ASH 2015

How is cancer-related venous thromboembolism treated in real world practice?

Prof Alok Khorana - Cleveland Clinic, Cleveland, USA

Venous thromboembolism is an issue in cancer and there are guidelines about how to treat it. But you’re looking into perhaps considering whether the guidelines are right or giving people advice. What did you do in this study that you’re reporting here?

We looked at practice patterns of what anticoagulants are used by clinicians and by patients in the real world setting. This was data from 2013 and 2014 so it’s really, really new. What we found was that even though low molecular weight heparins are the recommended guideline treatment only about a quarter of patients were getting that and half the patients were still getting warfarin, which is a much older drug, and about a quarter of patients were getting rivaroxaban which is one of the newer agents in this setting.

What do you think are the reasons for that, even though low molecular weight heparin is in the guidelines?

One big reason is convenience. The low molecular weight heparins are daily self-injections; cancer patients are already going through a lot of stuff and to add a daily self-injection is problematic. A second reason is cost, especially in the United States the costs of the low molecular heparins are substantially greater and direct to patient costs can also be quite high, depending on the type of insurance, health insurance, that patients have.

So from your investigation in the real world setting, what guidance can you give us now on this?

It sounds like, and it’s not just our abstract but there are a couple of other abstracts presented today, and it appears that using novel oral agents such as rivaroxaban is appropriate in some settings and in carefully selected patients. The guidelines will need to take this information into hand before making new recommendations. There are certainly high risk patients who are at really high risk for getting blood clots come back and in those patients it’s still appropriate to use low molecular weight heparins.

So really there’s a case to be made for looking into this rather seriously and perhaps revising guidelines, do you think?

Absolutely. I think there needs to be a risk adapted approach where we make one recommendation for patients who are at high risk and a different recommendation for patients who may not be as at high risk for recurrence of their thrombosis.

So how would you distil what doctors need to remember coming out of your piece of research here?

Number one is that many of these patients are admitted to the hospital for treatment of their thrombosis and that’s not really necessary. Many of these newer agents and even the older agents can be successfully treated in the outpatient setting. Also no need to admit the patient to the hospital unless they’re really sick. Second, use the appropriate anticoagulant, depending on the setting, and third, keep patient centeredness in mind, patient preferences are important in this setting, whether related to cost or other preferences and that should be kept in mind as well.

And many patients could be on an oral NOAC.

It’s certainly possible, yes.