2) … one of the world’s leading authorities on cancer-associated VTE as new faculty both here and on @cardiomet_ce: Dr. Alok Khorana @aakonc of @ClevelandClinic, to talk about advances and best treatment in this space! pic.twitter.com/sPCHClny6d
— @onc_ce (@onc_ce) October 25, 2022
4) Let’s start with a case. 67M retired schoolteacher w/remote history of smoking but no other significant comorbidities presents w/upper abdominal pain radiating to the back + weight loss. CT abdomen reveals mass in pancreas+liver mets. #FNA confirms #pancreaticadenocarcinoma.
— @onc_ce (@onc_ce) October 25, 2022
6) The correct answer is a., full-dose. A large pooled analysis of incidental #PE found recurrent #VTE was lower with anticoag LMWHs or vitamin K antagonists (6.2% or 6.4%), compared to 12% in untreated patients (HR 2.6; 95% CI 0.91-7.3) 🔓https://t.co/ihXOsipLW9 pic.twitter.com/MfmipsHWFk
— @onc_ce (@onc_ce) October 25, 2022
8) . . . their similar clinical outcomes compared with patients with cancer with symptomatic events”
— @onc_ce (@onc_ce) October 25, 2022
🔓https://t.co/L50nzPxEtz
10) Now that you’ve made a decision to anticoagulated, which agent should you choose?
— @onc_ce (@onc_ce) October 25, 2022
12) For initial treatment – if pt requires admission, @ASCO guidelines prefer #LMWH over #UFH. Otherwise, #DOACs (#apixaban, #rivaroxaban) or #LMWH transitioning to warfarin or LMWH monotherapy are all acceptable options . . . but let’s break down pros/cons
— @onc_ce (@onc_ce) October 25, 2022
14) c. Warfarin? That’s also tricky due to drug-drug interactions with 5FU+others, need for INR monitoring but may be appropriate choice in low- & middle-income countries #LMIC or other financial 💰 considerations
— @onc_ce (@onc_ce) October 25, 2022
16) A meta-analysis was performed with a primary outcome of VTE recurrence & key secondary outcomes of major bleeding, clinically relevant non-major bleeding #CRNMB & #gastrointestinal bleeding #GIB. VTE recurrence was lower in the FXaI group, w/absolute risk difference of -4%.
— @onc_ce (@onc_ce) October 25, 2022
18) In general, DOAC studies suggest improvement in recurrent VTE vs LMWH (which already previously showed improvement in rec VTE over warfarin) pic.twitter.com/2gKA7RKvlN
— @onc_ce (@onc_ce) October 25, 2022
20) If you look closely, increased major bleeding was primarily driven by #GIcancers (but really primarily luminal GI cancers) and noted in earlier trials but not in the more recent trials (?selection vs drug).
— @onc_ce (@onc_ce) October 25, 2022
22) Tune in tomorrow to discuss whether this patient’s #PE could have been prevented!
— @onc_ce (@onc_ce) October 25, 2022
Nods to @ThrombosisCan @LaurentBertole1 @ilyassahinMD @MarcCarrier1 @AggieLeeMD @SimonNoble @jzbos @cihan_ay_MD
24) Case reminder: 67M diagnosed with #pancreaticcancer developed #PE 2 months after 1L therapy with FOLFIRINOX. Could this have been prevented? pic.twitter.com/40zai4iYZF
— @onc_ce (@onc_ce) October 26, 2022
26) Although #VTE prophylaxis is used mostly in post-surgical and inpatient settings in pts with cancer, most VTEs actually occur in outpatient setting (since most systemic therapy for cancer is outpatient)
— @onc_ce (@onc_ce) October 26, 2022
28) Initial studies using #LMWH prophylaxis showed statistically significant reduction in #VTE but rates were low since patients were not selected based on risk pic.twitter.com/pvSaAYMBG6
— @onc_ce (@onc_ce) October 26, 2022
30) Validation has occurred in over 70K patients, first by Vienna grp @Cihan_Ay_MD & most recently in an Asian population (with modification for BMI) pic.twitter.com/56fs09Ji0C
— @onc_ce (@onc_ce) October 26, 2022
32) 14 yrs later, there are now multiple risk tools (listed here, in various stages of validation) Esp validated is #Viennascore by Pabinger, @cihan_ay_MD, et al
— @onc_ce (@onc_ce) October 26, 2022
🔓https://t.co/q7ILwvGkDT pic.twitter.com/1sF3THamPh
34) Specifically in #GIcancers (like our case), subgroup analysis of #AVERT showed substantial benefit with apixaban prophylaxis (4.6% VTE w/apixaban vs 20% w/placebo; 1 excess major bleed with apixaban NS) https://t.co/qjsYjJ2zyq
— @onc_ce (@onc_ce) October 26, 2022
36) Regardless, I often get “devil’s advocate” Qs that since prophylaxis does not improve #OS it is not necessary to use. But this is a standard not applied to, say, anti-emetics or bone-strengthening agents. Reduction of #VTE is a good for patients, regardless of impact on OS.
— @onc_ce (@onc_ce) October 26, 2022
38) A terrific model for #implementationscience comes from Vermont @ChrisHolmesMD where 94% of at-risk pts went on outpt prophylaxis slaying myth that cancer pts are not interested in outpt prevention @StopTheClot @lesllake @BethWaldron
— @onc_ce (@onc_ce) October 26, 2022
🔓https://t.co/uWkF2OGMFy pic.twitter.com/JXCDgUVrbc
39) And that's it, you made it! FREE CE/#CME! Just point your 🖱️to https://t.co/Vk2axaxjvW & grab your certificate! And FOLLOW us at @onc_ce and at @cardiomet_ce for more expert-led programs such as this!@academiccme #FOAMed @MedTweetorials @ckd_ce @Myeloma_Doc @AlexSpyropoul
— @onc_ce (@onc_ce) October 26, 2022