LUGANO-MADRID – Some stroke survivors may have underlying cancer, according to an observational study to be presented at the ESMO 2017 Congress in Madrid. (1)
“Post-mortem studies have suggested that cancer can develop after a stroke, but the magnitude of this association has not been described,” said lead author Dr Jacobo Rogado, medical oncology fellow, Hospital de La Princesa, Madrid, Spain. “We conducted a study that would allow us to establish whether this association actually exists and which factors may predict risk.”
The researchers reviewed the medical records of all 914 patients admitted from the emergency room to the stroke unit of Hospital de La Princesa between January 2012 and December 2014. A total of 381 patients met the inclusion criteria and were followed for 18 months from the diagnosis of stroke. Demographic and clinical data were collected and compared between those who did, and did not, develop cancer. Variables that were significantly associated with cancer in univariate analysis were then subjected to multivariate analysis.
During the 18-month follow-up, 29 (7.6%) of stroke survivors were diagnosed with cancer, most frequently in the colon, lung and prostate. This was higher than the expected incidence of 17 patients (4.5%), based on statistics for the general population.
The average time from stroke onset to cancer diagnosis was six months. Nearly 45% of cancer diagnoses occurred within the first six months after a stroke diagnosis. Almost two-thirds (62%) of cancer patients presented with metastatic or locally advanced disease.
Multivariate analysis revealed that older age (>76 years), previous diagnosis of cancer, high levels of fibrinogen (>450 mg/dl) and low levels of haemoglobin (<13 g/dl), were associated with cancer.
Rogado said: “We found that the incidence of cancer in stroke survivors was almost twice that of the general population. When cancer was diagnosed it was usually at an advanced stage, and the diagnosis was made within six months after a stroke. This indicates that the cancer was already present when the stroke occurred but there were no symptoms.”
“It has been suggested that cancer is a hypercoagulable state in which tumour cells activate the coagulation system,” he added. “This could explain our observation of higher fibrinogen in those who were diagnosed with cancer. It may be that the prothrombotic effect of cancer contributed to the strokes.”
Rogado said: “Stroke survivors should be followed clinically for the development of cancer in the 18 months after the diagnosis of stroke. This applies particularly to older patients who had cancer previously, or who have high fibrinogen or low levels of haemoglobin.”
Commenting on the research for ESMO, Dr Fausto Roila, director of medical oncology, Santa Maria della Misericordia Hospital, Perugia, Italy: "The link between stroke and cancer is an interesting issue that has been previously studied. (2-6) The design of this study has an important limitation, which is the lack of a matched control group; a case-control study would have been more suitable. Moreover, comparing the detected number of incident cases (29) with those observed in a general population (17), the difference is only 12 patients and this could be due to differences in age between the two groups. The general population includes people of all ages, while the case population (patients with stroke) is primarily older patients. Therefore, further studies are needed before a firm association can be established between stroke and cancer.”
Notes to Editors
Please make sure to use the official name of the meeting in your reports: ESMO 2017 Congress
- Abstract 1412P_PR ‘Ischemic stroke as cancer predecessor and associated predictors’ will be presented by Dr Jacobo Rogado during Poster Display Session on Sunday, 10 September, 13:15 to 14:15 (CEST), in Hall 8.
- Selvik HA, et al. Cancer-associated stroke: The Bergen NORSTROKE Study.Cerebrovasc Dis Extra. 2015;5(3):107–113. doi: 10.1159/000440730.
- Cocho D, et al. Predictors of occult cancer in acute ischemic stroke patients.J Stroke Cerebrovasc Dis. 2015;24(6):1324–1328. doi: 10.1016/j.jstrokecerebrovasdis.2015.02.006.
- Dearborn JL, et al. Stroke and cancer- A complicated relationship.J Neurol Transl Neurosci. 2014;2(1):1039.
- Prandoni P, et al. Cancer and venous thromboembolism. Lancet Oncol. 2005;6(6):401–410.
- Schwarzbach CJ, et al. Stroke and cancer: the importance of cancer-associated hypercoagulation as a possible stroke etiology. Stroke. 2012;43(11):3029–3034. doi: 10.1161/STROKEAHA.112.658625.
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Ischemic stroke as cancer predecessor and associated predictors
J. Rogado1, V. Pacheco1, R. Mondejar1, S. Quintas2, P. Gullón3, J. Dotor2, M.D. Fenor de la Maza1, B. Obispo1, G. Reig-Roselló2, T. Pascual1, A.I. Ballesteros Garcia1, O. Donnay1, J.M. Sánchez-Torres1, R. López Ruiz2, J. Vivancos2, R. Colomer Bosch1
1Medical Oncology, Hospital Universitario de La Princesa, Madrid/SPAIN, 2Neurology, Hospital Universitario de La Princesa, Madrid/SPAIN, 3Escuela Nacional De Sanidad, Instituto de salud Carlos III, Madrid/SPAIN
Background: Ischemic Stroke (IS) has been related to cancer in postmortem studies of oncologic patients and as being the first expression of an occult neoplasm, probably because of hypercoagulability attributed to cancer. The aim of the study was to detect an association between cancer and IS, and possible predictors of cancer among these patients.
Methods: Nine hundred seventeen patients with IS were retrospectively collected from January 2012 to December 2014 in our hospital with a following time of 18 months. Patients with active or previous cancer within 5 years, TIA or cerebral hemorrhage, inability to follow-up or absence of complementary study of IS were excluded. Detection of cancer divided the patients in two cohorts. Demographical, clinical, analytical and prognostic characteristics were collected and subsequently compared between patients with development of tumor (Cancer Patients -CP-) and those free of malignancy (No Cancer Patients -NCP-).
Results: Cancer were detected in 29 out of 381 IS patients who finally met criteria (7.61%), instead of the 17 patients expected, according to cancer incidence in general population. The mean time from IS onset to cancer diagnosis was 6 months, with 44.83% of the diagnoses within the first 6 months after IS. The most frequent locations were colon (24%), lung and prostate (14%). 62% of CP presented metastatic or locally advanced desease. Older age (p=0.003), previous cancer >5 years (p=0.042), higher fibrinogen (p=0.019) and lower hemoglobin (Hb) values (p=0.004) were predictors of occult neoplasm. No differences were found in other analytical parameters, thromboembolic risk factors, nor with the etiology and clinical manifestations of the stroke.
Conclusions: In our study IS is associated with cancer, based on the fact that the incidence is almost twice that of general population. The diagnosis of cancer was mainly in advanced stages and within 6 months from IS. It suggests the presence of cancer at the diagnosis of IS due to prothrombotic effect of cancer, without being atributted, therefore, to a greater medical control than general population. Older age, previous cancer, fibrinogen and Hb values were related to the diagnosis of cancer after IS, being potential predictors in this group of patients.
Keywords: Ischemic stroke, prothrombotic effect
Disclosure: All authors have declared no conflicts of interest.