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The 2022 edition of the International Conference on Thrombosis and Hemostasis Issues in Cancer (ICTHIC) took place from 27–29 May as a hybrid meeting, both in-person in Bergamo, Italy, and online through the virtual platform. Approximately 300 people attended the congress in person, with a further 150 joining online.
A Bayer-sponsored symposium, chaired by Professor Cihan Ay, explored how consideration of anticoagulant efficacy, safety and patient preference are all necessary to ensure optimal treatment for the prevention of venous thromboembolism (VTE) recurrence in patients with cancer-associated thrombosis (CAT).
In addition, initial findings from the OSCAR-UK (Observational Studies in Cancer Associated Thrombosis for Rivaroxaban – United Kingdom) study presented by Dr Ander Cohen demonstrated the comparable efficacy and safety of rivaroxaban in patients with CAT compared with low molecular weight heparin (LMWH) in a real-world setting.
At lunchtime on the Saturday of the congress, Bayer sponsored a symposium designed to explore how consideration of efficacy, safety and patient preference together, rather than as isolated factors, is essential for the optimal treatment of patients with CAT.. Professor Cihan Ay (Medical University of Vienna, Austria), chairing the session, introduced the concept of treatment as building and furnishing a house for a patient with CAT. He then discussed how the prompt diagnosis of CAT is crucial to lay the foundations for their treatment and explored how patient education on the risks of CAT can help to reduce the time to diagnosis.
Professor Cihan Ay presents plans for the patient house.
Dr Ander Cohen (King’s College London, UK) then constructed the walls of the house by using clinical data from the SELECT-D trial,1 and recent real-world findings from the OSCAR-US study,2 to demonstrate the efficacy of direct oral anticoagulants (DOACs) for the prevention of recurrent VTE in patients with cancer. Professor Cecilia Becattini (University of Perugia, Italy) added a protective roof by discussing the favourable safety profile of DOACs seen in clinical studies such as SELECT-D1 and real-world studies of patients with CAT such as OSCAR-US2 and data from the Mayo clinic.3 Finally, Dr Mari Thomas (University College London Hospitals, UK) considered the importance of patient preference, as assessed in studies such as COSIMO,4 thereby furnishing the house and turning it into a home for the patient.
Dr Mari Thomas highlights the importance of considering patient preference.
At the end of the session, there was the opportunity for the audience to consider the treatment homes that they are building for their own patients and to put questions to the panel.
Dr Ander Cohen presented initial results from OSCAR-UK. OSCAR-UK is a real-world study of patients with CAT from the Aurum and Clinical Practice Research Datalink registries in the UK, which forms part of the OSCAR study program alongside OSCAR-US (United States; presented at American Society of Hematology 2021) and OSCAR-SWE (Sweden; results expected later this year). The use of registry data allows for analysis of the effectiveness and safety profile of rivaroxaban for the treatment of CAT in patients in everyday practice, outside of the stringent participation criteria necessary in clinical trials. Dr Cohen presented findings for a cohort of 2259 patients with cancers for which the International Society on Thrombosis and Haemostasis guidelines recommend the use of DOACs for the prevention of VTE recurrence. At 3 months, the risks of VTE recurrence (sub-distribution hazard ratio 0.96; 95% confidence interval [CI] 0.25–3.74) and significant bleeding (sub-distribution hazard ratio 1.03; 95% CI 0.44–2.40) were comparable between rivaroxaban and LMWH, and these findings persisted at both 6 and 12 months. Patients treated with rivaroxaban were also more likely to remain on treatment for 1 year compared with those treated with LMWH.
Following an audience question from Dr Philippe Girard, Dr Cohen was also able to highlight the impressively large number of variables included in the propensity-score matching for OSCAR-UK. These findings therefore reinforce those from OSCAR-US2 and reiterate the favourability of rivaroxaban as a treatment option for the protection of patients with CAT.
Dr Ander Cohen presents 3-month results from the OSCAR-UK study.
Cohen A. Comparison of VTE recurrence, bleeding-related hospitalization and all-cause mortality in patients with active cancer in two patient populations, based upon cancer types considered to have high and low risks of bleeding, receiving DOACs or LMWH – The OSCAR-UK Study. ICTHIC, 27–29 May 2022.
An updated version of the European Society for Medical Oncology (ESMO) clinical practice guidelines on VTE in patients with cancer was due to be presented by Professor Anna Falanga but was unfortunately not published in time for the congress. Instead, Professor Falanga provided a general overview of what can be expected from the updated guidelines, highlighting that they will be practical and easy to apply across all European countries. She also provided an overview of evidence and guidelines on the use of anticoagulation in CAT, including a discussion of potential anti-cancer effects of anticoagulation.
The subject of whether long-term treatment of VTE is appropriate was debated in a session chaired by Dr Ander Cohen and Professor Suzanne Cannegieter, with Professor Agnes Lee arguing for the continuation of treatment and Professor Marcello Di Nisio presenting the case against it. Following well-argued justification on both sides of the debate, the presenters agreed that there is always a compromise to be made and that individualized treatment for each patient is the correct approach.
Debate: Duration of VTE treatment beyond 6 months: to continue or not to continue? ICTHIC, 27–29 May 2022.
Professor Rupert Bauersachs explored the often-raised concerns surrounding the risk of bleeding associated with the use of DOACs for the treatment of CAT. Using data on gastrointestinal and brain cancers as examples, he highlighted how the risk of bleeding is often related to the underlying cancer rather than the anticoagulant treatment used. He further noted that bleeding in gastrointestinal cancer in patients treated with a DOAC primarily occurs when the lesion is unresected.
Bauersachs R. Bleeding risk with direct oral anticoagulants. ICTHIC, 27–29 May 2022. PL-16
In a characteristically impassioned presentation, Professor Simon Noble highlighted how the risks of both thrombosis and cancer increase with age, but the median age of patients included in studies of CAT is lower than the median age of patients with CAT in the real-world. This means that we may not have appropriate data in a patient group that is at high risk of CAT, and management should therefore be patient centric and individualized.
Noble S. Risk benefit analysis of anticoagulation in elderly cancer patients. ICTHIC, 27–29 May 2022. PL-29
The risk of an interaction between cancer therapy and anticoagulation is an often-cited concern for the treatment of CAT, with guidelines recommending the avoidance of DOACs if there is potential for drug–drug interactions (DDI). The aim of the international, TacDOAC registry is to evaluate the characteristics, bleeding and thrombotic outcomes in patients receiving both DOACs and targeted anti-cancer therapies.7 In this study. the incidence of major bleeding was 4% (95% CI 2–8%), and that of non-major bleeding was 6% (95% CI 3–10%).7 However, caution was noted at the degree of variability in results between the targeted agents included in the study.
Wang T-Z. Drug-drug interactions: implications for anticoagulation use in patients with cancer. ICTHIC, 27–29 May 2022. PL-15
Several targeted therapies, which act upon molecular pathways involved in cancer physiology, are associated with an increased risk of thromboembolism. However, established risk models for thrombosis in patients with cancer may underperform in the setting of targeted therapy, and the risks associated with these treatments should therefore be considered during the development of updated models.
Moik F. Venous and arterial thromboembolism in patients with cancer treated with targeted anti-cancer treatments. ICTHIC, 27–29 May 2022. PL-14
Observed increases in the incidence of VTE in patients with cancer compared with those without are primarily driven by higher rates of incidental pulmonary embolism, resulting from increases in the number of computed tomography scans being performed. This underscores the importance of understanding of the true incidence of CAT and the factors that drive VTE occurrence in these patients.
Mulder F. VTE in cancer in contemporary era. ICTHIC, 27–29 May 2022. PL-01