BELIEVE IT OR NOT, ECF IS DEAD

Thromboembolism in Patients With Advanced Gastroesophageal Cancer Treated With Anthracycline, Platinum, and Fluoropyrimidine Combination Chemotherapy: A Report From the UK National Cancer Research Institute Upper Gastrointestinal Clinical Studies Group

Naureen Starling, Sheela Rao, David Cunningham, Timothy Iveson, Marianne Nicolson, Fareeda Coxon, Gary Middleton, Francis Daniel, Jacqueline Oates, Andrew Richard Norman 

Originally published as JCO Early Release 10.1200/JCO.2008.19.4274 on April 27 2009


Journal of Clinical Oncology, Vol 27, No 23 (August 10), 2009: pp. 3786-3793
© 2009 American Society of Clinical Oncology.

From the Royal Marsden Hospital National Health Service Foundation Trust, Surrey and London; Southampton University Hospital National Health Service Trust, Southampton; Salisbury Hospital National Health Service Foundation Trust, Salisbury; Oncology–Anchor Unit, Aberdeen Royal Infirmary, Aberdeen; Northern Centre for Cancer Treatment, Newcastle-Upon-Tyne; St Luke's Cancer Centre, Guildford; and Plymouth Oncology Centre, Plymouth, United Kingdom. 

Corresponding author: David Cunningham, MD, FRCP, Department of Medicine, Royal Marsden Hospital, Downs Rd, Sutton, Surrey, SM2 5PT United Kingdom; e-mail: david.cunningham@rmh.nhs.uk.

Purpose Data concerning the prevalence of and outcomes related to thromboembolic events (TEs) in patients with advanced gastroesophageal cancer who are undergoing chemotherapy are limited. 

Patients and Methods This was a prospective, exploratory analysis of TEs in a randomized, controlled trial of 964 patients recruited between 2000 and 2005 and treated with epirubicin/platinum/fluoropyrimidine combination chemotherapy for advanced/locally advanced gastroesophageal cancer. Regimens were epirubicin (E), cisplatin (C), fluorouracil (F; ECF); E, C, capecitabine (X; ECX); E, F, oxaliplatin (O; EOF); and EOX. Continuously infused F was administered via a central venous access device (CVAD) with 1 mg of warfarin for thromboprophylaxis. The principal outcome was the incidence of TEs (venous and arterial) in the whole treated patient cohort, according to chemotherapy, associated with CVADs and TE-related prognoses. 

Results The incidences of any, of venous, and of arterial TEs among 964 treated patients were 12.1% (95% CI, 10.7 to 14.3), 10.1% (95% CI, 8.3 to 12.3), and 2.2% (95% CI, 1.4 to 3.4) respectively. There were fewer TEs in the O compared with the cisplatin groups (EOF/EOX v ECF/ECX: 7.6% v 15.1%; P = .0003). C was identified as a risk factor for TE in multivariate analysis (hazard ratio [HR], 0.51; 95% CI, 0.34 to 0.76; P = .001). There was no difference in the incidence of TEs for the F group compared with the capecitabine groups. The incidence of CVAD-related thrombosis was 7.0% (ECF/EOF arms). Overall survival was worse for patients who experienced TEs versus no TEs (median survival, 7.4 v 10.5 months; HR, 0.8; 95% CI, 0.64 to 0.99; P = .043). 

Conclusion This analysis has prospectively quantified the incidence/pattern of TEs among patients with advanced gastroesophageal cancer who were treated with four triplet regimens, has demonstrated a differential thrombogenic effect according to platinum use, and has noted a poorer outcome associated with TE during treatment. Chemotherapy-related TE should contribute to the risk/benefit assessment of treatment. 

Supported in part by Hoffmann-La Roche Inc and sanofi-aventis. 

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article. 

Clinical trial information can be found for the following: NCT51678883. 

The authors acknowledge NHS funding to the NIHR Biomedical Research Centre.