Expert Opinion
Episode 1: Identifying and stratifying risk of cancer-associated venous thromboembolism (VTE)
In episode 1, Dr Alok Khorana (Case Western Reserve University) and Dr Barnes explore why cancer can drive higher risk of VTE, the importance of warning patients of the symptoms of blood clot, and ways to think about risk-stratifying patients who could be at risk of developing CAT. Dr Khorana describes effective approaches to identifying cancer patients at higher risk of VTE, and the implementation of evidence into clinical practice.
Episode 2: The treatment landscape for cancer-associated VTE
Episode 2 covers the treatment landscape of CAT and how the field has evolved. Dr Khorana discusses the real-world evidence of adherence to injectables versus clinical trial evidence. He stresses the importance of taking a patient’s values and preferences into account when making treatment decisions, and he describes thrombocytopenia, and how to treat objectively identified VTE. The take home message is to educate patients about blood clots: to take the matter seriously because it is an important complication of people with cancer.
Episode 3: Real-world evidence for venous thromboembolism
Drs Barnes and Gregory Piazza (Harvard Medical School) discuss the importance of shared decision-making when determining the most suitable anticoagulation therapy for a patient with VTE. Dr Piazza shares insights on the risk of recurrence with his patients, the importance of reviewing intrinsic and extrinsic risk factors, and how to leverage real-world evidence alongside clinical trial data.
Episode 4: Management of challenging cancer-associated VTE and anticoagulation
Episode 4 begins with a discussion on treatment selection for thrombocytopenia. In practice, Dr Deborah Siegal (University of Ottawa) always checks the platelet count in patients at risk of thrombocytopenia, as this affects the suitability of prescribing anticoagulation therapy. The inferior vena cava (IVC) filter in managing protracted thrombocytopenia should be used with care, due to the high complication rate. Dr Siegal outlines strategies for balancing risk of bleeding and VTE recurrence in patients brain tumours and VTE.
Dr Siegal describes clinical situations suitable, or not suitable, for anticoagulation therapy, in the setting of CAT-VTE. For example, can direct anticoagulation therapy be prescribed for patients with liver metastases? This episode concludes with discussion on best-practices for managing CAT-VTE following 6 months of treatment.
Episode 5: Assessment and guideline recommendations for recurrent VTE in patients without cancer
Dr Anita Rajasekhar (University of Florida) categorises some of the causes and reversible or non-reversible risk factors of VTE for patients without cancer, and the relationship of these to treatment selection. Patient preferences for treatment are important where the cause of VTE is not verified. She also speaks to the location of the clot and VTE risk, and the benefits and limitations of formal assessment of recurrence or bleeding risk. Dr Rajasekhar reviews the guidelines she consults in making clinical decisions for recurrent VTE.
Episode 6: Treatments and guideline recommendations for managing cancer-associated VTE
In this episode, Dr Rajasekhar reviews anticoagulation treatments suitable for CAT (metastatic or non-metastatic cancer), her treatment selection process, and the role of warfarin in this patient group. She outlines her approach to treatment duration for CAT, the appropriateness of using an inferior vena cava (IVC) filter, and her preferred guidelines.
Meet the experts
Dr Geoffrey Barnes
Dr Barnes is a cardiologist and vascular medicine specialist at the University of Michigan. His clinical and research interests are the care of patients with thrombotic conditions, and/or who require the use of anticoagulant medications. He serves as co-director for the Michigan Anticoagulation Quality Improvement Initiative (MAQI2), co-director of the Michigan Program for Value Enhancement. He serves in leadership roles with numerous organisations including the American College of Cardiology, Society for Vascular Medicine, and International Society on Thrombosis and Haemostasis.
Disclosures:
Consulting fees: Pfizer/Bristol Myers Squibb, Janssen, Bayer, Boston Scientific, Abbott Vascular.
Research grants: Blue Cross Blue Shield of Michigan, National Heart, Lung, and Blood Institute (NHLBI), the Agency for Healthcare Research and Quality (AHRQ).
He is on the Board of Directors of the Anticoagulation Forum.
Dr Gregory Piazza
Dr Gregory Piazza is Associate Professor of Medicine at Harvard Medical School, and Director of Vascular Medicine at Brigham and Women’s Hospital. Dr Piazza’s practice focuses on the evaluation, management, and prevention of VTE, thrombosis-related infertility, and stroke prevention in atrial fibrillation. He is also an author on over 140 peer-reviewed publications, and his research investigates innovative treatment of VTE, thrombosis-related infertility, and prevention of stroke.
Disclosures:
Research grant support from EKOS/BTG International, Bristol Myers Squibb, Daiichi-Sankyo, Bayer, Portola, Janssen.
Consulting fees: Pfizer, Thrombolex.
Dr Deborah Siegal
Dr Deborah Siegal is Associate Professor of Medicine at the University of Ottawa and Associate Scientist at the Ottawa Hospital Research Institute. Her research interests include management of anticoagulant-related bleeding, restarting anticoagulants after bleeding, perioperative management of anticoagulation for urgent surgery, and ischaemic stroke in patients with cancer. She has published over 100 peer-reviewed articles (h-index 36).
Disclosures:
Honoraria: BMS-Pfizer, Servier, Astra Zeneca, Roche.
Funding: CIHR, CanVECTOR/Heart and Stroke Foundation of Canada, the American Society of Hematology.
Dr Alok Khorana
Alok A Khorana is Professor of Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, the Sondra and Stephen Hardis Chair in Oncology Research, Vice-Chair for Academic Development of the Taussig Cancer Institute (part of Case Comprehensive Cancer Center) and Director of the Gastrointestinal Malignancies Program at the Cleveland Clinic, Cleveland, Ohio. His research program focuses on predictive factors and drug development in cancer-associated thrombosis and gastrointestinal cancers.
Disclosures:
Consulting honoraria: Janssen, Pfizer, Sanofi, BMS, Anthos, WebMD.
Funding: NHLBI, CDC, National Cancer Institute, the Hardis Family, the Porter Family Fund, VeloSano, the Cleveland Clinic Center for Excellence, the Scott Hamilton CARES Initiative, Stand Up To Cancer (Colorectal Cancer “Dream Team”), the V Foundation.
Dr Anita Rajasekhar
Dr Rajasekhar is Associate Professor at the University of Florida and is the adult medical director of the UF Hemophilia Treatment Center. Her clinical interests include diagnosis and treatment of thrombotic and bleeding disorders. Dr Rajasekhar serves on the Anticoagulation Forum Board of Directors. She is an active member of the American Society of Hematology with current and prior memberships on the Committee on Quality, Subcommittee on Stewardship and Systems-based Hematology, Scientific Committee on Thrombosis and Vascular Biology, and Recruitment and Retention Working Group. She helped develop various international evidence-based guidelines focusing on thrombosis and hemostasis in special populations.
Disclosures:
Advisory boards for Alexion, Baxter, Bayer, Kedrion Biopharma, Octapharma Plasma.
Funding: Alnylam (Sanofi Genzyme), Baxalta (Shire), Biomarin, Dimensions Therapeutics, Genetech, Janssen Pharmaceuticals, Roche, Bio Products laboratory, LTD, Takeda.
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