Venous Thromboembolism (VTE) Prevention with Semuloparin in Cancer Patients Initiating Chemotherapy: Benefit-Risk Assessment by VTE Risk in SAVE-ONCO

Cancer patients receiving chemotherapy are at increased risk for VTE. Recent oncology guidelines emphasize the need for randomized studies with VTE risk assessment in these patients (Streiff MB, et al. JNCCN. 2011;9:714–777). Semuloparin is a new ultra-low-molecular-weight heparin with high anti-factor Xa and minimal anti-factor IIa activities. The SAVE-ONCO study investigated semuloparin vs placebo for VTE prevention in cancer patients receiving chemotherapy.

Patients with metastatic or locally advanced cancer of lung, pancreas, stomach, colon-rectum, bladder or ovary initiating a chemotherapy course, were randomized to once-daily subcutaneous semuloparin 20 mg or placebo until change of chemotherapy. The primary efficacy outcome was a composite of symptomatic deep-vein thrombosis, any non-fatal pulmonary embolism, or VTE-related death. The main safety outcome was clinically relevant bleeding (major and non major). Baseline VTE risk was assessed by a score specifically developed and validated in chemotherapy-treated cancer patients (Khorana AA, et al. Blood. 2008;111:4902–7). According to this predictive model a score of 2 was assigned to very high-risk cancer sites (pancreatic or gastric), a score of 1 was assigned to high-risk cancer sites (lung, ovarian, or bladder cancer) and 1 is added to the score for each of the following parameters: platelet count ≥350 × 10⁹/L, hemoglobin <10 g/dL and/or use of erythropoietin-stimulating agents, leukocyte count >11 × 10⁹/L, and body mass index ≥35 kg/m².

Among the 3212 patients randomized, the majority had lung (36.6%) or colorectal (28.9%) cancer and approximately two-thirds had metastatic cancer. In total, 550 (17.4%) of patients enrolled were at high risk of VTE, 1998 (63.2%) were at moderate risk, and 614 (19.4%) were at low risk (VTE risk score of ≥ 3, 1–2, or 0 points, respectively). All risk groups were well balanced between the treatment groups. Median treatment duration was approximately 3.5 months. Overall, semuloparin significantly reduced VTE or VTE-related death by 64% (p<0.0001; Table) vs placebo. The treatment effect was consistent across various levels of VTE risk (interaction p-value=0.6048; Table). Clinically relevant bleeding occurred in 2.8% and 2.0% of the patients in the semuloparin and placebo groups, respectively (Table). The incidence of major bleeding was similar: 1.2% and 1.1% patients in the semuloparin and placebo groups, respectively (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.55–1.99). No increased incidence of clinically relevant bleeding was observed with semuloparin vs placebo across various levels of VTE risk (interaction p-value=0.9409; Table).

In cancer patients receiving chemotherapy, thromboprophylaxis with semuloparin was consistently associated with a favorable benefit-risk profile across various levels of VTE risk, but greatest in moderate to high risk patients. Antithrombotic prophylaxis should be considered in patients with cancer receiving chemotherapy, particularly in those who are at moderate to high risk of VTE.

George:Viamet: Consultancy, Research Funding; Sanofi: Consultancy, Speakers Bureau; Pfizer: Consultancy, Research Funding, Speakers Bureau; Novartis: Consultancy, Research Funding, Speakers Bureau; Medivation: Consultancy; Janssen: Consultancy, Research Funding, Speakers Bureau; Ipsen: Consultancy, Research Funding; Genentech/Roche: Consultancy, Speakers Bureau; Dendreon: Consultancy, Research Funding, Speakers Bureau; Bayer: Consultancy; Astellas: Consultancy; GSK: Research Funding, Speakers Bureau; BMS: Research Funding; Exelixis: Research Funding. Agnelli:GlaxoSmithKline: Honoraria; Boehringer Ingelheim: Consultancy, Honoraria; Bayer: Consultancy, Honoraria; sanofi-aventis: Honoraria. Fisher:Boehringer Ingelheim: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Bayer: Honoraria, Research Funding; sanofi-aventis: Honoraria, Research Funding. Kakkar:Bayer HealthCare: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; sanofi-aventis: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Boehringer-Ingelheim: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Bristol-Meyers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Eisai: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; ARYx Therapeutics: Consultancy; Canyon: Consultancy; GlaxoSmithKline: Honoraria. Lassen:Astellas Pharma Europe: Consultancy; Bayer HealthCare AG: Consultancy; Bristol-Myers Squibb: Consultancy; Boehringer Ingelheim: Consultancy; GlaxoSmithKline: Consultancy; Merck Serono: Consultancy; Pfizer: Consultancy; Protola Pharma: Consultancy; sanofi-aventis: Consultancy. Mismetti:sanofi-aventis: served as a member of Steering Committees. Mouret:Bayer HealthCare: Consultancy, Honoraria; sanofi-aventis: Consultancy, Honoraria; Bristol-Myers Squibb: Consultancy, Honoraria. Lawson:Sanofi: Employment. Turpie:Astellas Pharma Europe: Consultancy; Bayer HealthCare AG: Consultancy; Portola Pharma: Consultancy; sanofi-aventis: Consultancy.