Articles

Is there a place for thromboprophylaxis in cancer patients?

BJMO - volume 16, issue 2, march 2022

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

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)

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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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