- Email: [email protected]
RE: Spurdle and Webb
154
Letters to the Editor
RE: Spurdle and Webb
Re: Venous thromboembolism prophylaxis: Is two better than one?
Spurdle and colleagues responded [1] to our publication describing an excess of early onset multiple myeloma in endometrial cancer patients and their relatives [2], reporting data from the Australian National Endometrial Cancer Study that does not provide evidence for an increased incidence of myeloma. These are important data, and the differences in our study and theirs might be explained in a number of ways. It is unclear to us whether 0 cases of myeloma among 807 uterine cancer cases is really different than the 2 in 368 we reported. Furthermore, it is unclear how the authors came up with the estimate of 1.0 cases of myeloma expected among 807 endometrial cancer patients. Regardless, we would like to suggest possible explanations for the differences in findings for our two studies. First, our cohort included African Americans who have a higher risk for myeloma than Caucasians. One myeloma case in our series was an African American. We do not know if the Australian population included individuals of African decent. Second, there may be unappreciated biases in the ascertainment of patients in our series. One possibility is that because we are a tertiary care center, women with a prior malignancy would seek care for their second cancer at a center such as ours. The two women in our series with both myeloma and uterine cancer could reflect this sort of referral bias. Third, the incidences in our study and/or the Australian study may not be reliable given the modest sample sizes and the true incidence is actually between the two values reported. Since the time of submission of our original report, we have ascertained N 100 new uterine cancer probands. No additional cases of myeloma have been reported, neither among the original cohort, nor among the recently accrued patients. It is noteworthy that a cousin of one of the new probands was reported to have myeloma. Larger series and a solid epidemiologic study design like the one used by Spurdle and colleagues will be required to resolve the question of whether there is shared risk for myeloma and uterine cancers. References [1] Spurdle A, Webb P, on behalf of the Australian National Endometrial Cancer Study. Re: Excess of early onset multiple myeloma in endometrial cancer probands and their relatives suggets common susceptibility. Gynecol Oncol 2008;109:153 (in this issue). [2] Zighelboim I, Babb S, Gao, Powell M, Mutch DG, Goodfellow PJ. Excess of early onset multiple myeloma in endometrial cancer probands and their relatives suggests common susceptibility. Gynecol Oncol 2007;105: 390–4.
Israel Zighelboim Paul J. Goodfellow* Division of Gynecologic Oncology, Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO, USA *Corresponding author. E-mail address: [email protected]. 11 December 2007 doi:10.1016/j.ygyno.2007.12.008
To the Editor: In their editorial “Venous thromboembolism prophylaxis: Is two better than one?” [1], Drs. Einstein and Hartenbach discuss the responses of surveyed SGO members regarding the incidence of pulmonary embolism (PE) in their practices [2]. The authors note that the majority of respondents think that this complication occurs in no more than 2% of their major gynecologic cancer operations, and lament these respondents' “gross underestimation” of the risk. To support this contention they reference Martino et al [3] who reported a 4.1% risk of PE in those given external pneumatic compression (EPC) for prophylaxis during 507 major gynecologic cancer surgeries. Interestingly, they do not present the data from Clarke-Pearson et al. [4,5] and Maxwell et al. [6] on pulmonary embolism with EPC alone, though these studies are referenced elsewhere in the editorial. Clarke-Pearson reported on 945 cancer patients treated perioperatively with EPC alone for whom the combined percentage of PE and deep venous thrombosis (DVT) was 2.1% [4]. In this study there were 15 pulmonary emboli and 9 DVT. Also reported by the Duke University group were two other randomized trials, in which an additional 207 patients undergoing major surgery for gynecologic malignancy using EPC alone for DVT prophylaxis had no pulmonary emboli diagnosed [5,6]. Combining the 3 Duke studies, with more than twice as many major gynecologic cancer surgeries as the Martino study, one can derive an approximate PE risk of 1.1% with EPC alone⁎. Perhaps the SGO membership is not so ignorant after all. Additionally, if one examines the Martino study [3] in some detail, one sees that the ovarian cancer patients, who comprised 47% of the major cancer operations in this study, had a 6.8% PE rate with EPC alone, versus the uterine cancer patients (33% of patients) who had a 1.2% rate. In many gynecologic oncology practices endometrial cancer is more commonly seen than ovarian cancer, so again the SGO members may not be so far off the mark. The subject of DVT/PE prophylaxis and particularly which patients should receive combined prophylaxis (EPC and an anticoagulant) is clearly an important one in gynecologic oncology. Distortions of the data that do exist, however, do us all a disservice as we grapple with these decisions in the absence, so far, of a randomized trial that tells us which gynecologic oncology patients benefit from combined prophylaxis and which do not. There is useful evidence in our literature to assist in risk stratification. Based on their data, Clarke-Pearson et al recommended consideration of combined prophylaxis in cancer patients over 60 years of age, or with a prior DVT/PE [4]. The Martino study suggests that ovarian cancer patients may be a subgroup that benefits from combined prophylaxis [3]. But treating lower risk patients with combined prophylaxis has potentially important disadvantages which should be considered and discussed. Multiple studies, including a review of more than 70 randomized trials in general, orthopedic, and urologic surgery [7], have concluded that bleeding is increased with
Letters to the Editor
RE: Spurdle and Webb
Re: Venous thromboembolism prophylaxis: Is two better than one?
Spurdle and colleagues responded [1] to our publication describing an excess of early onset multiple myeloma in endometrial cancer patients and their relatives [2], reporting data from the Australian National Endometrial Cancer Study that does not provide evidence for an increased incidence of myeloma. These are important data, and the differences in our study and theirs might be explained in a number of ways. It is unclear to us whether 0 cases of myeloma among 807 uterine cancer cases is really different than the 2 in 368 we reported. Furthermore, it is unclear how the authors came up with the estimate of 1.0 cases of myeloma expected among 807 endometrial cancer patients. Regardless, we would like to suggest possible explanations for the differences in findings for our two studies. First, our cohort included African Americans who have a higher risk for myeloma than Caucasians. One myeloma case in our series was an African American. We do not know if the Australian population included individuals of African decent. Second, there may be unappreciated biases in the ascertainment of patients in our series. One possibility is that because we are a tertiary care center, women with a prior malignancy would seek care for their second cancer at a center such as ours. The two women in our series with both myeloma and uterine cancer could reflect this sort of referral bias. Third, the incidences in our study and/or the Australian study may not be reliable given the modest sample sizes and the true incidence is actually between the two values reported. Since the time of submission of our original report, we have ascertained N 100 new uterine cancer probands. No additional cases of myeloma have been reported, neither among the original cohort, nor among the recently accrued patients. It is noteworthy that a cousin of one of the new probands was reported to have myeloma. Larger series and a solid epidemiologic study design like the one used by Spurdle and colleagues will be required to resolve the question of whether there is shared risk for myeloma and uterine cancers. References [1] Spurdle A, Webb P, on behalf of the Australian National Endometrial Cancer Study. Re: Excess of early onset multiple myeloma in endometrial cancer probands and their relatives suggets common susceptibility. Gynecol Oncol 2008;109:153 (in this issue). [2] Zighelboim I, Babb S, Gao, Powell M, Mutch DG, Goodfellow PJ. Excess of early onset multiple myeloma in endometrial cancer probands and their relatives suggests common susceptibility. Gynecol Oncol 2007;105: 390–4.
Israel Zighelboim Paul J. Goodfellow* Division of Gynecologic Oncology, Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO, USA *Corresponding author. E-mail address: [email protected]. 11 December 2007 doi:10.1016/j.ygyno.2007.12.008
To the Editor: In their editorial “Venous thromboembolism prophylaxis: Is two better than one?” [1], Drs. Einstein and Hartenbach discuss the responses of surveyed SGO members regarding the incidence of pulmonary embolism (PE) in their practices [2]. The authors note that the majority of respondents think that this complication occurs in no more than 2% of their major gynecologic cancer operations, and lament these respondents' “gross underestimation” of the risk. To support this contention they reference Martino et al [3] who reported a 4.1% risk of PE in those given external pneumatic compression (EPC) for prophylaxis during 507 major gynecologic cancer surgeries. Interestingly, they do not present the data from Clarke-Pearson et al. [4,5] and Maxwell et al. [6] on pulmonary embolism with EPC alone, though these studies are referenced elsewhere in the editorial. Clarke-Pearson reported on 945 cancer patients treated perioperatively with EPC alone for whom the combined percentage of PE and deep venous thrombosis (DVT) was 2.1% [4]. In this study there were 15 pulmonary emboli and 9 DVT. Also reported by the Duke University group were two other randomized trials, in which an additional 207 patients undergoing major surgery for gynecologic malignancy using EPC alone for DVT prophylaxis had no pulmonary emboli diagnosed [5,6]. Combining the 3 Duke studies, with more than twice as many major gynecologic cancer surgeries as the Martino study, one can derive an approximate PE risk of 1.1% with EPC alone⁎. Perhaps the SGO membership is not so ignorant after all. Additionally, if one examines the Martino study [3] in some detail, one sees that the ovarian cancer patients, who comprised 47% of the major cancer operations in this study, had a 6.8% PE rate with EPC alone, versus the uterine cancer patients (33% of patients) who had a 1.2% rate. In many gynecologic oncology practices endometrial cancer is more commonly seen than ovarian cancer, so again the SGO members may not be so far off the mark. The subject of DVT/PE prophylaxis and particularly which patients should receive combined prophylaxis (EPC and an anticoagulant) is clearly an important one in gynecologic oncology. Distortions of the data that do exist, however, do us all a disservice as we grapple with these decisions in the absence, so far, of a randomized trial that tells us which gynecologic oncology patients benefit from combined prophylaxis and which do not. There is useful evidence in our literature to assist in risk stratification. Based on their data, Clarke-Pearson et al recommended consideration of combined prophylaxis in cancer patients over 60 years of age, or with a prior DVT/PE [4]. The Martino study suggests that ovarian cancer patients may be a subgroup that benefits from combined prophylaxis [3]. But treating lower risk patients with combined prophylaxis has potentially important disadvantages which should be considered and discussed. Multiple studies, including a review of more than 70 randomized trials in general, orthopedic, and urologic surgery [7], have concluded that bleeding is increased with