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Risk of Venous and Arterial Thromboembolic Events in Patients Receiving Targeted Anti-cancer Therapy – A Nationwide Cohort Study

F. Moik1, C. Ay1, E. Horváth-Puhó2, I. Pabinger1, F. Mulder3, N. van Es3, H.T. Sørensen2

1Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria, 2Department of Clinical Epidemiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark, 3Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, Netherlands

Abstract Number: OC 23.2

Meeting: ISTH 2021 Congress

Theme: Venous Thromboembolism » Cancer Associated Thrombosis

Background: Recent data show high rates of venous and arterial thromboembolism (VTE/ATE) associated with targeted anti-cancer therapies.

Aims: We aim to provide comprehensive population-level data on absolute and relative risks of VTE/ATE in patients treated with immune-checkpoint-inhibitors (ICIs), multi-kinase-inhibitors (MKIs), VEGF-, HER-2-, EGFR-, and ALK-/ROS-targeted therapies.

Methods: Danish medical registries were used to identify 31,224 cancer patients treated with specific targeted therapies during 2004-2018. Cumulative VTE/ATE incidence after targeted treatment initiation was computed using competing-risk analysis. Relative risk of VTE was evaluated using conditional logistic regression in a case-control analysis, separately assessing exposure to targeted treatments within 3 months and at any time before VTE. VTE cases within cancer types were matched (4:1-ratio) by age, sex, cancer diagnosis year, and index date to controls without VTE. Multivariable adjustment was performed for cancer stage, comorbidities, and time from cancer diagnosis to index date.

Results: Cumulative 1-year risk of VTE were highest for anti-EGFR (6.3% [95%CI: 5.8-6.9]), anti-VEGF (6.0% [5.6-6.5]), and ICI-treatment (5.7% [4.9-6.7]). Corresponding risks of ATE were highest for anti-ALK/ROS-therapy (3.6% [1.3-7.7]), ICIs (2.2% [1.7-2.8]), and MKIs (1.9% [1.4-2.4]) (Table 1).

Agent / agent group n Cumulative incidence of VTE (95%CI) Cumulative incidence of ATE (95%CI)
3 mo. 6 mo. 12 mo. 24 mo. 3 mo. 6 mo. 12 mo. 24 mo.
Immune-checkpoint-inhibitor (ICI) 3,259 1.09
(0.77-1.49)
3.91
(3.26-4.65)
5.68
(4.86-6.59)
7.26
(6.24-8.37)
0.37
(0.21-0.64)
1.29
(0.94-1.75)
2.23
(1.72-2.84)
3.06 (2.40-3.83)
Anti-angiogenic (VEGF-targeted) 10,902 0.78
(0.63-0.96)
4.29
(3.92-4.69)
6.02
(5.57-6.48)
7.72
(7.21-8.24)
0.32 (0.23-0.44) 1.14 (0.96-1.36) 1.80 (1.56-2.07) 2.40 (2.12-2.71)
Multi-kinase inhibitors (MKIs) 2,907 0.83
(0.55-1.22)
3.71
(3.05-4.46)
4.61
(3.87-5.43)
6.03
(5.16-6.99)
0.35 (0.18-0.62) 1.32 (0.94-1.79) 1.87 (1.41-2.43) 3.21 (2.57-3.95)
HER2-neu targeted  9,980 0.30
(0.21-0.43)
1.30
(1.09-1.54)
1.72
(1.48-1.99)
2.42
(2.12-2.74)
0.14 (0.08-0.23) 0.35 (0.24-0.48) 0.68 (0.53-0.86) 1.15 (0.95-1.38)
EGFR-targeted 7,682 0.99
(0.79-1.24)
4.69
(4.23-5.18)
6.31
(5.77-6.87)
7.92
(7.32-8.56)
0.41 (0.28-0.57) 1.26 (1.02-1.53) 1.74 (1.46-2.06) 2.40 (2.06-2.77)
ALK/ROS-targeted 155 1.29
(0.25-4.21)
3.94
(1.61-7.92)
5.49
(2.55-10.06)
6.34
(3.09-11.22)
1.29 (0.25-4.21) 1.29 (0.25-4.21) 3.58 (1.33-7.70) 3.58 (1.33-7.70)

Cumulative incidence at 3, 6, 12, and 24 months of venous thromboembolism (VTE, comprising deep vein thrombosis and/or pulmonary embolism) and arterial thromboembolism (ATE, comprising ischaemic stroke, myocardial infarction, and acute peripheral arterial occlusion) in preselected targeted anti-cancer agent groups in competing risk analysis, accounting for all-cause mortality as a competing outcome event.
In lung cancer, VTE risk was associated with recent ICIs (odds ratio (OR): 1.45 [1.01–2.07]) and anti-EGFR-therapy (OR: 2.12 [1.65–2.73]). VTE risk was associated with recent ICI exposure in melanoma (OR: 6.48 [3.07–13.65]. Colorectal cancer patients had elevated VTE risk with recent anti-VEGF- (OR: 2.49 [2.09–2.97]) or anti-EGFR-treatment (OR: 3.33 [2.64–4.21]) (Table 2).

Cancer type Treatment
 
OR for VTE within 3 months of treatment OR for VTE at any time after treatment
Unadjusted  Adjusted Unadjusted Adjusted
Colorectal cancer 
 
Anti-VEGF  3.48 
(2.95–4.10)
2.49 
(2.09–2.97)
3.54 
(3.10–4.05)
2.70
(2.34–3.12)
Anti- EGFR 4.75 
(3.80–5.95)
3.33 
(2.64–4.21)
3.85 
(3.21–4.62)
2.86 
(2.36–3.46)
Lung cancer
 
 
 
ICIs 1.82 
(1.28–2.59)
1.45 
(1.01–2.07)
2.23 
(1.63–3.04)
1.82 
(1.33–2.50)
Anti-EGFR 2.78 
(2.17–3.56)
2.12 
(1.65–2.73)
3.23 
(2.62–3.99)
2.49 
(2.01–3.09)
ALK/ROS 1.22 
(0.44–3.41)
0.86
(0.31–2.44)
1.25 
(0.53–2.97)
0.89 
(0.37–2.12)
Anti-VEGF 1.44 
(1.04–1.98)
1.03 
(0.75–1.43)
1.90 
(1.50–2.41)
1.43 
(1.13–1.82)
Melanoma ICIs 7.45 
(3.58–15.47)
6.48 
(3.07–13.65)
6.81
(4.24–10.93)
5.25 
(3.22–8.58)
Urogenital cancer 
 
ICIs 2.76 
(1.10–6.90)
1.75 
(0.69–4.45)
2.39 
(1.18–4.86)
1.46 
(0.70–3.04)
MKIs 3.11 
(2.28–4.26)
1.94 
(1.39–2.70)
2.80 
(2.10–3.73)
1.81 
(1.33–2.46)

Matched case-control analysis using conditional logistic regression. Cases comprise adult patients with a given cancer diagnosis and subsequent VTE, and controls comprise adult patients with a given cancer without subsequent VTE. Matching of controls to cases in a 4:1 ratio was based on age, sex, year of cancer diagnosis, and year of index date (cases: VTE diagnosis date, controls: VTE diagnosis date of matched cases, with controls having to be alive and at risk on index date). Exposure was defined as treatment with a given targeted agent within 3 months prior to the index date (“recently exposed”) or at any time point prior to the index date (“ever exposed”). Multivariable adjustment was performed for tumour stage at diagnosis, Charlson Comorbidity Index score, and time from cancer diagnosis to index date.

Conclusions: In this nationwide analysis, we provide large-scale data for the first time on targeted anti-cancer therapies and VTE/ATE risk. The absolute thrombotic risk was substantial, and VTE-risk was relatively increased compared to controls for certain agent groups. These observations could allow identification of high-risk populations for thromboembolic events among cancer patients. Treatment data updated to 2020 will be presented at the meeting.

To cite this abstract in AMA style:

Moik F, Ay C, Horváth-Puhó E, Pabinger I, Mulder F, van Es N, Sørensen HT. Risk of Venous and Arterial Thromboembolic Events in Patients Receiving Targeted Anti-cancer Therapy – A Nationwide Cohort Study [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/risk-of-venous-and-arterial-thromboembolic-events-in-patients-receiving-targeted-anti-cancer-therapy-a-nationwide-cohort-study/. Accessed May 19, 2022.

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