Prophylactic Anticoagulants in Upper GI Cancer Patients

Zosia Chustecka

July 02, 2012

July 2, 2012 — Although cancer itself elevates the risk for venous thromboembolism (VTE), and chemotherapy elevates it still further, the general consensus of expert opinion is that evidence is insufficient to recommend prophylactic use of anticoagulants in all patients. However, it has long been argued that a special case can be made for patients with certain types of cancer.

At the 14th World Congress on Gastrointestinal Cancer, which was organized in partnership with the European Society for Medical Oncology and held in Barcelona, Spain, 2 separate groups of researchers from the United Kingdom proposed that patients with upper gastrointestinal (UGI) malignancies represent such a special case.

"We have already changed our practice as a result of an earlier trial in pancreatic cancer patients," Rajarshi Roy, FRCR, from the department of oncology at the Hull & East Yorkshire NHS Trust, in Hull, United Kingdom, told Medscape Medical News. That study, the UK Fragem Trial, showed that prophylactic anticoagulation with dalteparin significantly reduced the risk for all VTE in pancreatic cancer patients being treated with gemcitabine (European Journal of Cancer. 2012;48;1283-1292).

As a result of that study, Dr. Roy and colleagues use prophylactic dalteparin to treat their patients with pancreatic cancer, which is notorious for being highly thrombogenic.

Now, they propose extending this to other patients with UGI malignancies, because these patients are also at high risk for VTE.

In a poster presentation at the meeting, investigators reported a particularly high rate of VTE in patients with gastroesophageal junction (GOJ) cancers. In the literature, this has been estimated at around 10% to 13%, but researchers reported a much higher rate of 21.5%. Their data were derived from a retrospective analysis of 65 patients with GOJ cancer, which found that 14 patients developed a VTE during or after completion of neoadjuvant chemotherapy with a platinum-containing regimen. Of these, 8 patients (12%) had a pulmonary embolism, 5 (8%) had lower limb deep vein thrombosis, and 1 had subclavian vein thrombosis with an indwelling venous line. Four of the patients who developed a pulmonary embolism died within 30 days of surgery, despite therapeutic anticoagulation with low molecular weight heparin, the authors note.

Dr. Roy commented to Medscape Medical News that there may be a case to be made for the use of prophylactic anticoagulation in all patients with UGI malignancies, and his team is proposing a clinical trial in this population. "One option is to use prophylaxis during the preoperative period when patients are receiving chemotherapy and/or radiotherapy," he added.

Also proposing such a trial was another group of UK researchers, led by Caroline Chau, from the department of medical oncology, at the Queen Alexandra Hospital, Portsmouth, United Kingdom. This group also presented a retrospective review of data, this time from 115 patients with upper GI malignancies who underwent neoadjuvant chemotherapy and surgery. More than half of these patients (59%) had cancer of the esophagus, 28% had GOJ cancer, and 13% had stomach cancer.

Dr. Chau and colleagues reported a 12.2% incidence of VTE, with 7 patients developing a pulmonary embolism and another 7 developing deep vein thrombosis.

"Patients who suffered a VTE have inferior outcomes in terms of survival, at least in the early stages of treatment," researchers note. This was independent of all other variables analyzed, including age, gender, disease site, histology, tumor size, and nodal involvement.

"We propose a prospective randomized controlled study of the use of prophylactic anticoagulation in outpatients receiving neoadjuvant chemotherapy for UGI malignancies," Dr. Chau and colleagues conclude.

14th World Congress on Gastrointestinal Cancer. Abstracts P-0012 and P-006. Presented June 29, 2012.

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