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Factors associated with thrombosis among solid organ cancer patients in Kuala Lumpur, Malaysia

Thrombosis Journal volume 23, Article number: 25 (2025) Cite this article

Abstract

Background

Patients with solid organ cancers are at increased risk of developing cancer-associated thrombosis (CAT), a complication driven by a complex interplay of patient-specific factors, cancer characteristics, and treatment modalities. Data on CAT and its associated risk factors within diverse ethnic groups, such as the Malaysian population, remains limited. This observational, cohort study aimed to address this gap by determining the incidence of CAT and identifying associated risk factors among multi-ethnic Malaysian patients with solid organ cancers.

Methods

This study included solid organ cancer patients aged ≥ 18 who attended HCTM and HKL from May 2022 to August 2023. The baseline demographics, and clinical characteristics, were acquired at the cancer diagnosis. Data on cancer treatment, thrombotic events and anticoagulation therapy during the study and its treatment were documented. Multivariable logistic regression analysis was performed to determine the independent factors associated with CAT in solid organ cancer.

Results

A total of 250 solid organ cancer patients were included, with a mean age of 57.7 (13.7) years. This multi-ethnic cohort consisted of mostly Malay patients (55.2%), followed by Chinese (33.2%) and Indian & others (11.6%). The prevalence of CAT at baseline was 4.8%, while the incidence of CAT during follow-up was 12%. Poor performance status and obesity were associated with CAT at baseline. Univariable logistic regression showed platelets ≥ 450 × 109/L and Khorana score ≥ 3 had significantly higher risks of CAT at baseline. Stage IV disease, radiotherapy and chemotherapy, namely platinum-based chemotherapy and antimetabolites were associated with CAT during follow-up. The ROC analysis showed that the KRS significantly predicted CAT (area under the curve, 0.701 (95%CI: 0.594–0.808, p = 0.001).

Conclusions

This study highlights the prevalence of CAT at baseline and the incidence of CAT during follow-up, similar to other studies. Patients’ clinical characteristics were associated with CAT at baseline while disease and treatment factors were associated with CAT at follow-up. These findings emphasise the need for targeted thromboprophylaxis in high-risk populations and highlight the importance of risk stratification tools such as the Khorana score for optimal patient management. Future studies involving larger patient cohorts and longer study duration would be beneficial. These findings provide valuable insights to inform clinical decision-making, optimise patient outcomes, and minimise potential risks.

Introduction

Thrombosis is a significant concern in patients with solid cancers, with various factors influencing its occurrence and management. Studies have shown that cancer patients, especially those with solid tumours, such as lung, gastrointestinal, ovarian, and pancreatic cancers, have an increased risk of developing venous thromboembolism (VTE) [1,2,3] The incidence of cancer-associated thrombosis (CAT) varies by cancer type and population group. A large cohort study in the UK found an incidence rate of 13.9 VTE cases per 1000 person-years in 83,203 cancer patients, while a Taiwanese study found an incidence of 1.85 cases per 1,000 person-years in a larger cohort of 497,180 patients [4, 5]. Cumulative incidence rates for VTE in cancer have been reported to range from 5 to 8% [6, 7]. Furthermore, this special population face a 1.5-2-fold increased risk of arterial thrombotic events compared to non-cancer individuals, with factors such as tumour burden and specific neoplasm characteristics influencing the risk [8]. Understanding the epidemiology, risk factors, and pathogenesis of CAT in solid organ cancers is vital for improving patient outcomes.

CAT results from a complex interplay of clinical factors, cancer cell-specific procoagulant properties, and host inflammatory responses, leading to a hypercoagulable state and increased thrombotic risk. The risk factors for thrombosis in cancer patients include tumour-related factors; such as type and stage, patient-related factors; such as age, obesity, and performance status, treatment-related factors; such as chemotherapy and surgery, and specific cancer biomarkers [9]. Certain malignancies such as pancreatic, kidney, ovarian, lung, and stomach cancers are associated with higher rates of VTE [9]. Chemotherapy, immunomodulatory agents, novel targeted therapies, surgery, and central venous access further increase the risk of thrombosis [10]. The pathogenesis of thrombosis in cancer involves direct coagulation activation, platelet activation, inflammatory responses, and inhibition of fibrinolysis [9] Notably, studies have indicated that COVID-19 patients with cancer did not exhibit a significantly higher incidence of VTE compared to non-cancer COVID-19 patients; however, they had significantly higher in-hospital mortality rates [11]. Additionally, cancer patients with COVID-19 have shown poorer in-hospital outcomes, including higher mortality rates, more extended hospital stays, and increased total hospital charges [12]. Understanding the interplay between these factors is crucial for developing effective prevention and treatment strategies for thrombosis in this cohort.

Despite advancements in understanding CAT in solid organ cancers, several knowledge gaps regarding optimal thromboprophylaxis strategies persist. Current guidelines differ in their recommendations for specific patient groups and settings. Although validated risk assessment models (RAMs) exist, their application in clinical practice is inconsistent in the real world. The Khorana score (KS), developed in 2008, is a widely utilised model but has limitations concerning certain cancer types [13]. A meta-analysis by Mulder et al. highlighted that while the KS aided in identifying high-risk ambulatory cancer patients for thromboprophylaxis, most thrombotic events occur outside this high-risk category [14]. Conversely, the Padua Prediction Score (PPS) can be utilized for hospitalised cancer patients but does not account for arterial thrombosis or specific cancer characteristics. The PROTECHT score (Predicting Risk of Thromboembolic and Cardiovascular Events in Patients with Cancer and Atrial Fibrillation) adds cisplatin/carboplatin or gemcitabine-based agents with a total score ranges from 0 to 8, and a score of ≥ 3 indicating a high risk of VTE [15]. On the other hand, the CONKO score developed in 2013, as a modification of the Khorana score, replaces the BMI parameter with the Eastern Cooperative Oncology Group (ECOG) performance status to enhance predictive accuracy [16].

Anticoagulation remains the cornerstone treatment for VTE; however, its use among cancer patients poses challenges due to an increased bleeding risk and potential drug-tumor interactions. Direct oral anticoagulants (DOACs) have come into focus due to their simplified administration and possible therapeutic advantages in CAT. A meta-analysis by Frere et al., which included six randomised controlled trials (RCTs), demonstrated the safety and efficacy of DOACs in this patient population [17]. Another comparative effectiveness study also supported that DOACs were associated with a higher persistence rate, lower risk of VTE recurrence, lower risk of major bleeding, and improved mortality [18] In the cancer-related VTE anticoagulation strategies (CANVAS) study, DOACs were as effective as LMWH in preventing VTE recurrence during a six-month follow-up period [19].

With rising global cancer rates, implementing effective thromboprophylaxis among high-risk individuals is essential while balancing the associated bleeding risks. Given the scarcity of data on CAT events in solid organ cancers, the risk factors and the burden of the disease in Malaysia, this study aimed to determine the CAT prevalence at baseline, incidence during follow-up and the risk factors among the multi-ethnic Malaysian solid organ cancer patients in two tertiary-level hospitals in Kuala Lumpur, Malaysia. The findings will enhance the existing knowledge base on CAT within this demographic. By elucidating the epidemiology and risk factors associated with CAT among our patient population, we hope to inform clinical decision-making and guide the development of evidence-based thromboprophylaxis protocols. Ultimately, this research aims to improve the overall quality of care for patients diagnosed with solid organ cancers.

Materials and methods

Study design and participants

This study was part of the CAT registry, an observational cohort study which was conducted at two tertiary-level hospitals, Hospital Canselor Tuanku Muhriz (HCTM) and Hospital Kuala Lumpur (HKL), from May 2022 to August 2023. This study was approved by the Research Ethics Committee of Universiti Kebangsaan Malaysia (FF-2022-099) and the Medical Research and Ethics Committee (MREC) of the Malaysian Ministry of Health (MOH) (NMRR ID-22-01438-MW4 (IIR)). Before participation, written informed consent was obtained from all subjects per international ethical guidelines, and all participant information was anonymised to maintain confidentiality.

We enrolled consecutive adult active solid cancer patients diagnosed between May 2022 and February 2023, and the follow-up period ended in August 2023. Patients aged 18 years and older with newly diagnosed and recurrent solid organ cancers with confirmed histopathological findings before commencement of any definitive cancer treatment (chemotherapy, radiotherapy or targeted treatment) were included in this study. Those with haematological malignancies were excluded from the study as they were enrolled in a separate investigator-initiated research.

Outcomes and operative definition

In this study, CAT is defined as clinically diagnosed venous or arterial thromboembolism, incidental or symptomatic, confirmed by imaging. Active cancer is characterised by a diagnosis made in the last six months, the presence of recurrent, regionally advanced or metastatic forms, or if the cancer has been treated within the previous six months [20]. Meanwhile, recurrent cancer is defined as patients for whom all planned cancer treatments had been completed and who had at least 6 months of stable disease before disease progression was detected within the past year [7]. In this study, the presence of deep vein thrombosis (DVT) or pulmonary embolism (PE), confirmed by objective tests, was considered VTE. DVT was objectively verified using standard imaging techniques, including duplex ultrasonography, computer tomography venography, or magnetic resonance venography [21]. Meanwhile, PE was documented by contrast-enhanced computed tomography or ventilation-perfusion scintigraphy [21]. Thrombosis at other sites, such as the abdomen, was diagnosed using contrast-enhanced computed tomography (CECT). All CT and CTPA image analyses were performed by consultant radiologists at the respective hospitals who were blinded to the clinical information. Disagreements were resolved through discussion with the principal investigator of this study until a consensus was reached to reduce the inter-rater reliability.

Data collection

Baseline demographic details, including age, sex, ethnicity, smoking history, and co-morbidities such as diabetes mellitus, hypertension, and cardiovascular disease, were collected at the time of cancer diagnosis prior to starting of any treatment. Patient information regarding height and weight was recorded to calculate the body mass index (BMI) according to the Asian classification [22]. The Eastern Cooperative Oncology Group (ECOG) performance status (PS), graded from 0 to 5, was documented.

Information on cancer characteristics were collected, including the site of cancer, histological type, disease status, and whether the cancer was newly diagnosed or recurrent. Cancer staging was based on the TNM Classification system. The study patients were managed with routine clinical care as per the physicians’ discretion, and no interventions were specified. Cancer treatment modalities included surgical intervention, chemotherapy, radiation, targeted therapy, hormonal therapy, or palliative care, with any additional treatments documented during the observation period. Chemotherapy was categorised as either single-agent or multi-agent therapy. The RAMs for CAT were calculated using the validated KS and PPS, specifically for non-surgical hospitalised patients, using the parameters at cancer diagnosis. The patients’ COVID-19 history within 90 days preceding any thrombotic event was also recorded.

Patient data were followed up and collected every 3 months at the clinic, ward or through phone calls in the case of defaulted outpatient appointments to document any CAT events or deaths. They were observed for at least six months for any symptomatic or incidental finding of CAT event and treatment received. They received anticoagulant treatment as per the local institution’s guidelines.

Statistical analysis

Based on an earlier study by Ahmat et al., the CAT incidence in Malaysia was 7.6% [19]. The sample size was calculated using the formula in OpenEpi (version 3), an open-source calculator SSProportion, with an additional 10% for missing data or dropout rate, considering a confidence interval (CI) of 95% and a p-value of 0.05, the total sample size for two centres was n = 240.

Demographic and clinicopathologic characteristics of all cancer patients were analysed using descriptive statistical methods. The normality of the data was assessed using the Kolmogorov-Smirnov test, and data are reported as mean [standard deviation (SD)] or proportions as appropriate. We used the two-sample t-test or Mann-Whitney U test to compare continuous variables and Chi-square or Fisher’s exact tests to compare categorical variables between those with and without CAT. The analysis was performed as a complete case analysis, therefore there was no imputation of missing values. Multiple logistic regression was performed to determine the risk factors for CAT [Odds ratio (OR) and 95% confidence interval (CI)]. We selected variables in the multiple regression analysis based on clinical relevance and results from the univariate analysis. A p-value less than 0.05 signifies statistical relevance. We created receiver operating characteristic (ROC) curves, computing their 95% confidence intervals (CIs) to gauge the predictive accuracy of both the Khorana and Padua scores. All statistical analyses were conducted using IBM SPSS Version 28 (IBM Corporation). Two investigators (SAMJ and NRT) performed data cleaning and validation.

Results

Study population characteristics

Between 1 May 2022 and 28 February 2023, 273 cancer patients were screened. After excluding patients with haematological malignancies and those diagnosed with previous VTE, 250 patients were enrolled in the study (Fig. 1).

Fig. 1
figure 1

Overall study flowchart

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Table 1 presents the demographic and clinical characteristics of our cohort of 250 solid organ cancer patients. The mean age of all patients was 57.7 (13.7) years. A significant majority (64.8%) were under the age of 65. The cohort was evenly split by sex. The majority of patients were Malay (55.2%), followed by Chinese (33.2%), Indian (9.6%), and a small percentage from other ethnic backgrounds (2.0%). Almost two-thirds of the patients were non-smokers (63.6%). According to the Eastern Cooperative Oncology Group (ECOG) performance status, 40.4% of patients had a status of 0 (fully active), 46.0% had a status of 1 (restricted in physically strenuous activity), 10.4% had a status of 2 (ambulatory and capable of all self-care), and 3.2% had a status of 3 (capable of only limited self-care). The mean BMI for the cohort was 24.7 (6.5) kg/m². According to the BMI for the Asian population, 10.0% of patients were underweight (BMI < 18.5 kg/m2, while a total of 54.4% were overweight and obese. The prevalence of comorbid conditions included diabetes mellitus (32.8%), hypertension (44.4%), and cardiovascular disease (6.4%). Baseline laboratory parameters at diagnosis showed mean haemoglobin (Hb) and platelet of 11.7 (1.9) g/dL and 329 (112) x109/L, respectively. Most patients (96.8%) had newly diagnosed disease. At diagnosis, 75.6% of patients had stage 3–4 disease.

Table 1 Demographic and cancer characteristics (a) of our study population and (b) comparison between patients with and without CAT at baseline
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Thrombotic events

A total of 27 patients had CAT throughout the study period, of which 12 had CAT at baseline and 15 had CAT during follow-up. Table 2 summarizes the sites of thrombosis. None of our patients received thromboprophylaxis. Rivaroxaban was the only DOAC used for CAT treatment in our study. Nine patients with CAT did not receive any anticoagulant due to high bleeding risk. Five patients were initially treated with LMWH and switched to DOAC before discharge. One patient required inferior vena cava (IVC) filter insertion as she had severe vaginal bleeding.

Table 2 Summary of CAT events in the study (baseline and during follow up)
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Figure 2 illustrates the distribution of thrombosis (n = 27) across various cancer types. Although colorectal cancer showed the highest number of patients in our study population, only 6.2% (5/80) had CAT. Head and neck, and gynaecological cancers also had notable CAT proportions, with 15.2% (5/33) and 21.1% (4/19) of patients, respectively. In contrast, there were no cases of thrombosis among the genitourinary, stomach, bone, liver and cancer groups.

Fig. 2
figure 2

Bar chart showing the number (n) and percentage (%) of patients with CAT (n = 27) according to cancer types

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CAT at baseline and its associated factors

Twelve (4.8%) of patients had CAT at baseline. Five patients had both DVT and PE, in which three involved upper extremities, one patient had arterial thrombosis, two had PE alone and four had thrombosis at unusual sites.

Table 1 compared the demographic and clinical characteristics between patients with and without CAT at baseline There was a significant association between age, performance status and BMI with CAT at baseline, p = 0.048, 0.041 and 0.030, respectively. However, no significant differences were observed between the groups in terms of sex, ethnicity, smoking status, or comorbidities, including diabetes mellitus, hypertension, and cardiovascular disease. There was also no significant association between the recent COVID-19 infection and CAT, p = 0.73.

Incidence of CAT during follow-up

The mean follow-up period was 9 (2.6) months. Fifteen CAT events were documented throughout the follow-up period. Four patients had PE alone, six had DVT alone, two had arterial thrombosis, and three had thrombosis at unusual sites. The 6-month incidence of CAT among the population at risk was 12% (95% CI: 10—14%). Only four cases were symptomatic. Seven patients experienced CAT within the first three months of diagnosis.

Table 3 Demographic and cancer characteristics (a) of our study population and (b) comparison between patients with and without CAT during follow-up
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There was a significant association between radiotherapy and chemotherapy administration with occurrence of CAT during follow-up, p = 0.015 and = 0.049 respectively (Table 3). Chemotherapy containing platinum or antimetabolites was significantly associated with CAT, p = 0.022 and = 0.003 respectively. Ten patients refused any cancer treatment and were referred to palliative care.

Risk factors of CAT at baseline among solid cancer patients

Univariable and multivariable analysis of factors correlated with the presence of CAT at baseline is shown in Table 4. We found that patients with platelet counts > 450 × 109/L and Khorana score ≥ 3 had a greater probability of presenting with CAT at baseline. However, both were not significant independent risk factors for thrombosis in multivariate analysis.

Table 4 Associated risk factors of CAT at baseline among solid organ cancer patients
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Receiver operator characteristics (ROC) analyses of predictive power for VTE risk

Our study utilised two risk assessment models: the Khorana and the Padua scores. Overall, the Khorana Score appears to have superior predictive performance for VTE with an area under the curve (AUC) of 0.701 (95% CI: 0.594–0.808, p = 0.001) in this dataset, compared to the Padua Score, an AUC of 0.586 (95% CI: 0.465–0.707, p = 0.465), as shown in Fig. 3.

Fig. 3
figure 3

Receiver Operating Characteristic (ROC) curve comparing the Khorana and Padua Scores’ predictive power for CAT

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Discussion

In this study, we investigated the prevalence of CAT at baseline, the incidence of CAT during follow-up and their risk factors in a cohort of solid organ cancer patients. Our results showed a prevalence of 4.8% of thrombosis, in keeping with literature that reports a range of 4–20% for CAT among cancer patients, particularly those with advanced disease [23]. These findings offer valuable insights into the burden of CAT within the urban population in Kuala Lumpur, Malaysia. A systematic review by Lee et al. on the epidemiology of CAT in Asia revealed that the rates of CAT are generally lower in Asian populations compared to Caucasians [23]. Two studies reported the incidence of CAT at 0.5% in India and 13% in Japan [23]. Our study showed the 6-month incidence of CAT was 12%. According to the GARFIELD-VTE registry involving 10,684 patients across 28 countries, approximately one in ten patients diagnosed with VTE had active cancer, with incidence rates varying by cancer site, stage, and type, ranging from 1.85 to 9.88 per 1000 person-years [24]. There is limited data on the incidence of the first CAT beyond the first six months of diagnosis. However, a systematic review found that the incidence of recurrent VTE between 6 and 12 months post-diagnosis ranges from 1 to 12%, with higher rates in patients with residual vein thrombosis [25] However, it is essential to note that CAT may be underdiagnosed, particularly in asymptomatic and outpatient settings. This potential selection bias could lead to underrepresenting the true incidence within our study population.

The distribution of CAT prevalence varied significantly across different cancer types, with particularly high associations observed in pancreatic cancer and germ cell tumours in our study. Although colorectal cancer represented the largest group in our cohort, it exhibited a relatively low CAT rate of 6.2%. Our findings were similar to Ikeda et al. who reported a 6.4% of VTE at enrolment among 2477 colorectal cancer patients [26]. These findings suggest the necessity for increased awareness and proactive screening for CAT among high-risk cancer patients, not necessarily the commonest one. The high proportion of upper limb thrombosis (18.5%) and abdominal vein thrombosis (18.5%) observed in our cohort is in concordance with reports of thrombosis involving unusual sites in cancer patients, likely contributed by vascular endothelial injury [27].

The CAT events in our study were mainly comprised of VTE, three arterial thrombosis events are worth highlighting. Based on the Surveillance, Epidemiology, and End Results (SEER) database, the incidence of arterial thromboembolic events in cancer patients was 4.7% [28]. Certain drugs, such as platinum-based agents, taxanes and targeted therapies, such as vascular endothelial growth factor inhibitors and tyrosine kinase inhibitors, have been associated with high rates of ATEs [28]. Cancer patients are prone to have increased platelet reactivity, which predisposes them to ATEs [28].

We found that patients with platelet counts > 450 × 109/L and Khorana score ≥ 3 had a greater probability of presenting with CAT at baseline. However, the factors were not significant in multivariate analysis. High platelet counts were found to be a risk factor in the Cancer and Thrombosis Study (CATS) [29]. The underlying mechanism that leads to the high PC in a subgroup of cancer patients is yet unclear. Results of studies to illustrate platelet counts association with thrombopoietin were inconsistent.

A recent study in Malaysia found that the prevalence of overweight among Malaysian adults was 50.1%, which is quite alarming [30]. After adjusting our BMI data according to the classification for Asian patients, we found no signification association between obesity and CAT in our cohort. The delicate balance between the pro-inflammatory cytokines release and the anti-inflammatory reaction is disrupted in obesity, predisposing to vascular endothelial dysfunction [31]. Obesity itself is a risk factor for VTE in the general population; thus, having cancer augments the risk of thrombosis. A case-control study involving 732 patients showed obesity was associated with a 6.2-fold increased risk for VTE [32] The impact of obesity on CAT may be mediated by other factors such as site and type of cancer or coexisting inflammation. However, a 10-year retrospective cross-sectional study on CAT among solid tumours in China had conflicting results; 67.7% of the VTE patients were of normal BMI, possibly due to the differences in lifestyle and physique [33].

Previous studies have shown that higher cancer stage has been associated with increased VTE risk [34,35,36]. Metastatic cancer significantly contributes to the risk of VTE through various mechanisms and patient-specific factors. The interplay between cancer biology and coagulation processes creates a hypercoagulable state, leading to increased thrombotic events. We noted that cancer stage 4 was significantly associated with CAT events during follow-up in our study. This is most likely due to the aggressive nature of the respective cancer and possibly higher levels of procoagulant activity of circulating tumour cells favouring metastasis in stage 4 cancers [37]. Tumour-associated microvesicles and tissue factor expression activate coagulation pathways, further increasing thrombotic risk [9, 38].

Poorer performance status (ECOG > 2) was associated with a higher possibility of having CAT at baseline. Though this factor was not statistically significant in the regression analysis, the trend suggests that patients with reduced physical activity and poorer functional status may be at higher risk for thrombosis due to immobility and cancer progression. We found that recent COVID-19 infection was not associated with risk of CAT. Nevertheless, this remains a clinical concern given the heightened pro-thrombotic state induced by COVID-19, especially in patients with cancer. Literature on the impact of recent COVID-19 on the incidence of VTE among cancer patients exhibits conflicting results. COVID-19 infection in cancer patients was found to be associated with increased odds of PE but not a statistically significant increase in overall VTE risk [39]. However, VTE incidence was similar to previously reported in the general population with COVID-19 infection in another retrospective cohort study [40].

The Khorana score was developed in 2008 to assess the risk of VTE in ambulatory cancer patients, and its predictive value has been validated in several studies. Univariable regression analysis demonstrated that KRS was significantly associated with CAT at baseline in our study. This was similar to a study in Japan [41]. Our ROC analysis showed that the KRS significantly predicted CAT (area under the curve, 0.701 (95% CI: 0.594–0.808, p = 0.001). We would like to highlight that the BMI cutoff value on the Khorana score is ≥ 35 kg/m2, while for the Asian population, obesity is defined as a BMI ≧ of 25 kg/m2. Thus, a study in Korea showed that a modified Khorana score is better at predicting VTE, where the BMI value was adjusted to suit the Asian population [42]. Given the platinum and gemcitabine parameters in the PROTECHT score and the substitution of BMI with performance status in the CONKO score, an algorithm combining these RAMs performed at different timelines i.e. at baseline and follow-up will be useful in determining patients at high risk of CAT throughout the course of the disease.

Cancer therapy is also one of the main factors in the development of CAT. Our study showed significant associations between platinum-based agents and antimetabolites with CAT at follow-up. Univariable analyses confirmed a relative increase in the risk of VTE with platinum-based therapy as reported previously [43]. Platinum-based agents have been shown to induce endothelial cell dysfunction, including proinflammatory changes and an increased expression of cell adhesion molecules [44],

We observed that none of the 27 patients with CAT received thromboprophylaxis, although most of these patients had moderate to high-risk KRS. In Malaysia, DOACs are used on a limited basis, especially for primary thromboprophylaxis, due to scarce resources and a lack of awareness among physicians. Therefore, increasing awareness of utilising the risk assessment models for both VTE and bleeding is as important as educating on the international recommendations on thromboprophylaxis among cancer patients. However, we also need to balance the overall quality of life (QOL), as a recent study in Malaysia showed that the overall health-related QOL of CAT patients was lower than in the general population [45].

To our knowledge, this is among the few published studies on CAT conducted in Malaysia. The information we have gathered would be helpful for oncologists as it depicts the actual situation and burden of CAT. However, our data can only be applied to patients similar to our study cohort concerning tumour sites, stage, patients’ age and ethnicity, thus cannot be generalised. Malaysia is a multiracial country with Malay, Chinese, Indians and other minorities; therefore, clinicians need their local study to make more accurate CAT management decisions. We acknowledge that our study has limitations given the observational study design, which limits the amount of data that can be obtained, such as VTE recurrence and survival. The constraints of collecting data at two tertiary referral centres where the biology of the cancers was more complicated. There was also patient selection bias in this study, which may affect the validity and generalisability of the study results. The multivariable analysis in our study may be underpowered because of the smaller number of events and the number of variables assessed. Asymptomatic patients were not actively screened for CAT using diagnostic imaging, which may underestimate the disease burden. Future studies should focus on larger, prospective cohorts to confirm these findings and explore the utility of thromboprophylaxis in different cancer settings. Thus, it is essential to highlight that the result of this study should be interpreted cautiously.

Conclusion

The prevalence of CAT at baseline was 4.8%, while the incidence of CAT during follow-up was 12%, similar to other studies. Poor performance status and obesity were associated with CAT at baseline. Univariable logistic regression showed platelets ≥ 450 × 109/L and Khorana score ≥ 3 had significantly higher risks of CAT at baseline. Stage IV disease, radiotherapy and chemotherapy, namely platinum-based chemotherapy and antimetabolites were associated with CAT during follow-up. These findings emphasise the need for targeted thromboprophylaxis in high-risk populations and highlight the importance of risk stratification tools such as the Khorana score for optimal patient management. Future studies involving larger patient cohorts and longer study duration would be beneficial.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors would like to thank the Dean of the Faculty of Medicine, Universiti Kebangsaan Malaysia and the Director of Hospital Canselor Tuanku Muhriz for their support throughout this study. We also would like to thank all staff members in the Clinical Haematology Unit, Department of Medicine, Faculty of Medicine UKM, Hospital Canselor Tuanku Muhriz (HCTM), Oncology Department, Hospital Kuala Lumpur and Department of Radiotherapy and Oncology, Faculty of Medicine, Universiti Kebangsaan Malaysia. Part of this study was presented in the poster presentation at the International Society on Thrombosis and Haemostasis Congress 2024, Bangkok, Thailand.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Clinical Haematology Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia

    Lailatulema Abbas, Sivakumar Palaniappan, Guang Yong Chong & Nor Rafeah Tumian

  2. Hospital Canselor Tuanku Muhriz (HCTM), Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia

    Lailatulema Abbas, Sivakumar Palaniappan, Guang Yong Chong, Sharifa Ezat Wan Puteh & Nor Rafeah Tumian

  3. Oncology Department, Hospital Kuala Lumpur, Jalan Pahang, Kuala Lumpur, 50586, Malaysia

    Ibtisam Muhamad Nor

  4. Department of Radiotherapy and Oncology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia

    Fuad Ismail

  5. Department of Public Health Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur, 56000, Malaysia

    Sharifa Ezat Wan Puteh

  6. School of Mathematical Sciences, College of Computing, Informatics and Mathematics, Universiti Teknologi MARA, Shah Alam, Selangor, 40450, Malaysia

    Siti Afiqah Muhamad Jamil

Authors
  1. Lailatulema Abbas
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  2. Ibtisam Muhamad Nor
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  4. Sivakumar Palaniappan
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  5. Guang Yong Chong
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  6. Sharifa Ezat Wan Puteh
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  8. Nor Rafeah Tumian
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Contributions

Conceptualization: NRT. Data curation: LA, IMN, FI, SP, CGY. Formal analysis: LA, SEWP, SAMJ. Methodology: LA, NRT. Project administration: LA, IMN, FI, SP, CGY. Supervision: NRT, SP. Writing- original draft: LA. Writing, reviewing and editing manuscripts: NRT, SEWP, SAMJ. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Nor Rafeah Tumian.

Ethics declarations

Ethics approval and consent to participate

This study was approved by the Research Ethics Committee of Universiti Kebangsaan Malaysia (FF-2022-099) and the Medical Research and Ethics Committee (MREC) of the Malaysian Ministry of Health (MOH) (NMRR ID-22-01438-MW4 (IIR)), and it is in accordance with the Helsinki Declaration (IV adaptation). Written informed consent was obtained from all participants. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Competing interests

The authors declare no competing interests.

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Abbas, L., Muhamad Nor, I., Ismail, F. et al. Factors associated with thrombosis among solid organ cancer patients in Kuala Lumpur, Malaysia. Thrombosis J 23, 25 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12959-025-00710-2

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Keywords

Thrombosis Journal

ISSN: 1477-9560

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