C. Vulsteke MD, PhD

Cancer, chronic kidney disease and thrombosis

SUMMARY

Chronic kidney disease (CKD) and cancer are intertwined in many ways. In fact, cancer can cause CKD either directly or indirectly through the treatment adverse effects, while CKD may conversely be a risk factor for cancer. According to the Belgian Renal Insufficiency and Anticancer Medications (BIRMA) study, 64% of patients with cancer had a glomerular filtration rate (GFR) <90 ml/min/1.73m² and 16% of them presented with a mildly to severely decreased GFR (i.e.; <30 ml/min/1.73m² or 30–60 ml/min/1.73m²). As many anticancer drugs are predominantly excreted in the urine, tailoring the drug dose to the renal function of the individual patient is a crucial consideration. Furthermore, patients with cancer and CKD are also at an increased risk of thrombosis. Therefore, safe and effective drugs for the treatment and prevention of thrombotic events are necessary.

(BELG J MED ONCOL 2023;17(2):46–51)

Highlights in gynaecological cancers

The 2022 annual meeting of the European Society of Medical Oncology (ESMO) was a grand cru when it comes to ovarian cancer, with the presentation of long-term data of several pivotal studies evaluating firstline maintenance therapy with a PARP inhibitor. Also, in the recurrent ovarian cancer setting, there was some interesting PARP news. In addition to this, ESMO featured the presentation of multiple studies evaluating checkpoint inhibitors in the management of ovarian cancer, endometrium and cervical cancer.

(Belg J Med Oncol 2022;16(8):380–6)

Is there a place for thromboprophylaxis in cancer patients?

SUMMARY

Venous thromboembolism (VTE) is common in cancer patients. It is associated with poor outcomes and increased mortality. In fact, VTE is known as the second most common cause of mortality in cancer patients. Although the benefit of thromboprophylaxis is clear for acutely ill hospitalised cancer patients, routine prophylaxis is not recommended for all ambulatory cancer patients. The reason is the risk to treat a high proportion of patients who do not need treatment and an increased risk of major bleeding. Here we highlight the importance of adequate risk assessment models to select patients at an increased VTE risk and present pivotal trial results that form the basis for the latest international treatment guidelines related to thromboprophylaxis in cancer patients.

(BELG J MED ONCOL 2022;16(2):53–9)

An update on the management of metastatic clear-cell renal cell carcinoma: the BSMO expert panel recommendations

SUMMARY

The management of recurrent or metastatic renal cell carcinoma is evolving fast, with new therapeutic options becoming available that may improve the outcome of patients. In this paper, recent evolutions are discussed and recommendations are made regarding the management of renal cell carcinoma in a Belgian context.

(BELG J MED ONCOL 2020;14(2):56–70)

The role of direct oral anticoagulants in the management of cancer-associated thrombosis

SUMMARY

Cancer patients are at an increased risk of venous thromboembolism (VTE). The current standard initial treatment of an acute episode of VTE in cancer patients consists of the administration of three to six months of subcutaneous low molecular weight heparin (LMWH) at a dose adjusted to the body weight. The efficacy and safety profile of LMWHs are well established, but a drawback of these agents is that they require daily subcutaneous administration. In addition, they are mainly cleared through the kidneys, and their use in patients with severe renal insufficiency may require dose reduction or monitoring of the anti-Xa activity. To address the issues with LMWH, several direct oral anticoagulants (DOAC) have been developed for the treatment of VTE. In contrast to LMWHs and vitamin K antagonist, DOACs directly interfere with thrombin or activated factor X (FXa). DOACs have now become standard treatment options in the general management of VTE, but until recently, there were no results of clinical trials specifically assessing the role of DOACs in the treatment of cancer-associated thrombosis. Recently, the Hokusai VTE cancer study and preliminary data from the Select-D trial demonstrated that DOACs are non-inferior to LMWH in preventing recurrent VTE. However, both studies also show that this comes at the cost of an increased rate of both major and clinically-relevant non-major bleeding. Especially in the subgroup of patients with gastrointestinal cancer, the benefit in VTE recurrence with the DOAC seems to be outbalanced by a significantly increased bleeding risk. Based on the available results, DOACs might represent an interesting alternative for LMWH in certain subgroups of patients, but with an important list of exceptions. It seems reasonable not to use DOACs in patients with a high bleeding risk, and especially in patients with gastrointestinal cancer, DOACs should not be the first-line choice. In summary, while LMWHs are currently the standard of care in the acute management of cancer-associated thrombosis, the advent of DOACs is welcomed for patients at a low bleeding risk who are in need of long-term anticoagulation.

(BELG J MED ONCOL 2019;13(2):46–53)

Screening for occult cancer in patients with unprovoked venous thromboembolism: Belgian expert guidance

Unprovoked venous thromboembolism (VTE) may be the earliest sign of malignancy, and as a result, screening for occult cancer in these patients has become routine practice. However, the elaborateness of this screening is subject to debate and varies between medical centres. This study’s expert panel, consisting of oncologists and thrombosis specialists, aimed to develop a practical Belgian guidance for adequate cancer screening in patients with unprovoked VTE. In summary, comprehensive non-invasive cancer screening consisting of a medical history assessment, physical examinations, basic blood tests and a chest X-ray is sufficient to pick up the vast majority of occult cancers. When specific abnormalities are picked up by the battery of tests in the comprehensive non-invasive cancer screening, more extensive screening using CT scans are recommended. Routine CT screening in all patients presenting with an unprovoked VTE does not provide a significant clinical benefit and should not be routinely performed. In the presence of specific risk factors (e.g., older age, smoking history, previous VTE), physicians are advised to be more vigilant. Finally, given the significant anxiety that cancer screening may cause to patients, accurate and clear patient communication is key. A complete list of guidance statements is provided at the end of the article.

(BELG J MED ONCOL 2018;12(7):326–329)

Artificial intelligence for the oncologist: hype, hubris or reality?

Keeping up with the rising amount of clinical data, guidelines and approvals of new antineoplastic drugs is a major challenge for every oncologist. Artificial intelligence promises to address this and to revolutionise health care and cancer treatment. What is the current state of artificial intelligence for the oncologist, and is it ready for prime time? In this article, the current, available tools of artificial intelligence are highlighted, which try to take a privileged role in the daily practice of the oncologist.

(BELG J MED ONCOL 2018;12(7)330–333)