Where next in cancer-associated thrombosis?
Patient case: Reducing treatment burden and supporting recovery
Think about how you would treat the following patient.
- Joyce is 64 years old and has been a headteacher for 17 years. She is married and has two grown-up children and three young grandchildren. In her spare time, she paints
- Last year, she was diagnosed with metastatic ovarian cancer and underwent cytoreductive surgery followed by combination chemotherapy with paclitaxel and carboplatin
- She responded well to treatment, but 2 weeks after the end of chemotherapy she presented with shortness of breath resulting from a large bilateral pulmonary embolism (PE)
- The PE was treated initially with low molecular weight heparin (LMWH)
- It is now 4 months on and Joyce remains in complete remission; she wants to know if she can stop her anticoagulant injections
What do the guidelines say?
Previously, there was often clinical uncertainty on the use of oral anticoagulants to treat cancer-associated thrombosis (CAT). However, in 2019, several guidelines were brought up to date with clinical evidence and now provide clear advice on protecting patients with cancer from venous thromboembolism (VTE).
The 2019 European Society of Cardiology (ESC) Guidelines for the Management of PE, the 2019 American Society of Clinical Oncology (ASCO) Guidelines Update for VTE Treatment in Patients with Cancer and the 2019 International Initiative on Thrombosis and Cancer (ITAC) Guidelines for the Treatment of VTE in Patients with Cancer all provide guidance on the situations where patients can be switched to oral anticoagulation.1-3
These new recommendations are based on the results of multiple clinical trials that show that, with regard to efficacy and safety, rivaroxaban or edoxaban are suitable alternatives to LMWH.4-6
So, would Joyce be considered suitable for anticoagulation with an oral anticoagulant?
Assuming that her renal function was not severely impaired (i.e. ≥30 ml/min) and that she did not have a high-risk of gastrointestinal or genitourinary bleeding, all three 2019 clinical guidelines would recommend rivaroxaban, edoxaban or LMWH equally for up to 6 months.-13
Beyond 6 months, extended anticoagulation would depend on an assessment of Joyce’s individual risk of recurrent VTE. If her risk of recurrence justified extended anticoagulation, continuation on rivaroxaban or edoxaban would be appropriate.1-3
Maximizing quality of life
Joyce is unlikely to be alone in wanting to stop parenteral anticoagulation.
The COSIMO study found that, assuming equal efficacy and safety, route of administration was the single most important factor that affected the treatment preferences of patients with CAT – more so than interactions with food or alcohol, or distance to visit the doctor. Unsurprisingly, oral administration was preferred to parenteral.7
Patients in COSIMO ranked route of administration as the most important element of anticoagulation treatment7
COSIMO also evaluated the change in patient-reported outcomes in patients with CAT who switched to rivaroxaban from standard of care (in 96.6% of cases this was LMWH therapy).8
Following the switch, patient-reported treatment satisfaction was significantly increased after 4 weeks, and this difference was maintained at 6 months.8Based on these data, switching Joyce to rivaroxaban would allow her to see a rapid improvement in her quality of life.
Summary
Until recently, there was uncertainty around whether non-vitamin K antagonist oral anticoagulants were suitable alternatives to LMWH. However, in light of recent data showing the efficacy and safety of rivaroxaban and edoxaban, updated guidelines now provide reassurance that patients with CAT can often be treated with these anticoagulants.1-3
Today, the major question around anticoagulation in patients with CAT is how treatment choices affect outcomes beyond efficacy and safety. Rivaroxaban is currently the only non-vitamin K antagonist oral anticoagulant with published data showing how it can improve the patient experience of anticoagulation.7,8
When treating patients like Joyce, always consider how anticoagulation decisions can both prevent a devastating VTE recurrence and allow patients to focus on living their lives.
References
- 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
- 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 2019: doi:10.1200/JCO.19.01461. Return to content
- ITAC: Farge D, Frere C, Connors JM, Ay C, Khorana AA, Munoz A, Brenner B, Kakkar A, Rafii H, Solymoss S, Brilhante D, Monreal M, Bounameaux H, Pabinger I, Douketis J; International Initiative on Thrombosis and Cancer (ITAC) advisory panel. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol. 2019 Oct;20(10):e566-e581. doi:10.1016/S1470-2045(19)30336-5. Return to content
- Raskob G.E., van Es N., Verhamme P. et al. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med. 2018;378(7):615–24. Return to content
- Young AM, Marshall A, Thirlwall J et al. Comparison of an oral Factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT-D). J Clin Oncol 2018;36:2017–2023. Return to content
- Prins M.H., Lensing A.W.A., Brighton T.A. et al. Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN-DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials. Lancet Haematol. 2014;1(1):e37–e46. Return to content
- Picker N, Cohen AT, Maraveyas A et al. Patient preferences regarding anticoagulation therapy in patients with cancer having a VTE event - a discrete choice experiment in the COSIMO study. 61st American Society of Hematology. Orlando, FL, USA, 7–10 December 2019 2019. Poster 2159. 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
Managing anticoagulation during the COVID-19 pandemic
See Also
Keeping it simple: Single drug approaches to VTE treatment
See Also
Supporting the treatment of patients with low-risk pulmonary embolism at home
See Also
Time for a change? Switching anticoagulants in patients with AF or VTE
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Updated date 10/10/2022
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