Venous Thromboembolic Disease

Venous thromboembolism (VTE) is a common, life-threatening condition in patients with cancer. Results from a recent retrospective study of 66,106 hospitalized adult cancer patients with neutropenia showed that 2.74% to 12.10%, depending on the type of malignancy, experienced VTE during their first hospitalization; the occurrence of VTE has been reported to increase the likelihood of death for cancer patients by 2- to 8-fold. The definition of VTE includes both deep venous thrombosis (DVT) and pulmonary embolism, with the former divided into 4 categories, differing in terms of associated morbidity, treatment, and long-term effects. Pathophysiologic explanations of the origin of VTE in cancer include known hypercoagulability (e.g., procoagulants, such as tissue factor from cancer cells), vessel wall damage, and vessel stasis from direct compression. The incidence of cancer-associated VTE is further increased by additional risks factors, such as thrombophilic mutations, prolonged immobilization, surgical procedures, and chemotherapeutic regimens. These guidelines specifically outline strategies to prevent and treat VTE in adult patients either diagnosed with cancer or in whom cancer is clinically suspected. These guidelines are characterized by iterative evaluations of the therapeutic advantages of implementing pharmacologic anticoagulation measures based on both the perceived risk for bleeding (i.e., contraindications to anticoagulation) and the cancer status of the patient. Important updates for 2008 include new work-up recommendations and changes in the recommendations for outpatient prophylaxis and diagnosis and treatment of heparin-induced thrombocytopenia.

Ovarian Cancer

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer and the fifth most common cause of cancer mortality in women in the United States; in 2008, an estimated 21,650 new diagnoses and 15,520 deaths will occur from this neoplasm. Fewer than 40% of women with ovarian cancer are cured. The incidence increases with age and is most prevalent in the eighth decade of life, with an incidence of 57 per 100,000 women. The median age at diagnosis is 63 years, and 70% of patients present with advanced disease; because of the location of the ovaries, ovarian cancer has been difficult to diagnose at an earlier, more curable stage. Epidemiologic studies have identified risk factors in the cause of ovarian cancer. A 30% to 60% decreased risk for cancer is associated with younger age at pregnancy and first birth ( 25 years), the use of oral contraceptives, and/or breast-feeding. Family history (patients having ≥ 2 first-degree relatives with ovarian cancer), including linkage with BRCA1 and BRCA2 genotypes, has been associated with early-onset disease; however, these patients account for only 5% of all women with ovarian cancer. The NCCN guidelines discuss epithelial ovarian cancer as well as less common ovarian histopathologies, including germ cell neoplasms, carcinosarcomas (malignant mixed Müllerian tumors of the ovary), and ovarian stromal tumors. For 2008, updates include the addition of platinum-based combination therapy as a possible treatment modality for recurrence and a listing of preferred agents for acceptable recurrence modalities. New information was also added to the section on clinical presentation.

Featured Articles

VTE as a Quality Indicator
Myron Goldsmith, MD; George Whitelaw, RPh; and Denise A. Cannaday, JD

Venous thromboembolism (VTE) is still the most common preventable cause of hospital death, with cancer a known significant risk factor for its development. Prophylaxis to prevent VTE in hospitalized surgical and medical patients has been suboptimal; efforts for improvement have been unsuccessful. Recent practice guidelines on VTE from the National Comprehensive Cancer Network and the American Society of Clinical Oncologists have further highlighted this relationship and could bridge performance measures and outcomes that can affect the strategies for preventing this disease. Hospitals and physicians with poor performance data will have problems with reimbursement from payors. This article makes the case that specific oncology VTE measures should be developed to help decrease the current poor rates of VTE prophylaxis and improve hospital and physician compliance.

Treating Superficial Venous Thrombophlebitis
Jason T. Lee, MD, and Maziyar A. Kalani, BS

Superficial venous thrombophlebitis (SVT) is characterized as a localized inflammatory condition of the venous vessels underlying the skin and arises from thrombosis of a superficial vein. Clinical presentation usually involves pain, erythema, and tenderness at the sites of inflammation. Although the condition is usually self-limited and not serious or fatal, it can be debilitating, limit movement and certain capabilities, or progress and cause pulmonary embolism. SVT is typically associated with venous valvular insufficiency, pregnancy, infection, and prothrombotic conditions, including malignancy. Currently, medical therapies comprising bedrest, elastic stockings, compression bandages, nonsteroidal anti-inflammatory drugs, and low molecular weight heparins are used to reduce the extension of inflammation and recurrence of thrombotic events in patients experiencing SVT. In patients refractory to conservative measures, surgical interventions such as phlebectomy, sclerotherapy, saphenous junction ligation, or saphenous vein stripping are potential treatments.

Ovarian Cancer Biomarkers: Current Options and Future Promise
Christine M. Coticchia, PhD; Jiang Yang, PhD; and Marsha A. Moses, PhD

As more effective, less toxic cancer drugs reach patients, the need for accurate and reliable cancer diagnostics and prognostics has become widely appreciated. Nowhere is this need greater than in ovarian cancer, with most women diagnosed late in disease progression. The ability to sensitively and specifically predict the presence of early disease and its status, stage, and associated therapeutic efficacy has the potential to revolutionize ovarian cancer detection and treatment. This article reviews current ovarian cancer diagnostics and prognostics and potential biomarkers that are being studied and validated. Some of the most recent molecular approaches being used to identify genes and proteins are presented, which may represent the next generation.

The Role of Cytoreductive/Debulking Surgery in Ovarian Cancer
Mark T. Wakabayashi, MD, MPH; Paul S. Lin, MD; and Amy A. Hakim, MD

The median survival of patients with ovarian cancer has been increasing over the past few decades. In patients with epithelial ovarian cancer, chemotherapy and intraperitoneal chemotherapy has increased survival; platinum agents combined with taxanes have become standard treatment. Cytoreductive surgery to a tumor or remove any gross disease has also been shown to increase survival. Recently, many institutions have been performing aggressive/ultra-radical procedures to achieve this result. Interval cytoreduction may also benefit patients whose initial surgery is suboptimal, especially if the first procedure was performed by a surgeon unfamiliar with the disease. All of these procedures should be performed by a specialist trained in ovarian cancer surgery.