Key result
The Khorana score exhibited poor capability in accurately discriminating venous thromboembolism risk among cancer patients, with a pooled C-index of 0.59 in observational studies and 0.61 in randomized controlled trials.
Why the study?
Although recommended by clinical guidelines for identifying ambulatory cancer patients at high risk of venous thromboembolism during chemotherapy, the Khorana score's predictive performance remains debated.
Does the Khorana score accurately predict venous thromboembolism risk in cancer patients?
Systematic Review
Does the Khorana score accurately predict venous thromboembolism risk in cancer patients?
Effect estimate: pooled C-index 0.59 (95% CI 0.57-0.60)
Despite being recommended by clinical guidelines, the Khorana score exhibits poor discriminative ability for predicting VTE risk across most cancer types and clinical settings, suggesting it should be used with caution.
Khorana score shows inadequate VTE discrimination in cancer; challenges guideline recommendations and supports refined risk models.
BACKGROUND: Venous thromboembolism is the leading cause of death in cancer patients, second only to tumor progression. The Khorana score is recommended by clinical guidelines for identifying ambulatory cancer patients at high risk of venous thromboembolism during chemotherapy. However, its predictive performance is debated among cancer patients. OBJECTIVES: To map the applicability of the Khorana score in cancer patients and to assess its predictive performance across various cancer types, providing guidance for clinicians and nurses to use it more appropriately. DESIGN: Systematic review and meta-analysis. METHODS: A comprehensive literature search of the electronic database was first conducted on August 30, 2023, and updated on May 20, 2024. Studies examining the Khorana score's predictive performance (including but not limited to the areas under the curve, C-index, and calibration plot) in cancer patients were included. The Prediction Model Risk of Bias Assessment Tool (PROBAST) was applied to evaluate the methodological quality of the included studies. Data synthesis was achieved via random-effects meta-analysis using the R studio software. The subgroup analysis was performed according to the study design, clinical setting, cancer type, anti-cancer treatment stage, and country. RESULTS: The review incorporated 67 studies, including 58 observational studies and nine randomized controlled trials. All included studies assessed the Khorana score's discrimination, with the C-index ranging from 0.40 to 0.84. The pooled C-index for randomized controlled trials was 0.61 (95 % CI 0.51-0.70), while observational studies showed a pooled C-index of 0.59 (95 % CI 0.57-0.60). Subgroup analyses revealed the pooled C-index for lung cancer, lymphoma, gastrointestinal cancer, and mixed cancer patients as 0.60 (95 % CI 0.53-0.67), 0.56 (95 % CI 0.51-0.61), 0.59 (95 % CI 0.39-0.76), and 0.60 (95 % CI 0.58-0.61), respectively. Inpatient and outpatient settings had the pooled C-index of 0.60 (95 % CI 0.58-0.63) and 0.58 (95 % CI 0.55-0.61), respectively. Calibration was assessed in only four studies. All included studies were identified to have a high risk of bias according to PROBAST. CONCLUSION: The Khorana score has been widely validated in various types of cancer patients; however, it exhibited poor capability (pooled C-index<0.7) in accurately discriminating VTE risk among most types of cancer patients either in inpatient or outpatient settings. The Khorana score should be used with caution, and high-quality studies are needed to further validate its predictive performance. REGISTRATION: The protocol for this study is registered with PROSPERO (registration number: CRD42023470320).
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Huang et al. (2024) conducted a systematic review in Cancer (venous thromboembolism risk). Khorana score was evaluated on Discrimination of venous thromboembolism risk (C-index) (pooled C-index 0.59, 95% CI 0.57-0.60). The Khorana score exhibited poor capability in accurately discriminating venous thromboembolism risk among cancer patients, with a pooled C-index of 0.59 in observational studies and 0.61 in randomized controlled trials.
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