Patient preference: How can it help to reduce the burden of thrombosis in patients with cancer-associated thrombosis?
Isabella had barely come to terms with her diagnosis of cancer when she was diagnosed with cancer-associated thrombosis (CAT). She is not alone in this, because patients with cancer are at higher risk of venous thromboembolism (VTE) compared with the general population,1 and CAT is cited as the second leading cause of death in these patients, after cancer itself.2
Is there anything that could be done to reduce the burden of thrombosis in patients with cancer, like Isabella?
Patients with CAT suffer from a high symptomatic and emotional burden
Throughout their lifetime, 1 in 5 patients with cancer will suffer from a VTE event.3 Furthermore, the burden of VTE falls disproportionately on the most vulnerable patients with cancer – during hospitalization, during treatment and in patients with metastatic disease.3
It is always necessary to consider ways to reduce the treatment burden in patients with CAT. As Professor Alexander Cohen explains in this ThrombosisAdviser podcast, ‘it’s fair to say that you really can’t underestimate the importance of what’s known as “patient experience”.
Reducing the burden of injections is one of the ways to reduce the treatment burden. Results from a discrete choice experiment have shown that patients with CAT would prefer oral over injectable anticoagulants if the efficacy and safety of the drugs were equivalent.4 Additionally, a retrospective claims database analysis showed that 44% of patients with CAT who were prescribed low molecular weight heparin (LMWH) switched to another anticoagulant after a median of 23 days, suggesting that many patients may prefer alternative therapy even after a short treatment duration.5
Patient persistence with initial LMWH therapy in CAT is low CAT, cancer-associated thrombosis; LMWH, low molecular weight heparin
Patients with CAT show better persistence with oral versus injectable anticoagulants
LMWHs have traditionally been used to prevent VTE recurrence in patients with CAT.6 However, LMWHs have some drawbacks, such as the burden of daily injections.7 The treatment burden becomes even more relevant when the treatment duration is taken into account. Current clinical guidelines recommend that anticoagulants should be used for at least 3 to 6 months, or indefinitely while cancer is active, to prevent VTE recurrence in patients with cancer.8-12
Non-vitamin K antagonist oral anticoagulants (NOACs), such as rivaroxaban, have the potential to increase the quality of life and treatment satisfaction in patients with CAT.13 Patients with CAT receiving NOACs show better persistence, adherence to the type of treatment, and lower discontinuation rates than those receiving parenteral anticoagulants.14 Furthermore, retrospective claims data analyses showed that up to 37% of patients with CAT who initially received injectable anticoagulants, and up to 61% of patients who received oral anticoagulants, remained on the same therapy at 6 months.5,15
Patients with CAT show better persistence with oral versus injectable anticoagulants over 6 months LMWH, low molecular weight heparin
These numbers suggest that, as Professor Alexander Cohen explains in this ThrombosisAdviser podcast, ‘improved treatment satisfaction will have an impact on that [patient] experience and may also impact important clinical outcomes such as adherence and clinical events.’
Patient satisfaction improved after switching from LMWHs to rivaroxaban
The data from retrospective analyses support higher patient persistence with oral anticoagulants.5,14,15 However, as Professor Alexander Cohen mentions, ‘patient-reported outcomes are the key to understanding patient experience ’. This highlights the need to assess patient preferences in CAT treatment.
The COSIMO study investigated patient satisfaction with VTE treatment and/or prevention of VTE recurrence in patients with CAT who switched to rivaroxaban therapy from traditional anticoagulants (LMWH or vitamin K antagonists [VKAs]).13 The main study outcome was patient-reported treatment satisfaction, evaluated as change in Anti-Clot Treatment Scale (ACTS) Burdens score at week 4 compared with baseline.13 Additionally, the study assessed patient-reported outcomes in treatment satisfaction over time.13
The study enrolled 505 patients who had switched to rivaroxaban from LMWH (96.6%) or a VKA (3.4%).16 A significant improvement in patient-reported ACTS Burdens score was seen by week 4 (mean change in ACTS Burdens score from baseline, 3.9±6.7; p<0.0001 versus baseline), which signifies a reduction in perceived burden of treatment.16 Furthermore, the benefit increased over time for up to 6 months (mean change in ACTS Burdens score from baseline at 6 months, 4.8±7.3; p<0.0001 versus baseline).16 Quality of life was also assessed using Functional Assessment in Chronic Illness Therapy (FACIT) Fatigue score, with an increase in FACIT score signifying an improvement in quality of life.16 Mean FACIT Fatigue scores were similar at baseline (34.4) and week 4 (34.2; p=0.45).16 However, the mean FACIT Fatigue scores significantly increased at 3 months (36.3; p=0.001 versus baseline) and 6 months (36.9; p<0.0001 versus baseline), demonstrating an improvement in health-related quality of life.13,16
Rivaroxaban increased treatment satisfaction in patients with CAT as showed by increase in ACTS Burdens score in the COSIMO study ACTS, Anti-Clot Treatment Scale; CAT, cancer-associated thrombosis; SD, standard deviation
These results show that satisfaction with CAT treatment is increased when patients switch from parenteral LMWHs to rivaroxaban. As Professor Jeffrey Weitz summarized in the ICTHIC 2021 congress, ‘patients have greater satisfaction with an oral, simple to use regimen that does not require monitoring.’
Conclusions
Clinical guidelines highlight the role of anticoagulation for reducing the risk of recurrent VTE in patients with cancer.8-11 However, standard of care parenteral anticoagulation may be associated with lower treatment persistence than NOACs.5,14,15 Emerging data from the COSIMO study shows that rivaroxaban has the potential to increase patient satisfaction and reduce the burden of treatment in patients with CAT, such as Isabella.16
References
- Walker AJ, Card TR, West J et al. Incidence of venous thromboembolism in patients with cancer - A cohort study using linked United Kingdom databases. Eur J Cancer 2013;49:1404–1413. Return to content
- Khorana AA, Francis CW, Culakova E et al. Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J Thromb Haemost 2007;5:632–634. Return to content
- Lyman GH. Venous thromboembolism in the patient with cancer: Focus on burden of disease and benefits of thromboprophylaxis. Cancer 2011;117:1334–1349. Return to content
- Picker N, Lee AY, Cohen AT et al. Anticoagulation treatment in cancer-associated venous thromboembolism: assessment of patient preferences using a discrete choice experiment (COSIMO Study). Thromb Haemost 2021;121:206–215. Return to content
- Khorana AA, Yannicelli D, McCrae KR et al. Evaluation of US prescription patterns: Are treatment guidelines for cancer-associated venous thromboembolism being followed? Thromb Res 2016;145:51–53. Return to content
- Ng S, Carrier M. Prevention and treatment of cancer-associated thrombosis. Curr Oncol 2020;27:275–278. Return to content
- Wharin C, Tagalakis V. Management of venous thromboembolism in cancer patients and the role of the new oral anticoagulants. Blood Rev 2014;28:1–8. Return to content
- Farge D, Frere C, Connors JM et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2019;20:e566–e581. Return to content
- National Comprehensive Cancer Network. Cancer-associated venous thromboembolic disease, Version 1.2020.Plymouth Meeting, PA, USA: National Comprehensive Cancer Network, Inc. 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf [accessed 4 March 2021]. National Comprehensive Cancer Network. Cancer-associated venous thromboembolic disease, Version 1.2020.Plymouth Meeting, PA, USA: National Comprehensive Cancer Network, Inc. 2020. Available at: https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf [accessed 4 March 2021]. Return to content
- Key NS, Khorana AA, Kuderer NM et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol 2020;38:496–520. Return to content
- Lyman GH, Carrier M, Ay C et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: Prevention and treatment in patients with cancer. Blood Adv 2021;5:927–974. Return to content
- Konstantinides SV, Meyer G, Becattini C et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543–603. Return to content
- Cohen AT, Maraveyas A, Beyer-Westendorf J et al. COSIMO - patients with active cancer changing to rivaroxaban for the treatment and prevention of recurrent venous thromboembolism: a non-interventional study. Thromb J 2018;16:21. Return to content
- Guo JD, Hlavacek P, Poretta T et al. Inpatient and outpatient treatment patterns of cancer-associated thrombosis in the United States. J Thromb Thrombolysis 2020;50:386–394. Return to content
- Khorana AA, McCrae KR, Milentijevic D et al. Current practice patterns and patient persistence with anticoagulant treatments for cancer-associated thrombosis. Res Pract Thromb Haemost 2017;1:14–22. Return to content
- Cohen AT, Maraveyas A, Beyer-Westendorf J et al. Patient-reported outcomes associated with switching to rivaroxaban for the treatment of venous thromboembolism in patients with active cancer. European Society of Medical Oncology. Barcelona, Spain, 27 September–1 October 2019. Poster P1774P. Return to content
See Also
Podcast: Seeing the Bigger Picture in Cancer-Associated Thrombosis
See Also
International Conference on Thrombosis and Hemostasis Issues in Cancer 2021
See Also
Cancer-associated thrombosis: Protecting your patients
See Also
Where next in cancer-associated thrombosis?
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