PMID- 34878173
OWN - NLM
STAT- MEDLINE
DCOM- 20220106
LR  - 20230216
IS  - 1469-493X (Electronic)
IS  - 1361-6137 (Linking)
VI  - 12
IP  - 12
DP  - 2021 Dec 8
TI  - Anticoagulation for the initial treatment of venous thromboembolism in people 
      with cancer.
PG  - CD006649
LID - 10.1002/14651858.CD006649.pub8 [doi]
LID - CD006649
AB  - BACKGROUND: Compared with people without cancer, people with cancer who receive 
      anticoagulant treatment for venous thromboembolism (VTE) are more likely to 
      develop recurrent VTE. OBJECTIVES: To compare the efficacy and safety of three 
      types of parenteral anticoagulants (i.e. fixed-dose low molecular weight heparin 
      (LMWH), adjusted-dose unfractionated heparin (UFH), and fondaparinux) for the 
      initial treatment of VTE in people with cancer. SEARCH METHODS: We performed a 
      comprehensive search in the following major databases: Cochrane Central Register 
      of Controlled Trials (CENTRAL), MEDLINE (via Ovid) and Embase (via Ovid). We also 
      handsearched conference proceedings, checked references of included studies, and 
      searched for ongoing studies. This update of the systematic review is based on 
      the findings of a literature search conducted on 14 August 2021. SELECTION 
      CRITERIA: Randomised controlled trials (RCTs) assessing the benefits and harms of 
      LMWH, UFH, and fondaparinux in people with cancer and objectively confirmed VTE. 
      DATA COLLECTION AND ANALYSIS: Using a standardised form, we extracted data - in 
      duplicate - on study design, participants, interventions, outcomes of interest, 
      and risk of bias. Outcomes of interest included all-cause mortality, symptomatic 
      VTE, major bleeding, minor bleeding, postphlebitic syndrome, quality of life, and 
      thrombocytopenia. We assessed the certainty of evidence for each outcome using 
      the GRADE approach. MAIN RESULTS: Of 11,484 identified citations, 3073 were 
      unique citations and 15 RCTs fulfilled the eligibility criteria, none of which 
      were identified in the latest search. These trials enrolled 1615 participants 
      with cancer and VTE: 13 compared LMWH with UFH; one compared fondaparinux with 
      UFH and LMWH; and one compared dalteparin with tinzaparin, two different types of 
      low molecular weight heparin. The meta-analyses showed that LMWH may reduce 
      mortality at three months compared to UFH (risk ratio (RR) 0.66, 95% confidence 
      interval (CI) 0.40 to 1.10; risk difference (RD) 57 fewer per 1000, 95% CI 101 
      fewer to 17 more; low certainty evidence) and may reduce VTE recurrence slightly 
      (RR 0.69, 95% CI 0.27 to 1.76; RD 30 fewer per 1000, 95% CI 70 fewer to 73 more; 
      low certainty evidence). There were no data available for bleeding outcomes, 
      postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing 
      fondaparinux with heparin (UFH or LMWH) found that fondaparinux may increase 
      mortality at three months (RR 1.25, 95% CI 0.86 to 1.81; RD 43 more per 1000, 95% 
      CI 24 fewer to 139 more; low certainty evidence), may result in little to no 
      difference in recurrent VTE (RR 0.93, 95% CI 0.56 to 1.54; RD 8 fewer per 1000, 
      95% CI 52 fewer to 63 more; low certainty evidence), may result in little to no 
      difference in major bleeding (RR 0.82, 95% CI 0.40 to 1.66; RD 12 fewer per 1000, 
      95% CI 40 fewer to 44 more; low certainty evidence), and probably increases minor 
      bleeding (RR 1.53, 95% CI 0.88 to 2.66; RD 42 more per 1000, 95% CI 10 fewer to 
      132 more; moderate certainty evidence). There were no data available for 
      postphlebitic syndrome, quality of life, or thrombocytopenia. The study comparing 
      dalteparin with tinzaparin found that dalteparin may reduce mortality slightly 
      (RR 0.86, 95% CI 0.43 to 1.73; RD 33 fewer per 1000, 95% CI 135 fewer to 173 
      more; low certainty evidence), may reduce recurrent VTE (RR 0.44, 95% CI 0.09 to 
      2.16; RD 47 fewer per 1000, 95% CI 77 fewer to 98 more; low certainty evidence), 
      may increase major bleeding slightly (RR 2.19, 95% CI 0.20 to 23.42; RD 20 more 
      per 1000, 95% CI 14 fewer to 380 more; low certainty evidence), and may reduce 
      minor bleeding slightly (RR 0.82, 95% CI 0.30 to 2.21; RD 24 fewer per 1000, 95% 
      CI 95 fewer to 164 more; low certainty evidence). There were no data available 
      for postphlebitic syndrome, quality of life, or thrombocytopenia. AUTHORS' 
      CONCLUSIONS: Low molecular weight heparin (LMWH) is probably superior to UFH in 
      the initial treatment of VTE in people with cancer. Additional trials focusing on 
      patient-important outcomes will further inform the questions addressed in this 
      review. The decision for a person with cancer to start LMWH therapy should 
      balance the benefits and harms and consider the person's values and preferences.
CI  - Copyright (c) 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
FAU - Kahale, Lara A
AU  - Kahale LA
AD  - Faculty of Medicine, American University of Beirut, Beirut, Lebanon.
FAU - Matar, Charbel F
AU  - Matar CF
AD  - Department of Internal Medicine, University of Connecticut School of Medicine, 
      Farmington, Connecticut, USA.
FAU - Hakoum, Maram B
AU  - Hakoum MB
AD  - Department of Family Medicine, Cornerstone Care Teaching Health Center, Mt. 
      Morris, Pennsylvania, USA.
FAU - Tsolakian, Ibrahim G
AU  - Tsolakian IG
AD  - Department of Obstetrics and Gynaecology, Univeristy of Toledo, Toledo, Ohio, 
      USA.
FAU - Yosuico, Victor Ed
AU  - Yosuico VE
AD  - Buffalo Medical Group, Buffalo, New York, USA.
FAU - Terrenato, Irene
AU  - Terrenato I
AD  - Biostatistics-Scientific Direction, IRCCS Regina Elena National Cancer Institute, 
      Rome, Italy.
FAU - Sperati, Francesca
AU  - Sperati F
AD  - Biostatistics-Scientific Direction, IRCCS Regina Elena National Cancer Institute, 
      Rome, Italy.
FAU - Barba, Maddalena
AU  - Barba M
AD  - Division of Medical Oncology 2 - Scientific Direction, IRCCS Regina Elena 
      National Cancer Institute, Rome, Italy.
FAU - Schunemann, Holger
AU  - Schunemann H
AD  - Departments of Health Research Methods, Evidence, and Impact and of Medicine, 
      McMaster University, Hamilton, Canada.
FAU - Akl, Elie A
AU  - Akl EA
AD  - Department of Internal Medicine, American University of Beirut Medical Center, 
      Beirut, Lebanon.
LA  - eng
SI  - ClinicalTrials.gov/NCT01130025
SI  - ClinicalTrials.gov/NCT01448746
SI  - ClinicalTrials.gov/NCT00966277
PT  - Journal Article
PT  - Research Support, Non-U.S. Gov't
PT  - Review
PT  - Systematic Review
DEP - 20211208
PL  - England
TA  - Cochrane Database Syst Rev
JT  - The Cochrane database of systematic reviews
JID - 100909747
RN  - 0 (Anticoagulants)
RN  - 0 (Heparin, Low-Molecular-Weight)
RN  - 9005-49-6 (Heparin)
SB  - IM
UOF - Cochrane Database Syst Rev. 2018 Jan 24;1:CD006649. PMID: 29363105
MH  - Anticoagulants/adverse effects
MH  - Heparin/adverse effects
MH  - Heparin, Low-Molecular-Weight/adverse effects
MH  - Humans
MH  - *Neoplasms/complications
MH  - *Venous Thromboembolism/drug therapy
PMC - PMC8653422
COIS- HJS: panel member of the ASH VTE in cancer patients, Vice-Chair of the ASH VTE 
      guidelines and played various leadership roles from 1999 until 2014 with the 
      American College of Chest Physicians (ACCP) VTE guidelines. EAA served on the 
      executive committee of the ACCP Antithrombotic Therapy Guidelines published in 
      2016. All other review authors declare no conflicts of interest.
EDAT- 2021/12/09 06:00
MHDA- 2022/01/07 06:00
PMCR- 2022/12/08
CRDT- 2021/12/08 09:23
PHST- 2021/12/08 09:23 [entrez]
PHST- 2021/12/09 06:00 [pubmed]
PHST- 2022/01/07 06:00 [medline]
PHST- 2022/12/08 00:00 [pmc-release]
AID - CD006649.pub8 [pii]
AID - 10.1002/14651858.CD006649.pub8 [doi]
PST - epublish
SO  - Cochrane Database Syst Rev. 2021 Dec 8;12(12):CD006649. doi: 
      10.1002/14651858.CD006649.pub8.