Curbside Consults Podcast

Published October 25, 2019

Patients with cancer have a significantly higher risk of VTE. How do we assess risk for developing VTE in patients with cancer? Is there a role for primary VTE prophylaxis in cancer patients? If so what are our treatment options? On this podcast, our expert hematologist Dr Jean Connors delves into these questions and more.

00:54 Introduction
01:16 Clinical scenario
01:55 Why patients with cancer are at higher risk for VTE
03:40 Assessing risk of VTE in patients with cancer
05:30 Khorana risk assessment score – what is it?
09:33 When are patients with cancer at highest risk for VTE?
10:37 Introduction of recent literature on VTE prophylaxis in cancer patients
11:51 VTE prophylaxis guidelines in multiple myeloma vs. other cancers
12:41 AVERT trial summary and discussion
14:10 Criteria for major bleeding in VTE prophylaxis studies
14:45 Cassini Trial summary and discussion
15:10 Contrasting the Cassini and AVERT trials
18:15 Main findings of Cassini trial
19:40 Attrition in the AVERT and Cassini trial
21:07 Contrasting Intention to Treat vs. Per Protocol findings in the Cassini trial
22:19 How will these trials change practice?
23:36 Clinical applications of recent trials in use of DOACs in patients with cancer for VTE prophylaxis
24:53 Challenge of assessing bleeding risk in patients with cancer
26:14 Review of literature and approach to treatment of VTE in cancer patients
30:07 The importance of patient education and anticipatory guidance
30:41 Take away points

Listen to the podcast on Statistical Review – Power with Dr. Dave Harrington.

Additional Resources:

1. Apixaban to Prevent Venous Thromboembolism in Patients with Cancer (AVERT)
2. Rivaroxaban for Thromboprophylaxis in High-Risk Ambulatory Patients with Cancer (CASSINI)
3. KHORANA Score
4. Semuloparin for Thromboprophylaxis in Patients Receiving Chemotherapy for Cancer (Save-Onco)
5. Nadroparin for the Prevention of Thromboembolic Events in Ambulatory Patients with Metastatic or Locally Advanced Solid Cancer Receiving Chemotherapy: a randomized, placebo-controlled, double-blind study
6. Comparison of an Oral Factor Xa Inhibitor with Low Molecular Weight Heparin in Patients with Cancer with Venous Thromboembolism: Results of a Randomized Trial (SELECT-D)

The Curbside Consults series complements the foundational information in NEJM R360 Rotation Prep by taking a deep dive into key clinical topics with expert clinicians and educators. These podcasts explore and critique the evidence behind clinical practice and break down statistical concepts for the busy clinical trainee.

Jean M Connors MD is a clinical hematologist at Brigham and Women’s Hospital and Dana Farber Cancer Institute, the Medical Director of the inpatient Hemostatic Antithrombotic Stewardship program and the outpatient Anticoagulation Management Services, and an assistant professor of medicine at Harvard Medical School. She attended Johns Hopkins School of Medicine, did medical residency at Beth Israel Hospital Boston, and completed fellowship training in hematology-oncology at Brigham and Women’s Hospital and in transfusion medicine at the Harvard Joint Program in Transfusion Medicine.
Amanda Fernandes is a 2018-2019 NEJM editorial fellow.