Performance Status and Long-Term Outcomes in Cancer-Associated Pulmonary Embolism: Insights From the Hokusai-VTE Cancer Study

Ioannis T Farmakis; Stefano Barco; Anna C Mavromanoli; Stavros V Konstantinides; Luca Valerio

doi:10.1016/j.jaccao.2022.07.008

Performance Status and Long-Term Outcomes in Cancer-Associated Pulmonary Embolism: Insights From the Hokusai-VTE Cancer Study

JACC CardioOncol. 2022 Nov 15;4(4):507-518. doi: 10.1016/j.jaccao.2022.07.008. eCollection 2022 Nov.

Authors

Ioannis T Farmakis¹, Stefano Barco^{1

2}, Anna C Mavromanoli¹, Stavros V Konstantinides^{1

3}, Luca Valerio^{1

4}

Affiliations

¹ Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.
² Department of Angiology, University Hospital Zurich, Zurich, Switzerland.
³ Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece.
⁴ Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany.

Abstract

Background: Performance status (PS) is a reliable prognostic tool for overall survival in patients with cancer-associated pulmonary embolism (PE). However, its association with venous thromboembolism (VTE) recurrence and bleeding remains unclear.

Objectives: The aim of this study was to investigate whether PS at the time of PE diagnosis and its course during follow-up are linked to VTE-related outcomes.

Methods: In this post hoc analysis of the Hokusai-VTE Cancer study, multivariable survival analysis was used to examine the association of PS with anticoagulation discontinuation and the composite primary outcome of VTE recurrence or major bleeding in patients with cancer-associated PE. PS was assessed using the Eastern Cooperative Oncology Group (ECOG) scale at baseline and at predefined study follow-up visits.

Results: Overall, 652 patients with cancer-associated PE were included. During 12-month follow-up, PS worsened in 317 of 642 patients (49.4%) with complete ECOG data at the end of follow-up. Those with worse ECOG values over follow-up were more likely to discontinue anticoagulation for any reason apart from death (adjusted HR: 1.59; 95% CI: 1.31-1.93). The composite primary outcome occurred in 57 of 500 patients with baseline ECOG status 0 or 1 and in 32 of 152 patients with ECOG status 2 (cumulative incidence at 12 months 10.7% [95% CI: 8.2%-13.9%] vs 14.4% [95% CI: 9.7%-21.3%]). Worse ECOG values during follow-up were associated with greater risk for the composite outcome (adjusted HR: 2.13; 95% CI: 1.24-3.67).

Conclusions: ECOG PS is a valuable indicator for predicting VTE-related outcomes and may inform decision making regarding anticoagulation during follow-up in patients with cancer-associated PE.

Keywords: DVT, deep vein thrombosis; ECOG; ECOG, Eastern Cooperative Oncology Group; Eastern Cooperative Oncology Group; PE, pulmonary embolism; VTE, venous thromboembolism; anticoagulation; cancer; edoxaban; performance status; pulmonary embolism.