Epidemiology of Cancer-Associated Venous Thromboembolism in Patients With Solid and Hematologic Neoplasms in the Veterans Affairs Health Care System.
Epidemiology of Cancer-Associated Venous Thromboembolism in Patients With Solid and Hematologic Neoplasms in the Veterans Affairs Health Care System.
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DOI：
10.1001/jamanetworkopen.2023.17945
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发表时间：
2023-06-01
影响因子：
13.8
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这项队列研究评估了退伍军人事务部医疗保健系统中患有实体和血液肿瘤的患者中癌症相关静脉血栓形成(VTE)的发生率，并分析了与VTE风险相关的患者特定因素、癌症特定因素和治疗特定因素。癌症相关血栓形成(CAT)的发病率和风险模式是否随着癌症导向治疗的发展而改变？在退伍军人事务部卫生保健系统的434例 -203实体瘤和血液肿瘤患者的队列研究中，观察到CAT的发病率很高，在16年的研究期间，其年趋势稳定在4.2%~4.7%之间。癌症类型、分期和系统治疗与CAT显著相关，不同种族和民族的患者表现出不同程度的CAT风险。这些发现表明，在未来的静脉血栓栓塞症风险分层模型中，需要考虑患者特有的因素和治疗特有的因素，这些因素解释了随着时间的推移治疗环境的变化。确定癌症相关血栓形成(CAT)的发病率和风险的流行病学模式的变化，特别是随着癌症指导治疗的发展，对于风险分层至关重要。评估随时间推移CAT的发生率，并确定与其风险相关的患者特定因素、癌症特定因素和治疗特定因素。这项纵向的回溯性队列研究是从2006年到2021年进行的。随访时间从确诊之日起至2022年4月1日第一次静脉血栓栓塞症(VTE)事件、死亡、失去随访(定义为90天无临床接触)或行政审查为止。这项研究是在美国退伍军人事务部全国医疗保健系统内进行的。新诊断为侵袭性实体瘤和血液肿瘤的患者包括在研究中。对2022年12月至2023年2月的数据进行了分析。新诊断的侵袭性实体肿瘤和血液系统肿瘤。使用国际疾病分类、第九次修订、临床修改和国际疾病统计分类、第十次修订、临床修改和自然语言处理确认结果的组合来评估VTE的发生率。用累积发病率竞争风险函数估计CAT的发病率。建立多变量COX回归模型，评估基线变量与CAT的相关性。相关的患者变量包括人口统计学、地区、农村、区域剥夺指数、国家癌症研究所共病指数、癌症类型、分期、3个月内一线系统治疗(随时间变化的协变量)，以及其他可能与VTE风险相关的因素。共有434名 203患者(420名 244名男性[96.8%]；年龄中位数67[62-74]岁；7,414名亚洲或太平洋岛民患者[1.7%]；20名 193名西班牙裔患者[4.7%]；89名 371名非西班牙裔黑人患者[20.6%]；313名 157名非西班牙裔白人患者[72.1%])符合纳入标准。12个月龄猫的总发病率为4.5%，年趋势稳定在4.2%~4.7%之间。VTE的风险与肿瘤的类型和分期有关。除了确认实体瘤患者的已知风险分布外，侵袭性淋巴系肿瘤患者的VTE风险比惰性淋巴系或髓系血液病患者更高。与未接受治疗的患者相比，接受一线化疗(风险比1.44；95%CI，1.40-1.49)和免疫检查点抑制剂(HR，1.49；95%CI，1.22-1.82)的患者的调整后相对风险高于接受靶向治疗(HR，1.21；95%CI，1.13-1.30)或内分泌治疗(HR，1.20；95%CI，1.12-1.28)的患者。最后，与非西班牙裔白人患者相比，非西班牙裔黑人患者调整后的VTE风险显著较高(HR，1.23；95%CI，1.19-1.27)，而亚洲或太平洋岛民患者的调整后VTE风险显著低于非西班牙裔白人患者(HR，0.84；95%CI，0.76-0.93)。在这项癌症患者的队列研究中，静脉血栓栓塞症的发病率很高，在16年的研究期间，每年的趋势保持稳定。确定了与CAT风险相关的新的和已知的因素，在当前的治疗环境中提供了有价值的和适用的见解。
This cohort study assesses the incidence of cancer-associated venous thromboemoblism (VTE) among patients in the Department of Veterans Affairs health care system with solid and hematologic neoplasms and analyzes the patient-specific, cancer-specific, and treatment-specific factors associated with the risk of VTE. Have patterns of the incidence and risk of cancer-associated thrombosis (CAT) changed over time with the evolution of cancer-directed therapy? In this cohort study of 434 203 patients with solid tumor and hematologic neoplasms in the Department of Veterans Affairs health care system, a high incidence of CAT with yearly trends ranging stably from 4.2% to 4.7% over the 16-year study period was observed. Cancer type and stage and systemic treatment were significantly associated with CAT, and patients of different races and ethnicities demonstrated varying degrees of risk of CAT. These findings suggest that patient-specific and treatment-specific factors, accounting for changes in the treatment landscape over time, warrant consideration in future venous thromboembolism risk stratification models. Identifying changes in epidemiologic patterns of the incidence and risk of cancer-associated thrombosis (CAT), particularly with evolving cancer-directed therapy, is essential for risk stratification. To assess the incidence of CAT over time and to determine pertinent patient-specific, cancer-specific, and treatment-specific factors associated with its risk. This longitudinal, retrospective cohort study was conducted from 2006 to 2021. Duration of follow-up was from the date of diagnosis until first venous thromboembolism (VTE) event, death, loss of follow-up (defined as a 90-day gap without clinical encounters), or administrative censoring on April 1, 2022. The study took place within the US Department of Veterans Affairs national health care system. Patients with newly diagnosed invasive solid tumors and hematologic neoplasms were included in the study. Data were analyzed from December 2022 to February 2023. Newly diagnosed invasive solid tumors and hematologic neoplasms. Incidence of VTE was assessed using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification and International Statistical Classification of Diseases, Tenth Revision, Clinical Modification and natural language processing confirmed outcomes. Cumulative incidence competing risk functions were used to estimate incidence of CAT. Multivariable Cox regression models were built to assess the association of baseline variables with CAT. Pertinent patient variables included demographics, region, rurality, area deprivation index, National Cancer Institute comorbidity index, cancer type, staging, first-line systemic treatment within 3 months (time-varying covariate), and other factors that could be associated with the risk of VTE. A total of 434 203 patients (420 244 men [96.8%]; median [IQR] age, 67 [62-74] years; 7414 Asian or Pacific Islander patients [1.7%]; 20 193 Hispanic patients [4.7%]; 89 371 non-Hispanic Black patients [20.6%]; 313 157 non-Hispanic White patients [72.1%]) met the inclusion criteria. Overall incidence of CAT at 12 months was 4.5%, with yearly trends ranging stably from 4.2% to 4.7%. The risk of VTE was associated with cancer type and stage. In addition to confirming well-known risk distribution among patients with solid tumors, a higher risk of VTE was observed among patients with aggressive lymphoid neoplasms compared with patients with indolent lymphoid or myeloid hematologic neoplasms. Compared with no treatment, patients receiving first-line chemotherapy (hazard ratio [HR], 1.44; 95% CI, 1.40-1.49) and immune checkpoint inhibitors (HR, 1.49; 95% CI, 1.22-1.82) had a higher adjusted relative risk than patients receiving targeted therapy (HR, 1.21; 95% CI, 1.13-1.30) or endocrine therapy (HR, 1.20; 95% CI, 1.12-1.28). Finally, adjusted VTE risk was significantly higher among Non-Hispanic Black patients (HR, 1.23; 95% CI, 1.19-1.27) and significantly lower in Asian or Pacific Islander patients (HR, 0.84; 95% CI, 0.76-0.93) compared with Non-Hispanic White patients. In this cohort study of patients with cancer, a high incidence of VTE was observed, with yearly trends that remained stable over the 16-year study period. Both novel and known factors associated with the risk of CAT were identified, providing valuable and applicable insights in this current treatment landscape.