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Multicenter Study
. 2017 Aug 22;70(8):926-938.
doi: 10.1016/j.jacc.2017.06.047.

Risk of Arterial Thromboembolism in Patients With Cancer

Babak B Navi  1 , Anne S Reiner  2 , Hooman Kamel  3 , Costantino Iadecola  3 , Peter M Okin  4 , Mitchell S V Elkind  5 , Katherine S Panageas  2 , Lisa M DeAngelis  6
Affiliations
Multicenter Study

Risk of Arterial Thromboembolism in Patients With Cancer

Babak B Navi et al. J Am Coll Cardiol. .

Abstract

Background: The risk of arterial thromboembolism in patients with cancer is incompletely understood.

Objectives: The authors aimed to better define this epidemiological relationship, including the effects of cancer stage.

Methods: Using the Surveillance Epidemiology and End Results-Medicare linked database, the authors identified patients with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, pancreatic, or gastric cancer or non-Hodgkin lymphoma from 2002 to 2011. They were individually matched by demographics and comorbidities to a Medicare enrollee without cancer, and each pair was followed through 2012. Validated diagnosis codes were used to identify arterial thromboembolism, defined as myocardial infarction or ischemic stroke. Cumulative incidence rates were calculated using competing risk survival statistics. Cox hazards analysis was used to compare rates between groups at discrete time points.

Results: The authors identified 279,719 pairs of patients with cancer and matched control patients. The 6-month cumulative incidence of arterial thromboembolism was 4.7% (95% confidence interval [CI]: 4.6% to 4.8%) in patients with cancer compared with 2.2% (95% CI: 2.1% to 2.2%) in control patients (hazard ratio [HR]: 2.2; 95% CI: 2.1 to 2.3). The 6-month cumulative incidence of myocardial infarction was 2.0% (95% CI: 1.9% to 2.0%) in patients with cancer compared with 0.7% (95% CI: 0.6% to 0.7%) in control patients (HR: 2.9; 95% CI: 2.8 to 3.1). The 6-month cumulative incidence of ischemic stroke was 3.0% (95% CI: 2.9% to 3.1%) in patients with cancer compared with 1.6% (95% CI: 1.6% to 1.7%) in control patients (HR: 1.9; 95% CI: 1.8 to 2.0). Excess risk varied by cancer type (greatest for lung), correlated with cancer stage, and generally had resolved by 1 year.

Conclusions: Patients with incident cancer face a substantially increased short-term risk of arterial thromboembolism.

Keywords: ischemic stroke; myocardial infarction; thrombosis.

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Figures

Figure 1
Figure 1. Cumulative Incidence of Arterial Thromboembolism in Cancer Patients and Matched Controls
(A) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) compared to matched controls. (B) Cumulative incidence of myocardial infarction in patients with cancer (all types combined) compared to matched controls. (C) Cumulative incidence of ischemic stroke in patients with cancer (all types combined) compared to matched controls. (D) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) stratified by cancer stage at the time of cancer diagnosis. Staging was performed according to the American Joint Committee on Cancer staging schema except for patients with prostate cancer, who were staged according to the T (clinical) staging classification and patients with non-Hodgkin lymphoma, who were staged according to the Ann Arbor staging classification. Competing risk survival statistics were used to calculate incidence. Dashed lines are used to indicate 95% confidence intervals.
Figure 1
Figure 1. Cumulative Incidence of Arterial Thromboembolism in Cancer Patients and Matched Controls
(A) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) compared to matched controls. (B) Cumulative incidence of myocardial infarction in patients with cancer (all types combined) compared to matched controls. (C) Cumulative incidence of ischemic stroke in patients with cancer (all types combined) compared to matched controls. (D) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) stratified by cancer stage at the time of cancer diagnosis. Staging was performed according to the American Joint Committee on Cancer staging schema except for patients with prostate cancer, who were staged according to the T (clinical) staging classification and patients with non-Hodgkin lymphoma, who were staged according to the Ann Arbor staging classification. Competing risk survival statistics were used to calculate incidence. Dashed lines are used to indicate 95% confidence intervals.
Figure 1
Figure 1. Cumulative Incidence of Arterial Thromboembolism in Cancer Patients and Matched Controls
(A) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) compared to matched controls. (B) Cumulative incidence of myocardial infarction in patients with cancer (all types combined) compared to matched controls. (C) Cumulative incidence of ischemic stroke in patients with cancer (all types combined) compared to matched controls. (D) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) stratified by cancer stage at the time of cancer diagnosis. Staging was performed according to the American Joint Committee on Cancer staging schema except for patients with prostate cancer, who were staged according to the T (clinical) staging classification and patients with non-Hodgkin lymphoma, who were staged according to the Ann Arbor staging classification. Competing risk survival statistics were used to calculate incidence. Dashed lines are used to indicate 95% confidence intervals.
Figure 1
Figure 1. Cumulative Incidence of Arterial Thromboembolism in Cancer Patients and Matched Controls
(A) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) compared to matched controls. (B) Cumulative incidence of myocardial infarction in patients with cancer (all types combined) compared to matched controls. (C) Cumulative incidence of ischemic stroke in patients with cancer (all types combined) compared to matched controls. (D) Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer (all types combined) stratified by cancer stage at the time of cancer diagnosis. Staging was performed according to the American Joint Committee on Cancer staging schema except for patients with prostate cancer, who were staged according to the T (clinical) staging classification and patients with non-Hodgkin lymphoma, who were staged according to the Ann Arbor staging classification. Competing risk survival statistics were used to calculate incidence. Dashed lines are used to indicate 95% confidence intervals.
Central Illustration
Central Illustration. Cumulative Incidence of Arterial Thromboembolism in Cancer Patients
Cumulative incidence of arterial thromboembolism (composite of myocardial infarction and ischemic stroke) in patients with cancer compared to matched controls (left figure) and when stratified by cancer stage at the time of cancer diagnosis (right figure). Competing risk survival statistics were used to calculate incidence. Dashed lines are used to indicate 95% confidence intervals.
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