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A Summary of Guidelines for the Treatment of Cancer-Associated Thrombosis 09

Conclusion Subcommittee on Haemostasis and Malignancy for the and safety of novel oral anticoagulants versus low
SSC of the ISTH. Management of challenging cases of molecular weight heparin in cancer patients with venous
This review of updated CAT guidelines patients with cancer-associated thrombosis including thromboembolism: A systematic review and

effectively summarizes the treatment recurrent thrombosis and bleeding: guidance from the meta-analysis. Crit Rev Oncol Hematol. 2020;154:103074.
SSC of the ISTH. J Thromb Haemost.
doi:10.1016/j.critrevonc.2020.103074
recommendations for cancer-associated 2013;11(9):1760-1765. doi:10.1111/jth.12338
16) Short NJ, Connors JM. New oral anticoagulants and
VTE. 2 5) Khorana AA, Noble S, Lee AYY, et al. Role of direct oral the cancer patient. Oncologist. 2014;19(1):82-93.
anticoagulants in the treatment of cancer-associated doi:10.1634/theoncologist.2013-0239
venous thromboembolism: guidance from the SSC of the
The majority of guidance points are in ISTH. J Thromb Haemost. 2018;16(9):1891-1894. 17) Mendoza-Sanchez J, Silva F, Rangel L, et al. Benefit,
doi:10.1111/jth.14219 risk and cost of new oral anticoagulants and warfarin in
agreement with each other and emphasize atrial fibrillation; A multicriteria decision analysis. PLoS

on individualized treatment regimens after 6) Farge D, Frere C, Connors JM et al. 2019 international One. 2018;13(5):e0196361. Published 2018 May 3.
doi:10.1371/journal.pone.0196361
clinical practice guidelines for the treatment and
shared decision-making between the prophylaxis of venous thromboembolism in patients with
cancer. Lancet Oncol 2019;20:e566–e581.
healthcare professionals (HCPs) and the
patients. 2 7) National Comprehensive Cancer Network. 2020. NCCN
guideline on cancer associated venous thromboembolic
disease. Version 1. 2020.
The latest guidelines by the ASCO, ISTH, 8) Muñoz Martín AJ, Gallardo Díaz E, García Escobar I, et

ITAC, and SEOM 3,5,6,8 recommend the use of al. SEOM clinical guideline of venous thromboembolism
(VTE) and cancer (2019). Clin Transl Oncol.
DOACs owing to the growing real-world 2020;22(2):171-186. doi:10.1007/s12094-019-02263-z

evidence of their safety and efficacy in the 9) Soff GA, Mones J, Wilkins C, et al. Rivaroxaban
treatment of CAT. 15 treatment of cancer-associated venous
thromboembolism: Memorial Sloan Kettering Cancer
Center institutional experience. Res Pract Thromb
Haemost. 2019;3(3):349-356. doi:10.1002/rth2.12215
Despite the advantages of DOACs over Methods: associations of psoriasis with VTE or PVD.

parenteral anticoagulants and a favorable 10) Investigators E, Bauersachs R, Berkowitz SD, Brenner This review and meta-analysis followed the Had an exposure group that had patients with
B, Buller HR, Decousus H, et al. Oral rivaroxaban for
risk-benefit profile, careful patient selection symptomatic venous thromboembolism. N Engl J Med. Meta-analysis of Observational Studies in psoriasis and a non-exposure group that had
2010;363:2499–510.
should be made to avoid bleeding risks, renal Epidemiology (MOOSE) reporting guideline patients without psoriasis.
4
complications, and drug-drug interactions 2,16, 11) Investigators E P, Buller HR, Prins MH, Lensin AW, group19 and the Preferred Reporting Items for Reported the risk estimates of VTE and/or
Decousus H, Jacobson BF, et al. Oral rivaroxaban for the
17. treatment of symptomatic pulmonary embolism. N Engl J PVD.
Med. 2012;366:1287–97. Systematic Reviews and Meta-analyses
(PRISMA) reporting 2020 guideline. Studies with confirmed clinical diagnoses of
5
References: 12) Young AM, Marshall A, Thirlwall J, et al. Comparison psoriasis, VTE, and PVD.
of an Oral Factor Xa Inhibitor With Low Molecular Weight
Heparin in Patients With Cancer With Venous
1) Streiff MB. Thrombosis in the setting of cancer. Thromboembolism: Results of a Randomized Trial Data Sources:
Hematology Am Soc Hematol Educ Program. (SELECT-D). J Clin Oncol. 2018;36(20):2017-2023. Studies excluded:
2016;2016(1):196-205. doi:10.1200/JCO.2018.78.8034 MEDLINE, Embase, Cochrane Library, Web of
doi:10.1182/asheducation-2016.1.196 Science, and the Cumulative Index to Nursing Cross-sectional studies, case-control studies,
13) Khorana AA, Soff GA, Kakkar AK, et al. Rivaroxaban for
2) Streiff MB, Abutalib SA, Farge D, Murphy M, Connors Thromboprophylaxis in High-Risk Ambulatory Patients and Allied Health Literature were searched for case reports, editorials, review articles, and
JM, Piazza G. Update on Guidelines for the Management with Cancer. N Engl J Med. 2019;380(8):720-728. nonhuman studies were excluded. 2
of Cancer-Associated Thrombosis. Oncologist. doi:10.1056/NEJMoa1814630 publications that studied the associations of
2021;26(1):e24-e40. doi:10.1002/onco.13596 psoriasis with VTE or PVD from their
14) Cohen AT, Maraveyas A, Beyer-Westendorf J, et al.
3) Key NS, Khorana AA, Kuderer NM, et al. Venous Patient-reported outcomes associated with changing to respective inception to May 21, 2021. 2 Data Extraction:
Thromboembolism Prophylaxis and Treatment in Patients rivaroxaban for the treatment of cancer-associated First author, year of publication, country,
With Cancer: ASCO Clinical Practice Guideline Update. J venous thromboembolism - The COSIMO study. Thromb
Clin Oncol. 2020;38(5):496-520. Res. 2021;206:1-4. doi:10.1016/j.thromres.2021.06.021 Study Selection Criteria: database, study period, patient characteristics
doi:10.1200/JCO.19.01461
15) Camilli M, Lombardi M, Vescovo GM, et al. Efficacy Cohort studies that examined the (sample size, mean age, and sex), definition of
4) Carrier M, Khorana AA, Zwicker J, Noble S, Lee AY;

psoriasis, and outcomes of interest (VTE and There were 9 (69.2%) studies that reported The pooled risk estimates differed with incident VTE in patients with psoriasis but

PVD). 2 HR or SIR and were selected for quantitative geographic locations, with studies done in not in the US (Table 1).
2
The adjusted risk estimates, including hazard meta-analysis (Figure 1). Asia and Europe showing an increased risk of

ratios (HRs), risk ratios (RRs), and
standardized incidence ratios (SIRs), with 95%

confidence intervals (CIs). 2

Data Synthesis:
The meta-analyses were conducted using

Review Manager version 5.4.1 (The Cochrane
Collaboration), and Stata, version 17

(StataCorp). A P value of <0.05 was defined as
statistically significant. 2

HRs and SIRs were used for meta-analysis to
analyse risk for the entire study period. The

adjusted risk estimates of subgroups were
pooled when overall effects were not

available. 2
Crude risk estimates with 95% CI were

calculated when not available in the studies. 2
I statistic was used to quantify between-study Risk for Incident VTE:
2
heterogeneity with I >50% indicating moderate Based on the 9 studies (12,052,781
2
heterogeneity. 2 participants) examined, patients with

psoriasis had a 1.26-fold increased risk for
Results: incident VTE than those without psoriasis

Study Selection and their characteris- (pooled HR, 1.26; 95%, CI 1.08-1.48; I = 93%)
2
tics: (Figure 2). 2
A total of 1836 records were retrieved from

the literature search, 13 cohort studies The association remained significant in
(12,435,982 participants) out of which were patients with psoriatic arthritis but did not

selected for qualitative review (Figure 1). increase significantly in patients with
psoriasis alone (Table 1). 2

Out of the 13 studies selected, 9 (69.2%)
reported the risk estimates of incident VTE, The studies done on women showed an

and 4 (30.8%) reported the risk estimates of increased risk for VTE as opposed to those

incident PVD (Figure 1). done on men(Table 1). 2