Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation.

E. A. Akl, F. F. van Doormaal, M. Barba, G. Kamath, S. Y. Kim, S. Kuipers, S. Middeldorp, V. Yosuico, H. O. Dickinson, H. J. Schünemann

Research output: Contribution to journalArticle

Abstract

BACKGROUND: Basic research and clinical studies have generated the hypothesis that anticoagulation may improve survival in patients with cancer through an antitumour effect in addition to the antithrombotic effect. OBJECTIVES: To evaluate the efficacy and safety of heparin (including unfractionated heparin (UFH) and low molecular weight heparin (LMWH)) and fondaparinux to improve survival of patients with cancer. SEARCH STRATEGY: A comprehensive search for studies of anticoagulation in cancer patients including (1) A January 2007 electronic search of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ISI the Web of Science; (2) Hand search of the American Society of Clinical Oncology and of the American Society of Hematology; (3) Checking of references of included studies; and (4) Use of "related article" feature in PubMed. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in cancer patients without clinical evidence of venous thromboembolism comparing UFH, LMWH or fondaparinux to no intervention or placebo and RCTs comparing two of the three agents of interest. DATA COLLECTION AND ANALYSIS: Using a standardized form we extracted in duplicate data on methodological quality, participants, interventions and outcomes of interest including all cause mortality, venous thrombosis, symptomatic pulmonary embolism, major bleeding and minor bleeding. MAIN RESULTS: Of 3986 identified citations five RCTs fulfilled the inclusion criteria. In all included RCTs the intervention consisted of heparin ( either UFH or LMWH). The overall methodological quality of the included studies was acceptable. Overall, heparin therapy was associated with a statistically and clinically significant survival benefit (hazard ratio (HR) = 0.77; 95% CI: 0.65 to 0.91). In subgroup analyses, patients with limited small cell lung cancer experienced a clear survival benefit (HR = 0.56; 95% CI: 0.38 to 0.83). The survival benefit was not statistically significant for either patients with extensive small cell lung cancer (HR = 0.80; 95% CI: 0.60 to 1.06) or patients with advanced cancer (HR = 0.84; 95%: 0.68 to 1.03). The increased risk of bleeding with heparin was not statistically significant (RR = 1.78; 95% CI: 0.73 to 4.38). AUTHORS' CONCLUSIONS: Heparin has a survival benefit in cancer patients in general, and in patients with limited small cell lung cancer in particular. Heparin might be particularly beneficial in cancer patients with limited cancer or a longer life expectancy. Future research should investigate the survival benefit of different types of anticoagulants (in different dosing, schedules and duration of therapy) in patients with different types and stages of cancers.

Original languageEnglish
JournalThe Cochrane database of systematic reviews
Issue number3
Publication statusPublished - 2007

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Heparin
Survival
Neoplasms
Low Molecular Weight Heparin
Small Cell Lung Carcinoma
Randomized Controlled Trials
Hemorrhage
Venous Thromboembolism
Life Expectancy
Pulmonary Embolism
PubMed
MEDLINE
Venous Thrombosis
Anticoagulants
Appointments and Schedules
Placebos
Databases
Safety
Mortality
Therapeutics

ASJC Scopus subject areas

  • Medicine(all)

Cite this

Akl, E. A., van Doormaal, F. F., Barba, M., Kamath, G., Kim, S. Y., Kuipers, S., ... Schünemann, H. J. (2007). Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation. The Cochrane database of systematic reviews, (3).

Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation. / Akl, E. A.; van Doormaal, F. F.; Barba, M.; Kamath, G.; Kim, S. Y.; Kuipers, S.; Middeldorp, S.; Yosuico, V.; Dickinson, H. O.; Schünemann, H. J.

In: The Cochrane database of systematic reviews, No. 3, 2007.

Research output: Contribution to journalArticle

Akl, EA, van Doormaal, FF, Barba, M, Kamath, G, Kim, SY, Kuipers, S, Middeldorp, S, Yosuico, V, Dickinson, HO & Schünemann, HJ 2007, 'Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation.', The Cochrane database of systematic reviews, no. 3.
Akl, E. A. ; van Doormaal, F. F. ; Barba, M. ; Kamath, G. ; Kim, S. Y. ; Kuipers, S. ; Middeldorp, S. ; Yosuico, V. ; Dickinson, H. O. ; Schünemann, H. J. / Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation. In: The Cochrane database of systematic reviews. 2007 ; No. 3.
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T1 - Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation.

AU - Akl, E. A.

AU - van Doormaal, F. F.

AU - Barba, M.

AU - Kamath, G.

AU - Kim, S. Y.

AU - Kuipers, S.

AU - Middeldorp, S.

AU - Yosuico, V.

AU - Dickinson, H. O.

AU - Schünemann, H. J.

PY - 2007

Y1 - 2007

N2 - BACKGROUND: Basic research and clinical studies have generated the hypothesis that anticoagulation may improve survival in patients with cancer through an antitumour effect in addition to the antithrombotic effect. OBJECTIVES: To evaluate the efficacy and safety of heparin (including unfractionated heparin (UFH) and low molecular weight heparin (LMWH)) and fondaparinux to improve survival of patients with cancer. SEARCH STRATEGY: A comprehensive search for studies of anticoagulation in cancer patients including (1) A January 2007 electronic search of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ISI the Web of Science; (2) Hand search of the American Society of Clinical Oncology and of the American Society of Hematology; (3) Checking of references of included studies; and (4) Use of "related article" feature in PubMed. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in cancer patients without clinical evidence of venous thromboembolism comparing UFH, LMWH or fondaparinux to no intervention or placebo and RCTs comparing two of the three agents of interest. DATA COLLECTION AND ANALYSIS: Using a standardized form we extracted in duplicate data on methodological quality, participants, interventions and outcomes of interest including all cause mortality, venous thrombosis, symptomatic pulmonary embolism, major bleeding and minor bleeding. MAIN RESULTS: Of 3986 identified citations five RCTs fulfilled the inclusion criteria. In all included RCTs the intervention consisted of heparin ( either UFH or LMWH). The overall methodological quality of the included studies was acceptable. Overall, heparin therapy was associated with a statistically and clinically significant survival benefit (hazard ratio (HR) = 0.77; 95% CI: 0.65 to 0.91). In subgroup analyses, patients with limited small cell lung cancer experienced a clear survival benefit (HR = 0.56; 95% CI: 0.38 to 0.83). The survival benefit was not statistically significant for either patients with extensive small cell lung cancer (HR = 0.80; 95% CI: 0.60 to 1.06) or patients with advanced cancer (HR = 0.84; 95%: 0.68 to 1.03). The increased risk of bleeding with heparin was not statistically significant (RR = 1.78; 95% CI: 0.73 to 4.38). AUTHORS' CONCLUSIONS: Heparin has a survival benefit in cancer patients in general, and in patients with limited small cell lung cancer in particular. Heparin might be particularly beneficial in cancer patients with limited cancer or a longer life expectancy. Future research should investigate the survival benefit of different types of anticoagulants (in different dosing, schedules and duration of therapy) in patients with different types and stages of cancers.

AB - BACKGROUND: Basic research and clinical studies have generated the hypothesis that anticoagulation may improve survival in patients with cancer through an antitumour effect in addition to the antithrombotic effect. OBJECTIVES: To evaluate the efficacy and safety of heparin (including unfractionated heparin (UFH) and low molecular weight heparin (LMWH)) and fondaparinux to improve survival of patients with cancer. SEARCH STRATEGY: A comprehensive search for studies of anticoagulation in cancer patients including (1) A January 2007 electronic search of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ISI the Web of Science; (2) Hand search of the American Society of Clinical Oncology and of the American Society of Hematology; (3) Checking of references of included studies; and (4) Use of "related article" feature in PubMed. SELECTION CRITERIA: We included randomized controlled trials (RCTs) in cancer patients without clinical evidence of venous thromboembolism comparing UFH, LMWH or fondaparinux to no intervention or placebo and RCTs comparing two of the three agents of interest. DATA COLLECTION AND ANALYSIS: Using a standardized form we extracted in duplicate data on methodological quality, participants, interventions and outcomes of interest including all cause mortality, venous thrombosis, symptomatic pulmonary embolism, major bleeding and minor bleeding. MAIN RESULTS: Of 3986 identified citations five RCTs fulfilled the inclusion criteria. In all included RCTs the intervention consisted of heparin ( either UFH or LMWH). The overall methodological quality of the included studies was acceptable. Overall, heparin therapy was associated with a statistically and clinically significant survival benefit (hazard ratio (HR) = 0.77; 95% CI: 0.65 to 0.91). In subgroup analyses, patients with limited small cell lung cancer experienced a clear survival benefit (HR = 0.56; 95% CI: 0.38 to 0.83). The survival benefit was not statistically significant for either patients with extensive small cell lung cancer (HR = 0.80; 95% CI: 0.60 to 1.06) or patients with advanced cancer (HR = 0.84; 95%: 0.68 to 1.03). The increased risk of bleeding with heparin was not statistically significant (RR = 1.78; 95% CI: 0.73 to 4.38). AUTHORS' CONCLUSIONS: Heparin has a survival benefit in cancer patients in general, and in patients with limited small cell lung cancer in particular. Heparin might be particularly beneficial in cancer patients with limited cancer or a longer life expectancy. Future research should investigate the survival benefit of different types of anticoagulants (in different dosing, schedules and duration of therapy) in patients with different types and stages of cancers.

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