Articles

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

BJMO - volume 13, issue 2, march 2019

A. Awada MD, PhD, J-F. Baurain MD, PhD, P. Clement MD, PhD, P. Hainaut MD, S. Holbrechts MD, PhD, K. Jochmans MD, V. Mathieux MD, J. Mebis MD, M. Strijbos MD, PhD, C. Vulsteke MD, T. Vanassche MD, P. Verhamme MD

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)

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

BJMO - volume 12, issue 7, november 2018

A. Awada MD, PhD, J-F. Baurain MD, PhD, P. Clement MD, PhD, P. Hainaut MD, S. Holbrechts MD, PhD, K. Jochmans MD, V. Mathieux MD, J. Mebis MD, M. Strijbos MD, PhD, C. Vulsteke MD, T. Vanassche MD, P. Verhamme MD

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)

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Prevention of chemotherapy-induced nausea and vomiting: Belgian antiemetic treatment options anno 2018

BJMO - volume 12, issue 2, march 2018

W. Lybaert MD, P. Clement MD, PhD, K. Punie MD, J. Mebis MD, M. Renard , H. Wildiers MD, PhD

Summary

Chemotherapy-induced nausea and vomiting remains an important adverse effect of treatment in daily clinical practice. Recently, new data on combinations of antiemetic agents became available for the prevention of acute and delayed nausea/vomiting in patients receiving highly and moderately emetogenic chemotherapy. As a result, the leading international cancer societies updated their antiemesis guidelines. This text aims at providing guidance regarding these new regimens in the prophylaxis of chemotherapy-induced nausea and vomiting, with a particular focus on highly emetogenic chemotherapy.

(BELG J MED ONCOL 2018;12(2):51–60)

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Guidance for the prevention and treatment of venous thromboembolism in cancer patients

BJMO - volume 10, issue 7, november 2016

A. Awada MD, PhD, J-F. Baurain MD, PhD, P. Clement MD, PhD, P. Hainaut MD, S. Holbrechts MD, PhD, J-M. Hougardy , K. Jochmans MD, V. Mathieux MD, J. Mebis MD, M. Strijbos MD, PhD, C. Vulsteke MD, P. Verhamme MD

Summary

Venous thrombosis is a common complication in cancer patients and thromboembolism is the second most common cause of death. Several practice guidelines provide recommendations for the management of cancer-associated thrombosis. However, these guidelines do not sufficiently cover commonly encountered clinical challenges. With this expert panel, consisting of medical oncologists, haematologists, internists and thrombosis specialists, we aimed to develop a practical Belgian guidance for adequate prevention and treatment of cancer-associated thrombosis that covered several challenging situations encountered in daily clinic. This paper discusses the following topics: type and treatment duration of anticoagulant therapy, recurrent VTE despite anticoagulation, anticoagulation in case of renal impairment, liver disease and thrombocytopenia, the role of anti-Xa monitoring, central venous catheter-associated thrombosis, the position of direct oral anticoagulants and thromboprophylaxis, both in ambulatory and hospitalised patients. For an overview of the recommendations formulated by the expert panel, we refer to the key messages for clinical practice in this article.

(BELG J MED ONCOL 2016;10(7):249–255)

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Thrombo-embolic events in cancer patients with impaired renal function

BJMO - volume 9, issue 2, may 2015

I. Elalamy MD, PhD, J-L. Canon MD, PhD, A. Bols MD, PhD, W. Lybaert MD, L. Duck MD, K. Jochmans MD, L. Bosquée MD, PhD, M. Peeters MD, PhD, A. Awada MD, PhD, P. Clement MD, PhD, S. Holbrechts MD, PhD, J-F. Baurain MD, PhD, J. Mebis MD, J. Nortier MD, PhD

Venous thromboembolism is a frequent cause of mortality and morbidity in patients with malignancy. Thrombosis is one of the leading causes of death in patients with malignancy after cancer itself. As such, prompt recognition and treatment of venous thromboembolism are required in order to reduce the risk of venous thromboembolism-related mortality. This report reviews the interrelationship between cancer, renal insufficiency and venous thromboembolism. The working group behind this review article concludes that low molecular weight heparins decrease the risk of recurrent venous thrombosis in cancer patients without increasing major bleeding complications. Low molecular weight heparins are therefore recommended as first line antithrombotic treatment in cancer patients with a clear clinical benefit. In patients with renal dysfunction, who are at increased risk of bleeding and of thrombotic complications, preference should be given to unfractionated heparin or a low molecular weight heparin with a mean molecular weight such as tinzaparin, having less risk of plasma accumulation and offering the possibility to maintain full therapeutic dose.

(BELG J MED ONCOL 2015;9(2):53–60)

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New medical treatments in thyroid cancer

BJMO - volume 8, issue 3, july 2014

L. Decoster MD, PhD, F. Cornélis MD, E. Joosens MD, S. Henry MD, P. Specenier MD, PhD, P. Clement MD, PhD, On behalf of the Thyroid Task Force of the BSMO

Thyroid cancers are rare diseases and include types that range from indolent localised differentiated carcinomas to fulminant and lethal anaplastic disease. Until recently, treatment options for advanced or metastatic radio-iodine refractory thyroid cancer were limited. Recently kinase inhibitors targeting angiogenesis and other pathways have shown promising activity.

(BELG J MED ONCOL 2014;8(3):81–6)

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