Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, European Institute of Oncology, IEO, IRCCS, Milan, Italy.
Medical University of South Carolina, Charleston, SC, USA.
Eur J Cancer. 2024 Sep;209:114234. doi: 10.1016/j.ejca.2024.114234. Epub 2024 Jul 26.
Based on the Khorana score, guidelines recommend anticoagulation for primary prophylaxis (PP) in outpatients with cancer with an intermediate-to-high risk of venous thromboembolism (VTE). ONKOTEV score has been prospectively externally validated as novel risk assessment model (RAM) with good discriminatory performances but no direct comparisons with Khorana Score are available.
Using the ONKOTEV validation dataset (n = 425), we applied generalized decision curve analysis (gDCA) which integrates the principles of evidence-based medicine with treatment effects, model accuracy and patient preferences (weighted as the relative value [RV] of avoiding VTE versus major bleeding [MB]). The aim is to select the most optimal treatment strategy among multiple options: "no treatment", "treat all patients with DOAC/LMVH", or "use ONKOTEV/KHORANA scores to guide PP with DOAC/LMWH".
Results showed that ONKOTEV-guided PP (using DOAC or LMWH) remained the most optimal strategy for wide range assumption of treatment efficacy and patient's preference. For those patients, who value avoiding VTE more than MB, then offering DOAC to all patients represents the best strategy. When MBs are feared more than the morbidity of VTE, ONKOTEV-guided PP (DOAC) represents the best management strategy. In all cases, ONKOTEV outperformed Khorana for individualized VTE prevention.
When the two predictive models are integrated within a decision analysis framework, ONKOTEV appears superior to Khorana Score in guiding individualized prevention of cancer-related VTE in outpatients with cancer. The findings herein reported provide cutting edge insights in cancer care and support the spread of ONKOTEV score in the ambulatory cancer setting.
基于 Khorana 评分，指南建议对有中高危静脉血栓栓塞症（VTE）风险的门诊癌症患者进行抗凝的初级预防（PP）。ONKOTEV 评分已作为一种新的风险评估模型（RAM）进行前瞻性外部验证，具有良好的判别性能，但尚无与 Khorana 评分的直接比较。
我们使用 ONKOTEV 验证数据集（n=425），应用广义决策曲线分析（gDCA），该分析将循证医学的原则与治疗效果、模型准确性和患者偏好（加权为避免 VTE 与大出血 [MB] 的相对价值 [RV]）相结合。目的是在多种选择中选择最佳的治疗策略：“不治疗”、“用 DOAC/LMVH 治疗所有患者”或“使用 ONKOTEV/KHORANA 评分指导 DOAC/LMWH 的 PP”。
结果表明，ONKOTEV 指导的 PP（使用 DOAC 或 LMWH）仍然是在广泛假设治疗效果和患者偏好的情况下最优化的策略。对于那些更重视避免 VTE 而不是 MB 的患者，那么向所有患者提供 DOAC 是最佳策略。当 MB 比 VTE 的发病率更令人担忧时，ONKOTEV 指导的 PP（DOAC）是最佳管理策略。在所有情况下，ONKOTEV 在个体化 VTE 预防方面优于 Khorana。
当这两个预测模型在决策分析框架内整合时，ONKOTEV 在指导门诊癌症患者的癌症相关 VTE 个体化预防方面优于 Khorana 评分。本文的研究结果为癌症护理提供了前沿的见解，并支持在门诊癌症环境中推广 ONKOTEV 评分。
