrombosis..
What’s next….
33.
34. Enoxaparin (LMWH)
Dose of Enoxaparin (Clexane) LMWH
Usual Adult Dose for Deep Vein Thrombosis -
Prophylaxis
40 mg subcutaneously once a day
Duration of therapy: Usually 6 to 11 days; up to 14
days has been well tolerated in clinical trials.
Use: Prophylaxis of deep vein thrombosis (DVT) in
medical patients at risk for thromboembolic
complications due to severely restricted mobility
during acute illness.
35. Patients on active cancer
treatment
Extensive, routine prophylaxis for advanced
cancer patients receiving chemotherapy is not
recommended, but may be considered in high-
risk ambulatory cancer patients.
Consider LMWH, aspirin or adjusted-dose
warfarin (INR 1.5) in myeloma patients receiving
thalidomide plus dexamethasone or thalidomide
plus chemotherapy.
Prophylaxis in cancer patients receiving adjuvant
chemotherapy and/or hormone therapy is not
recommended.
36. In this study 123 patients were randomized; the
incidence of VTE, during the first 3 months, was
25% vs 3.5% in the standard and the experimental
group, respectively. Lethal VTE and sudden deaths
were seen only in the standard arm (9%), with none
in the experimental arm.
37. In this trial 1150 patients were randomized to receive nadroparin or
placebo; among those, 53 patients had locally advanced or
metastatic pancreatic cancer. The primary endpoint was the
composite of symptomatic venous or arterial thromboembolic events.
Thromboembolic events occurred in 2.0 and 3.9% of patients treated
with nadroparin and placebo, respectively, without increasing major
or minor bleeding. This trial, by using a LMWH, demonstrated for
the first time a statistically significant reduction of
thromboembolic events in ambulatory cancer patients receiving
chemotherapy for locally advancer or metastatic cancer.
38. Patients with lung or pancreatic cancer were
more likely to experience thromboembolic
events than were patients with breast,
gastrointestinal, ovarian, or head and neck
cancers, which suggested that these patient
groups may benefit from LMWH prophylaxis.
39. In a recent retrospective study involving >66 000
adults with cancer, 5.4% of patients developed
VTE over the 8 years of the study
Furthermore, in a retrospective study, cancer
patients were found to have a 3-fold higher risk for
recurrent VTE than patients who had an initial
VTE in the absence of malignancy
The probability of readmission for recurrent VTE
within 183 days was 22% for cancer patients
compared with 6.5% for those without malignancy.
40.
41. Patients with Central Venous
Catheters
In the last two decades, two open-label randomized
clinical trials suggested a role for prophylaxis with
warfarin or a LMWH in patients with a CVC
Four recent studies have assessed that the
incidence of symptomatic CVC-related VTE is in
general low, 3–4%, and that there is no statistically
significant difference between patients undergoing
and patients not undergoing prophylaxis
Extensive, routine prophylaxis to prevent CVC-
related VTE is not recommended
46. ASCO 2019 update
Changes to previous recommendations:
Clinicians may offer thromboprophylaxis with apixaban,
rivaroxaban, or LMWH to selected high-risk outpatients with cancer
(Khorana score ≥2); rivaroxaban and edoxaban have been added
as options for VTE treatment.
Patients with brain metastases are now addressed in the VTE
treatment section; and the recommendation regarding long-term
postoperative LMWH has been expanded.
Re-affirmed recommendations: Most hospitalized patients with
cancer and an acute medical condition require thromboprophylaxis
throughout hospitalization.
Thromboprophylaxis is not routinely recommended for all
outpatients with cancer.
Patients undergoing major cancer surgery should receive
prophylaxis starting before surgery and continuing for at least 7 to
10 days.
Patients with cancer should be periodically assessed for VTE risk,
and oncology professionals should provide patient education about
the signs and symptoms of VTE.
47. Management of Patients
with VTE
The aim of VTE treatment can be summarized
as follows:
To prevent fatal PE
To prevent recurrent VTE
To prevent long-term VTE and PE complication
such as post-thrombotic syndrome and chronic
thromboembolic pulmonary hypertension
48. Now, you have a patient
presenting with suspected lower
limb DVT…
How to deal with??
49. Investigation of DVT
A. Request baseline bloods (full blood count,
coagulation screen, renal and liver biochemistry) for
all patients.
B. Risk stratify for the likelihood of DVT:
Risk stratify patients using the two-level DVT
Wells score to estimate the clinical probability of
DVT.
52. If DVT LIKELY: Arrange proximal leg vein ultrasound
scan within 4 hours.
o If scan result cannot be obtained within 4 hours of
requesting, obtain a D-dimer and start treatment dose
dalteparin (or unfractionated heparin infusion if
creatinine clearance <20mL/min).
o Scan should be carried out within 24 hours and
anticoagulation reviewed when result available.
o If scan negative and D-dimer positive, do not continue
anticoagulant treatment, re-scan in 6 to 8 days. If repeat
scan negative consider alternative diagnosis.
o If patient was already on therapeutic anticoagulation at
presentation, continue anticoagulation and arrange senior
clinical review.
o Consider alternative diagnosis; if thought DVT most likely
diagnosis repeat scan should be performed in 6-8 days.
If scan establishes diagnosis of DVT…continue your
treatment
53. i. If DVT UNLIKELY: Request D-dimer and obtain
results.
If the D-dimer result is negative, consider
alternative diagnosis.
If the D-dimer result is positive (or patient is already
on anticoagulation), arrange proximal leg vein
ultrasound scan within 4 hours.
If scan result cannot be obtained within 4 hours
of requesting, start treatment dose dalteparin
(or unfractionated heparin infusion if creatinine
clearance <20mL/min). Scan should be carried
out within 24 hours and anticoagulation
reviewed when result available.
If scan establishes diagnosis of DVT, treat
57. Massive Pulmonary Embolism
When to suspect massive PE:
Suspect massive PE if:
Circulatory collapse (systolic BP < 100mmHg, HR > 120 beats
per minute)
Signs of shock or an episode of collapse
Start treatment pending results of investigations:
Bolus IV unfractionated heparin (5000 units) followed by
maintenance infusion
Call Chest Department residents
Arrange EMERGENCY CTPA with radiologists Imaging must
be performed immediately
If collapsed patient or too unwell for CTPA, make emergency
referral to the Cardiologists for urgent echocardiogram, or
consider thrombolysis on clinical grounds.
58.
59. Streptokinase
Pulmonary embolism
By intravenous infusion
• For Adult
250 000 units, dose to be given over 30 minutes, then
100 000 units every 1 hour for 24 hours, alternatively
1 500 000 units, dose to be given over 1–2 hours.
Deep-vein thrombosis,
Central retinal venous or arterial thrombosis
By intravenous infusion
• For Adult
250 000 units, dose to be given over 30 minutes, then
100 000 units every 1 hour for 12 hours for central
retinal venous or arterial thrombosis, or for 72 hours for
deep-vein thrombosis.
60. Non-massive Pulmonary
Embolism
Non-massive PE is PE without circulatory collapse.
1) Clinical
History – acute persisting dyspnoea, haemoptysis, pleuritic chest pain,
syncope
Examination – breathless, hypotension, cyanosis, tachycardia
These symptoms may be absent in some cases and may be subtle in
young, previously healthy individuals.
2) Investigation of suspected non-massive PE
See algorithm ii: investigation and management of Pulmonary Embolism
A. Request D-dimer test and baseline bloods (full blood count, coagulation
screen, renal and liver biochemistry) for all patients.
B. Risk stratify the patient using the two-level PE Wells score to estimate
the clinical probability of PE
63. If PE LIKELY: Arrange immediate CTPA.
If scan is negative, obtain results of D-dimer test.
Start therapeutic anticoagulation at same time as
requesting scan: treatment dose dalteparin (or
unfractionated heparin infusion if creatinine clearance
<20mL/min). Scan should be carried out as soon as
possible, and anticoagulation reviewed when result
available.
o If CTPA indeterminate, consider a proximal leg vein
ultrasound scan if symptomatic.
o If scans show no PE and no DVT, consider alternative
diagnosis.
If CTPA positive, commence initial treatment with
dalteparin (or unfractionated heparin infusion if
creatinine clearance <20mL/min)
64. If PE UNLIKELY: Obtain D-dimer results:
If the D-dimer result is negative, consider alternative
diagnosis
If the D-dimer result is positive (or patient is already on
anticoagulation), arrange immediate CTPA
Start therapeutic anticoagulation at same time as
requesting scan: treatment dose dalteparin (or
unfractionated heparin infusion if creatinine clearance
<20mL/min). Scan should be carried out as soon as
possible, and anticoagulation reviewed when result
available.
o If CTPA indeterminate, consider a proximal leg vein
ultrasound scan if symptomatic.
o If scans show no PE and no DVT, consider alternative
diagnosis.
o If scan positive, commence initial treatment with
dalteparin (or unfractionated heparin infusion if
creatinine clearance <20mL/min) (see below)
65. Enoxapren (LMWH)
Usual Adult Dose for Deep Vein Thrombosis
Outpatient: 1 mg/kg subcutaneously every 12 hours
Inpatient: 1 mg/kg subcutaneously every 12 hours or 1.5 mg/kg
subcutaneously once a day at the same time every day.
Duration of therapy: At least 5 days and until a therapeutic oral
anticoagulant effect has been achieved (INR 2 to 3). Average duration
is 7 days; up to 17 days has been well tolerated in controlled clinical
trials.
Comments: In both outpatient and inpatient treatments, warfarin
sodium therapy should be initiated when appropriate (usually within
72 hours of commencing enoxaparin).
Uses:
-Outpatient treatment of acute deep vein thrombosis (DVT) without
pulmonary embolism (PE) when administered in conjunction with
warfarin sodium.
-Inpatient treatment of acute DVT with or without PE when
administered in conjunction with warfarin sodium.
66. Further investigations??
ECG / blood gases - are not diagnostic and may be normal. Exclude other
causes for symptoms and signs.
Chest X-ray - PE is supported by atelectasis, oligaemic defect, pleural
effusion. However, the chest X-ray may be normal.
Laboratory investigations – FBC, coagulation screen, and renal and liver
biochemistry should be checked prior to anticoagulation. Do not request
thrombophilia investigations as they will not change acute management.
Troponin - Patients with clinical signs of acute right heart failure and a raised
troponin are at higher risk of complications, even if haemodynamically stable.
Troponin measurement should be undertaken in all patients for risk
stratification and monitoring.
Echocardiography – routine echo is not necessary and adds little
prognostic value to Troponin assessment.
A low D-dimer result (<500ng/mL) EXCLUDES a PE in patients who are
‘PE unlikely’ if the patient is not receiving anticoagulant therapy and the
onset of symptoms has been within the last week.
Remember that D-dimers are raised in many other clinical situations
(e.g. infection, malignancy, postoperatively, pregnancy, disseminated
intravascular coagulopathy)
Consider ultrasound leg scan if symptomatic of DVT and high PESI score
to assist further management plan (as in table below: patients with high PESI
score and acute DVT have an increased mortality risk).
67. PESI score for risk stratification of
patients with non-massive PE:
Criteria Score
Age 1 point per year
Male gender 10 points
Active cancer within 6 months 30 points
History of heart failure 10 points
History of chronic lung disease 10 points
Pulse ≥110 bpm 20 points
Systolic BP <100 mmHg 30 points
Respiratory rate ≥30 bpm 20 points
Temperature <36o
C 20 points
Altered mental status (disorientation, lethargy, stupor, or coma) 60 points
Arterial oxygen saturation < 90% 20 points
Total score:
68. Interpretation of PESI score: 30 day mortality risk
Score Class Mortality risk Management
<66 Class 1 Very low 0 to 1.6% Consider for ambulatory care / early discharge
if fulfil criteria – see Appendix 2. If not suitable
for ambulatory care, admit to hospital and
triage to acute respiratory take
66 - 85 Class 2 Low 1.7 to 3.5%
86 - 105 Class 3 Moderate 3.2 to 7.1% Manage as inpatient. Respiratory team
review. Repeat PESI at 48 hours: if repeat
PESI ≤ 85 they may be suitable for early
discharge.
106 - 125 Class 4 High 4.0 to 11.4% Manage as inpatient. Respiratory team
review. Assess troponin and leg ultrasound to
further risk stratify if possible candidate for
thrombolysis.
>125 Class 5 Very high 10.0 to 24.5%
69. Additional early management of PE
Patients with higher risk PESI score, raised
troponin and acute DVT should be considered
for a 24-48hr period of monitoring on ICU.
Thrombolysis should be considered if there are
signs of haemodynamic instability.
Supportive therapy with oxygen and analgesia
as required (maintain O2 sats >94-98% unless
underlying hypercapnia) - see oxygen guidelines
Patients at moderate risk (PESI score 86-105)
should be admitted and reassessed with the
PESI score at 48hours. If there score
subsequently falls into the low risk category, they
may be suitable for early discharge.
70.
71. Anticoagulation therapy in
patients with recurrent VTE
Patients adequately anticoagulated who develop VTE recurrence
should be checked for progression of their malignancy.
Cancer patients have a 3-fold risk of recurrent VTE and a 3- to 6-fold
risk of major bleeding while receiving anticoagulant treatment with a
VKA, as compared with patients without cancer [46].
Patients on long-term anticoagulation with VKA who develop VTE
when their INR is in the subtherapeutic range can be retreated with
UFH or LMWH until VKA anticoagulation achieves a stable INR
between 2.0 and 3.0.
If VTE recurrence occurs while the INR is in the therapeutic range
there are two options:
(i) either shift to another method of anticoagulation, such as s.c.
UFH maintaining a therapeutic aPTT (aPTT ratio from 1.5 to 2.5), or
LMWH at a weight-adjusted dose;
or (ii) or increase the INR (to a target of 3.5).
Full-dose LMWH (200 U/kg once daily) can be resumed in patients
with a VTE recurrence while receiving a reduced dose of LMWH or
VKA anticoagulation as a long-term therapy. Escalating the dose of
LMWH results in a second recurrent VTE rate of 9%; it is well
tolerated, with few bleeding complications
72.
73. Role of Direct Oral Anticoagulants in
VTE in cancer patients
DOACs are now approved by the US Food and Drug
Administration and European Medicines Agency for selected
indications in VTE prevention and treatment, but are not routinely
recommended in cancer patients.
These agents inhibit activated factor X (rivaroxaban,
apixaban, edoxaban) or thrombin (dabigatran etexilate)
The major concerns about DOACs in cancer patients include:
unpredictable absorption and higher risk of GI bleeding in
patients with mucositis,
inability to measure the anticoagulant activity by using
standard assays,
potential interaction with hormonal and chemotherapeutic
agents, altered metabolism in patients with renal dysfunction or
hepatic metastasis,
and lack of antidote when patients are actively bleeding
74. The DOACs, including the direct factor IIainhibitor
dabigatran and the factor Xainhibitors apixaban,
rivaroxaban, and edoxaban, are being investigated for
use in cancer patients
These agents offer many benefits over traditional
anticoagulants, including no requirement for laboratory
monitoring, feasibility of oral administration and a
reduced risk for food-drug interactions
All three agents have received regulatory approval for
the treatment of acute VTE in the general population,
but there remains a paucity of data on the efficacy and
safety of these agents in patients with cancer and
European regulatory authorities have advised against
the use of apixaban for the treatment of cancer-
associated VTE
75. A recent meta-analysis evaluated 9 RCTs and included
2,310 patients treated with DOACs
This analysis demonstrated a reduction in recurrent
VTE in patients treated with LMWH compared with
those receiving warfarin (RR, 0.52; 95% CI, 0.36–0.74)
Conversely, compared with warfarin, DOACs were not
associated with a significant reduction in recurrent VTE
(RR, 0.66; 95% CI, 0.39–1.11)
In this study, LMWH was associated with a
nonsignificant increase in major bleeding (RR, 1.06;
95% CI, 0.5–2.23), whereas DOACs showed a
nonsignificant decrease (RR, 0.78; 95% CI, 0.42–1.44)
Overall, in light of the paucity of data demonstrating the
safety and efficacy of these agents in cancer patients
and lack of appropriate control arms, current published
consensus guidelines do not recommend their use in
patients with cancer
76.
77.
78.
79. Dosing of DOACS
Treatment of deep-vein thrombosis,
Treatment of pulmonary embolism
By mouth For Adult
Initially 15 mg twice daily for 21 days, then maintenance
20 mg once daily, to be taken with food, for duration of
treatment
Prophylaxis of recurrent deep-vein thrombosis,
Prophylaxis of recurrent pulmonary embolism
By mouth For Adult
10 mg once daily, following completion of at least 6 months
of anticoagulant treatment, to be taken with food, consider
20 mg once daily in those at high risk of recurrence (such as
complicated comorbidities, or previous recurrence with
rivaroxaban 10 mg once daily).
80. ASCO 2019 Update
Initial anticoagulation may involve LMWH, UFH,
fondaparinux, or rivaroxaban.
For patients initiating treatment with parenteral
anticoagulation, LMWH is preferred over UFH for
the initial 5 to 10 days of anticoagulation for the
patient with cancer with newly diagnosed VTE
who does not have severe renal impairment
(defined as creatinine clearance less than 30
mL/min)
81. For long-term anticoagulation, LMWH, edoxaban,
or rivaroxaban for at least 6 months are preferred
because of improved efficacy over vitamin K
antagonists (VKAs).
VKAs are inferior but may be used if LMWH or
direct oral anticoagulants (DOACs) are not
accessible.
There is an increase in major bleeding risk with
DOACs, particularly observed in GI and potentially
genitourinary malignancies. Caution with DOACs is
also warranted in other settings with high risk for
mucosal bleeding. Drug-drug interaction should be
checked prior to using a DOAC
82. Anticoagulation with LMWH, DOACs, or VKAs
beyond the initial 6 months should be offered
to select patients with active cancer, such as
those with metastatic disease or those
receiving chemotherapy.
Anticoagulation beyond 6 months needs to be
assessed on an intermittent basis to ensure a
continued favorable risk-benefit profile
84. 1. Should hospitalized patients with cancer receive
anticoagulation for VTE prophylaxis?
2. Should ambulatory patients with cancer receive
anticoagulation for VTE prophylaxis during systemic
chemotherapy?
3. Should patients with cancer undergoing surgery receive
perioperative VTE prophylaxis?
4. What is the best method for treatment of patients with
cancer with established VTE to prevent recurrence?
5. Should patients with cancer receive anticoagulants in the
absence of established VTE to improve survival?
6. What is known about risk prediction and awareness of VTE
among patients with cancer?
7. What is WELLs score?
8. What is Khorana score and when to use it?