- Venous thromboembolism (VTEs) is common in cancer and increases over time.
- Risk stratification is crucial for weighing the risks and benefits of primary thrombosis prophylaxis.
- The management of cancer-associated thrombosis (CAT) depends specifically on the different points in time in the course of the cancer.
- The benefit-risk analysis of anticoagulation must be carried out regularly.
Prevention
VTE-related complications are common in cancer patients.The cumulative incidence of CATs increases over time for several reasons. These include longer patient survival, more frequent incidental findings and the introduction of new therapies, said Marc Carrier, head of the division of hematology at The Ottawa Hospital (Canada) during a special interest session at the ASH Annual Meeting_-2022. He summarized the clinical relevance of VTEs for oncology patients as well as the evidence on the efficacy and safety of anticoagulant regimens for the primary prevention of CATs.
VTEs are associated with morbidity and mortality and can be traumatic and distressing for patients. In fact, most CATs (up to 80 %) occur in outpatients. «We should think about how to educate our patients about signs and symptoms, and encourage them to see a doctor when they occur,» recommended Dr. Carrier.Primary thrombosis prophylaxis is safe and effective in outpatient cancer patients, but requires correct risk stratification based on a validated score (i.e. the Khorana score), supplemented by clinical evaluation and medical experience.
For outpatient cancer patients receiving systemic therapy, ASH guidelines recommend the following:
- low risk of thrombosis: no thrombosis prophylaxis
- intermediate risk: either thrombosis prophylaxis with a direct oral anticoagulant (DOAC) or no thrombosis prophylaxis
- high risk: Thrombosis prophylaxis with a DOAC or with low molecular weight (NMH), whereby thrombosis prophylaxis should be used with caution in persons at high risk of bleeding.
Treatment and secondary prevention
» What is special about these guidelines is that the Panel has added additional decision-relevant evidence such as resource use, cost-effectiveness, health equity, acceptance and feasibility,» said Radhika Gangaraju, Assistant Professor at the University of Alabama at Birmingham (AL, USA), who described the ASH guidelines on CAT treatment.Recommendations are given for three specific times: initial treatment (first 5–10 days after VTE diagnosis), short-term treatment (3–6 months after VTE diagnosis) and long-term treatment (> 6 months after VTE diagnosis).
Algorithm for anticoagulation in CAT cases:
- Assessment of whether there is a risk of bleeding or contraindication to anticoagulation
- Determination of drug interactions with DOAC:
- no drug interaction: DOAC prefer
- Interactions with DOAC: Preference for NMH (NMH is also used in patients with unresected intraluminal gastrointestinal [GI] or urogenital cancer, impaired GI absorption and for the treatment of extensive VTE preferred)
- Performing a regular risk-benefit analysis of anticoagulation at each clinical visit
- Continuation of anticoagulation in the presence of active cancer and metastatic disease and in patients receiving chemotherapy (observational studies support discontinuation of antithrombotics in patients with end-stage cancer due to a high risk of clinically relevant bleeding in the last weeks of life).
Implementation of the guidelines
The second part of the session was devoted to implementation strategies in cancer patients with VTE.Despite the recommendations, outpatient pharmacological prophylaxis is rarely performed in the USA. Obstacles to implementation include:
- lack of precision / Unavailability of risk stratification tools
- Lack of time
- Lack of awareness of this recommendation.
Two strategies were presented to fill these gaps. Ang Li, an assistant professor at Baylor College of Medicine (Houston, TX), provided an overview of the potential of leveraging optimized clinical informatics in modern electronic health record systems (ePAs) to support CAT compliance. Katy Toale, clinical pharmacology expert at MD Anderson Cancer Center (Houston, TX), described the anticoagulation management program she leads to ensure the safe and effective use of these drugs.
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Source — https://www.univadis.de/viewarticle/ash-2022-wie-man-venose-thromboembolien-bei-krebspatienten-verhindert-und-behandelt