2a) The program is intended for #healthcare professionals & supported by an independent educational grant from Anthos Therapeutics. Statement of accreditation & faculty disclosures at https://t.co/8oShcATovC.
— @onc_ce (@onc_ce) December 13, 2023
3) The problem #CAT = #cancer-associated #thrombosis is that pts w/cancer have an ⬆️risk of thrombosis
— @onc_ce (@onc_ce) December 13, 2023
🚨20%-30% of all #VTE occur in pts with cancer
🚑 #CAT is associated w/⬆️morbidity & mortality
Great schematic here from fellow faculty @aakonc , https://t.co/gteyliAuDp pic.twitter.com/PhWqzdNVvw
5) Evidence ➡️cancer itself is associated with a state of #hypercoagulability, driven by release of #procoagulant factors e.g. tissue factor #TF, from malignant tissue, & by inflammation-driven activation of endothelial cells, #platelets, & #leukocyteshttps://t.co/0atQUs2ipP pic.twitter.com/I3mtW4ljau
— @onc_ce (@onc_ce) December 13, 2023
7) Per 🔓 https://t.co/TfppSeg4km, the risk of #VTE varies over the natural history of #cancer, with the highest risk occurring during hospitalization and following the development of #metastatic disease. pic.twitter.com/piLWKFgcoj
— @onc_ce (@onc_ce) December 13, 2023
9) To that point, #LMWH was the 🪙 standard tx of acute #CAT for 15 years, based on #CLOT trial: ⬇️ #VTE recurrence w/ #dalteparin compared to #VKA.
— @onc_ce (@onc_ce) December 13, 2023
Since then, dalteparin (w/ dose ⬇️ to 75% after 1 mo) has become the comparator for all major studies
🔓 https://t.co/THDX0NfdNk pic.twitter.com/Fd1W6YWLoj
11) These were followed by #CANVAS, a #pragmatic #effectiveness trial of pts w/ #CAT randomized to #DOAC vs "SOC."
— @onc_ce (@onc_ce) December 13, 2023
Results:
1⃣ DOAC noninferior for preventing recurrent VTE
2⃣ No diff in major 🩸 (58.5% of DOAC was #apixaban)
3⃣ better adherence with DOAChttps://t.co/arT0KpuZ4O pic.twitter.com/6HilLZDIw1
13a) In #cancer, tho, one size rarely fits all. #Gastrointestinal #GI tumors are a problem! In #SELECT_D (riva vs dalt) the #DSMB advised enrolling no more upper GI malignancies. In #HOKUSAI, major 🩸on edox were GI in 22/32 cases, vs 5/16 GI with dalteparin.
— @onc_ce (@onc_ce) December 13, 2023
14) So how do we currently treat acute #CAT? There are many considerations: pic.twitter.com/aWXeP8Yozm
— @onc_ce (@onc_ce) December 13, 2023
16) Recurrent #VTE in #cancer: pic.twitter.com/VWvyaOvDou
— @onc_ce (@onc_ce) December 13, 2023
17b) See how we practice at🔓 https://t.co/2mi3v4rwRC: pic.twitter.com/WNLDFGtz2o
— @onc_ce (@onc_ce) December 13, 2023
19a) How long to treat?
— @onc_ce (@onc_ce) December 13, 2023
Most #RCT for #CAT 🛑at 6mos ➡️ guidelines advise only on tx first 6mos after acute VTE
👉 #DALTECAN: Ph 4 prospective single arm safety trial of dalteparin over 12mos ➡️low rate major bleeding🩸
(cont)
19c) Current consensus–beyond guidelines–is to continue therapeutic dose anticoagulation in the setting of persistent #cancer or continued cancer treatments pic.twitter.com/5E423RPlys
— @onc_ce (@onc_ce) December 13, 2023
20b) #EVE—presented at ISTH June 2023, NCT03080883
— @onc_ce (@onc_ce) December 13, 2023
At 12 months:
🩸MB+CRNMB: 8.9% vs 12.2% (HR 0.72, 95% CI 0.38-1.37)
🚑recurrent VTE: 5.0% vs 4.4% (HR 1.00, 95% CI 0.40 – 2.53)#API_CAT—ongoing pic.twitter.com/4an7rnCNHu
21b) Rationale 2⃣ : #FXI is a promising 📷for inhibition of pathologic thrombosis w/ minimal impairment of physiologic hemostasis 📷#FXI #ASO requires 30d lead in to suppress FXI production & 📷 levels, so not practical for acute VTE treatmenthttps://t.co/Igqaf9QnAl
— @onc_ce (@onc_ce) December 13, 2023
22a) #Abelacimabtrials for patients with #CAT are underway and have been designed with the issues in mind–esp about #intraluminal tumors–that we covered above in posts 13a & 13b ⤴️
— @onc_ce (@onc_ce) December 13, 2023
22c) Why two RCTs? For some pts with #CAT, #LMWH is the standard & for others #DOACs are the standard. The two concurrent RCTs address both these populations–with different 🩸 risk levels–with different control arms.
— @onc_ce (@onc_ce) December 13, 2023
23b) It's c, particularly #intraluminal #GI (and #GU) tumors. Current #SOC for #CAT in affected pts is #LMWH.
— @onc_ce (@onc_ce) December 13, 2023
24b) It's b, interference with thrombosis. By selectively inhibiting the intrinsic pathway at the #FXIa step, physiologic #hemostasis is not directly impacted, but pathologic #thrombosis is. For more education on this, ✔️out (& earn more🆓CE/#CME) at https://t.co/OQZyzk57I2
— @onc_ce (@onc_ce) December 13, 2023
25b) The #DMC for that study recommended closing it because of an "inferior efficacy" signal for #asundexian compared with the #DOAC. As noted above, in the #ASTER Ph 3 trial for #CAT, the #MAb #FXI inhibitor #abelacimab is being compared to apixaban.
— @onc_ce (@onc_ce) December 13, 2023
26) Thanks for joining us! You just earned 0.5hr 🆓CE/#CME, & you can claim your certificate NOW at https://t.co/mtM167V7LD. And join expert faculty @connors_md in FOLLOWING @onc_ce for the best #MedEd available wholly by #tweetorial!
— @onc_ce (@onc_ce) December 13, 2023