Risk-Directed Ambulatory Thromboprophylaxis in Lung and Gastrointestinal Cancers: The TARGET-TP Randomized Clinical Trial

Alexander, M; Harris, S; Underhill, C; Torres, J; Sharma, S; Lee, N; Wong, H; Eek, R; Michael, M; Tie, J; Rogers, J; Heriot, AG; Ball, D; MacManus, M; Wolfe, R; Solomon, BJ; Burbury, K

Author(s): Alexander, M; Harris, S; Underhill, C; Torres, J; Sharma, S; Lee, N; Wong, H; Eek, R; Michael, M; Tie, J; Rogers, J; Heriot, AG; Ball, D; MacManus, M; Wolfe, R; Solomon, BJ; Burbury, K;
Details: Publication Year 2023-09-21,Volume 9,Issue #11,Page 1536-1545
Journal Title: JAMA Oncology
Abstract: IMPORTANCE: Thromboprophylaxis for individuals receiving systemic anticancer therapies has proven to be effective. Potential to maximize benefits relies on improved risk-directed strategies, but existing risk models underperform in cohorts with lung and gastrointestinal cancers. OBJECTIVE: To assess clinical benefits and safety of biomarker-driven thromboprophylaxis and to externally validate a biomarker thrombosis risk assessment model for individuals with lung and gastrointestinal cancers. DESIGN, SETTING, AND PARTICIPANTS: This open-label, phase 3 randomized clinical trial (Targeted Thromboprophylaxis in Ambulatory Patients Receiving Anticancer Therapies [TARGET-TP]) conducted from June 2018 to July 2021 (with 6-month primary follow-up) included adults aged 18 years or older commencing systemic anticancer therapies for lung or gastrointestinal cancers at 1 metropolitan and 4 regional hospitals in Australia. Thromboembolism risk assessment based on fibrinogen and d-dimer levels stratified individuals into low-risk (observation) and high-risk (randomized) cohorts. INTERVENTIONS: High-risk patients were randomized 1:1 to receive enoxaparin, 40 mg, subcutaneously daily for 90 days (extending up to 180 days according to ongoing risk) or no thromboprophylaxis (control). MAIN OUTCOMES AND MEASURES: The primary outcome was objectively confirmed thromboembolism at 180 days. Key secondary outcomes included bleeding, survival, and risk model validation. RESULTS: Of 782 eligible adults, 328 (42%) were enrolled in the trial (median age, 65 years [range, 30-88 years]; 176 male [54%]). Of these participants, 201 (61%) had gastrointestinal cancer, 127 (39%) had lung cancer, and 132 (40%) had metastatic disease; 200 (61%) were high risk (100 in each group), and 128 (39%) were low risk. In the high-risk cohort, thromboembolism occurred in 8 individuals randomized to enoxaparin (8%) and 23 control individuals (23%) (hazard ratio [HR], 0.31; 95% CI, 0.15-0.70; P = .005; number needed to treat, 6.7). Thromboembolism occurred in 10 low-risk individuals (8%) (high-risk control vs low risk: HR, 3.33; 95% CI, 1.58-6.99; P = .002). Risk model sensitivity was 70%, and specificity was 61%. The rate of major bleeding was low, occurring in 1 participant randomized to enoxaparin (1%), 2 in the high-risk control group (2%), and 3 in the low-risk group (2%) (P = .88). Six-month mortality was 13% in the enoxaparin group vs 26% in the high-risk control group (HR, 0.48; 95% CI, 0.24-0.93; P = .03) and 7% in the low-risk group (vs high-risk control: HR, 4.71; 95% CI, 2.13-10.42; P < .001). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of individuals with lung and gastrointestinal cancers who were stratified by risk score according to thrombosis risk, risk-directed thromboprophylaxis reduced thromboembolism with a desirable number needed to treat, without safety concerns, and with reduced mortality. Individuals at low risk avoided unnecessary intervention. The findings suggest that biomarker-driven, risk-directed primary thromboprophylaxis is an appropriate approach in this population. TRIAL REGISTRATION: ANZCTR Identifier: ACTRN12618000811202.
Publisher: JAMA
Keywords: Adult; Humans; Male; Aged; Anticoagulants/adverse effects; Enoxaparin/adverse effects; *Venous Thromboembolism/prevention & control/chemically induced; Hemorrhage/chemically induced; *Thrombosis/drug therapy; *Gastrointestinal Neoplasms/drug therapy; Lung; Biomarkers
Research Division(s): Personalised Oncology
PubMed ID: 37733336
Publisher's Version: https://doi.org/10.1001/jamaoncol.2023.3634
Terms of Use/Rights Notice: Refer to copyright notice on published article.

Creation Date: 2023-09-27 08:47:29

Last Modified: 2023-11-20 03:24:03