The Khorana score for prediction of venous thromboembolism in cancer patients: a systematic review and meta-analysis

Frits I Mulder, Matteo Candeloro, Pieter W Kamphuisen, Marcello Di Nisio, Patrick M Bossuyt, Noori Guman, Kirsten Smit, Harry R Büller, Nick van Es, CAT-prediction collaborators, Frits I Mulder, Matteo Candeloro, Pieter W Kamphuisen, Marcello Di Nisio, Patrick M Bossuyt, Noori Guman, Kirsten Smit, Harry R Büller, Nick van Es, CAT-prediction collaborators

Abstract

We aimed to evaluate the performance of the Khorana score in predicting venous thromboembolic events in ambulatory cancer patients. Embase and MEDLINE were searched from January 2008 to June 2018 for studies which evaluated the Khorana score. Two authors independently screened studies for eligibility, extracted data, and assessed risk of bias. Additional data on the 6-month incidence of venous thromboembolism were sought by contacting corresponding authors. The incidence in each Khorana score risk group was estimated with random effects meta-analysis. A total of 45 articles and eight abstracts were included, comprising 55 cohorts enrolling 34,555 ambulatory cancer patients. For 27,849 patients (81%), 6-month follow-up data were obtained. Overall, 19% of patients had a Khorana score of 0 points, 64% a score of 1 or 2 points, and 17% a score of 3 or more points. The incidence of venous thromboembolism in the first six months was 5.0% (95%CI: 3.9-6.5) in patients with a low-risk Khorana score (0 points), 6.6% (95%CI: 5.6-7.7) in those with an intermediate-risk Khorana score (1 or 2 points), and 11.0% (95%CI: 8.8-13.8) in those with a high-risk Khorana score (3 points or higher). Of the patients with venous thromboembolism in the first six months, 23.4% (95%CI: 18.4-29.4) had been classified as high risk according to the Khorana score. In conclusion, the Khorana score can be used to select ambulatory cancer patients at high risk of venous thromboembolism for thromboprophylaxis; however, most events occur outside this high-risk group.

Copyright© 2019 Ferrata Storti Foundation.

Figures

Figure 1.
Figure 1.
PRISMA flow chart. ASH: American Society of Hematology; ISTH: International Society on Thrombosis and Haemostasis.
Figure 2.
Figure 2.
Venous thromboembolism incidence in the low-, intermediate-, and high-risk group over six months. Venous thromboembolism incidence in the low-risk (A), intermediate-risk (B), and high-risk (C) groups according to the Khorana score, over six months follow up.
Figure 3.
Figure 3.
Estimated incidence of venous thrombosis and proportion in the high-risk group over six months. Estimated incidence of venous thrombosis (A and C) and proportion of venous thromboembolic events allocated to the high-risk group (B and D). When considering two points or more as high-risk (C and D) instead of three points or more (traditional threshold, A and B), the proportion of venous thromboembolic events allocated to the high risk groups increases, but also results in a lower incidence. VTE: venous thromboembolism.

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