Khorana评分可估算癌症死亡风险

阿姆斯特丹——一项纳入超过1,500例患者的分析结果显示，一种常规用于评估癌症患者发生静脉血栓栓塞(VTE)风险的评分系统，还能用于估算这些患者的死亡风险。

奥地利维也纳医科大学的Cihan Ay博士在国际血栓症与止血学会(ISTH)大会上报告称，虽然这一发现还只是探索性的，但提示Khorana评分这种已得到确认的风险算式“不仅能用于制定VTE预防策略，或许还能支持抗癌治疗的临床决策过程”。

ASCO推荐的改良Khorana评分
 

2008年，Alok Khorana博士及其同事首次提出，用Khorana评分评估患者的VTE风险和对抗凝预防的需求(Blood 2008;111:4902-7)。此后，该评分接受了多次验证。今年早些时候，该评分的微改良版本(见表)被纳入到美国临床肿瘤学会(ASCO)VTE管理指南之中(J. Clin. Onc. 2013 [doi: 10.1200/JCO.2013.49.1118])。这部ASCO指南称，“专家组建议，采用微改良版Khorana评分，在对癌症患者启动化疗时进行VTE风险评估，并在之后定期进行该评估”。


Cihan Ay博士

“Khorana评分被用于识别需要接受血栓一级预防的患者。我的想法是，同时也将其用于评估癌症患者的总体预后。临床医生常常需要考虑患者的预后如何、需要治疗多久、应该采用多大的治疗强度等问题。假如患者预后不良，那么有些治疗可能就不值得尝试了。”

Ay博士及其同事对参加维也纳癌症与血栓研究的患有各类癌症的1,544例患者应用了微改良版Khorana评分。这些患者的平均年龄为62岁，大约45%为女性，平均随访约19个月。随访期间的全因死亡率为42%。最常见的肿瘤类型为肺癌(约250例)，其次为淋巴瘤、乳腺癌和脑癌(均超过200例)。研究者对Khorana进行了改良，将黑色素瘤加入癌症1分组，同时去掉了妇科肿瘤、膀胱癌和睾丸癌。

分析结果显示，患者的基线、治疗前Khorana评分与随访2年生存率之间存在强烈关联。466例(30%)评分为0的患者，死亡率为27%；489例(32%)评分为1的患者，死亡率为38%(与评分为0的患者相比，校正危险比为1.61)；405例(26%)评分为2的患者，死亡率为51%，校正危险比为2.8；184例(12%)评分≥3的患者，死亡率为63%，校正危险比为4。组间死亡率差异均具有统计学显著性。这种风险模型校正了年龄、性别和偶发性VTE等因素。

总体而言，在这一校正后模型中，改良Khorana评分每增加1分，死亡率即显著增加56%。

Ay博士声称无相关利益冲突。

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By: MITCHEL L. ZOLER, Internal Medicine News Digital Network

AMSTERDAM – A score routinely used to quantify cancer patients’ risk for developing venous thromboembolism also can be used to gauge their risk of death, according to an analysis of data from more than 1,500 patients.

The new findings are only exploratory, but they suggest that the well-established risk calculator known as the Khorana score "may support clinical decision making not only for VTE prophylaxis but also for anticancer treatment strategies," Dr. Cihan Ay said at the Congress of the International Society on Thrombosis and Haemostasis.

The link between higher Khorana scores and an increased rate of death over the following 2 years was independent of VTE occurrence, suggesting that the Khorana score identifies susceptibilities in addition to VTE than can cause death, said Dr. Ay, a hematologist-oncologist at the Medical University of Vienna.

Following the Khorana score’s introduction in 2008 by Dr. Alok Khorana and his associates (Blood 2008;111:4902-7) to assess a patient’s risk for VTE and need for anticoagulant prophylaxis, the score underwent several validations. Earlier this year, the score was adopted in a slightly modified form as part of the VTE management guidelines of the American Society of Clinical Oncology (J. Clin. Onc. 2013 [doi: 10.1200/JCO.2013.49.1118]).

The ASCO guidelines say that "the Panel recommends that patients with cancer be assessed for VTE risk at the time of chemotherapy initiation and periodically thereafter" using the slightly modified form of the Khorana score (see box). The 2013 formula from the ASCO Panel revised the original 2008 version of the Khorana score by adding primary brain tumors to the 2-point category and renal tumors to the 1-point category.

"The Khorana score is used to identify patients for primary thromboprophylaxis. My idea is to also use it to get information on general prognosis," Dr. Ay said in an interview. "There is often a discussion of the patient’s prognosis and how far to go with treatment, how intensive treatment should be. If patients have a poor prognosis, some treatments may not be worth trying."

Dr. Ay and his associates applied their own slight modification of the Khorana score to 1,544 patients with a variety of cancers enrolled in the Vienna Cancer and Thrombosis Study. The patients averaged 62 years old, about 45% were women, and they were followed for a mean of about 19 months, during which overall, all-cause mortality was 42%. The most common tumor type was lung cancer, in about 250 patients, followed by lymphoma, breast cancer, and brain tumors, which each affected more than 200 patients. The researchers modified the Khorana score by adding melanoma to the 1-point group of cancers and removing gynecologic, bladder, and testicular cancer from being assigned any points.

The analysis showed a strong link between patients’ Khorana scores at baseline, before treatment began, and their survival over the next 2 years of follow-up. The 466 patients (30%) with a score of 0 had a 27% mortality rate; the 489 patients (32%) with a score of 1 had a 38% mortality rate (adjusted hazard ratio, 61% compared with patients with a score of 0). The 405 patients (26%) with a score of 2 had a 51% mortality rate, a 2.8-fold increased mortality rate after adjustment, and the 184 patients (12%) with a score of 3 or more had a 63% mortality rate, a fourfold higher mortality rate after adjustment compared with patients with a score of 0. Between-group differences in mortality were all statistically significant. The hazard model adjusted for age, sex, and incident VTE.

Overall in the adjusted model, every 1-point increase in modified Khorana score linked with a statistically significant 56% increase in mortality, Dr. Ay said.

Dr. Ay said that he had no relevant disclosures.