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week 4.
Factors underlying cancer associated
thrombosis (CAT)
Cancer promotes hypercoagulability in patients
due to some or all of the following factors :
3
Long-term chemotherapy
Endothelial damage
Obstruction to blood flow by tumor masses
Procoagulant microparticles released from
cancer cells
Comorbid conditions
Advanced age
Restricted mobility
Management of VTE in cancer patients
Due to high VTE recurrence risk in patients with
CAT, especially in the first 6 months, extended
anticoagulation therapy has been recommended
if the bleeding risk is low.
4,5
guidelines
previous
The
included
low-molecular-weight heparin (LMWH) based
anticoagulation
antagonists (VKAs) for the initial and long-term
Vasoclick, Edition 1 therapy over vitamin
5) National Comprehensive Cancer Network.
Cancer-associated venous thromboembolic disease,
Version 1.2020. National Comprehensive Cancer Network,
Inc.; 2020. Available at: https://www.nccn.org/profession
als/physi cian_gls/pdf/vte.pdf [accessed 22 March 2022].
6) Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK,
Khorana AA, Leavitt AD, Lee AY, Macbeth F, Morgan RL,
Noble S. American Society of Hematology 2021
guidelines for management of venous thromboembolism:
prevention and treatment in patients with cancer. Blood
Adv. 2021; 5(4):927-974.
doi:10.1182/bloodadvances.2020003442
7) Yeh CH, Hogg K, Weitz JI. Overview of the new oral
anticoagulants: opportunities and challenges. Arterioscler
Thromb Vasc Biol. 2015;35:1056-1065.
8) Cohen AT, Maraveyas A, Beyer-Westendorf J, Lee AY,
Folkerts K, Abdelgawwad K, De Sanctis Y, Fatoba S,
Bamber L, Bach M, Mantovani LG. Patient-reported
outcomes associated with changing to rivaroxaban for
the treatment of cancer-associated venous
thromboembolism–The COSIMO study. Thromb Res.
2021; 206; 1-4. doi: 10.1016/j.thromres.2021.06.021
9) Maraveyas A, Beyer-Westendorf J, Lee AY, et al.
Cancer-Associated ThrOmboSIs - Patient-Reported
OutcoMes With RivarOxaban (COSIMO) - Baseline
characteristics and clinical outcomes. Res Pract Thromb
Haemost. 2021;5(8):e12604. doi:10.1002/rth2.12604
safety. The major drawbacks associated with
4, 5
VKA include strict requirement of monitoring of
international normalized ratio (INR) to track
anticoagulation status and interactions with food
and drugs.
4,5
However, patients’ adherence towards LMWH
over oral anticoagulants is low thereby affecting
patient outcomes. Major reasons are as follows :
4
Inconvenient intravenous infusion requires
recurrent hospital visits and clinical care
High treatment cost
Recently the international guidelines have been
updated to include recommendations for DOACs
in patients with cancer and VTE. The American
4,5
Society of hematology (ASH) 2021 guidelines
recommend the use of direct oral anticoagulants
(DOACs) for the short term treatment of VTE in
active cancer over low molecular weight heparin
(LMWH).
6
Rivaroxaban is a promising and convenient
K treatment of CAT owing to superior efficacy and
04
it can be administered to patients as a fixed oral
dose and without any requirement of routine
anticoagulation monitoring.
8
Cancer-associated thrOmboSIs –
patient-reported outcoMes with rivarOx-
aban (COSIMO) study:
The COSIMO study was designed to evaluate
patient satisfaction after planned change from
traditional anticoagulant therapy to rivaroxaban
therapy for cancer associated thrombosis
(CAT).
8, 9
Study plan:
A prospective, non-interventional, single-arm
cohort study enrolled patients from 55 sites
across Australia, Canada and Europe. 505
8,9
cancer patients who received rivaroxaban were
included in the study. During analysis, ratings
6
were reverse coded; as a result, higher scores
reflected greater patient treatment satisfaction.
Observations lasted for 6 months or until the
participant withdrew consent, died, or was lost to
treatment option for patients with CAT, because
9
questionnaires were performed at baseline, week
4, and months 3 and 6 for pairwise comparison
to mean scores at baseline (Figure 1).
8
Study outcome:
1) Percentage of patients who switched to
Rivaroxaban from other therapies
Majority of patients changed to Rivaroxaban
from LMWH therapy (96.65%), while few patients
changed from VKA and Fondaparinux as well
(Figure 2).
8
8 follow-up. Anti-Clot Treatment Scale (ACTS)
The common reasons for shifting to rivaroxaban
were mainly patient-related that were dependent
on their preferences and desires, as summarized
in table 1.
8
3) Patient-reported treatment satisfaction on
the ACTS Burdens subscale after switching to
Rivaroxaban :
8
a) At Baseline:
ACTS burden score was 51.8 out of 60
b) At Week 4:
Patients who remained in the study:
ACTS Burden score was significantly higher
(55.6 out of 60).
Significant
in
treatment
increase
satisfaction.
c) At 3 months and 6 months:
The ACTS Burden score was 56.2 and 56.5 out
of 60 at 3 and 6 months, respectively.
The results were statistically significant as in
2) Reasons for switching to rivaroxaban
Following a shift to rivaroxaban, there was a
significant improvement in patient treatment
satisfaction on the ACTS Burdens subscale at
week 4 and maintained at months 3 and 6.
The immediate increase in treatment
satisfaction at week 4 is strongly supportive
of treatment dependent nature of the change
in satisfaction.
The COSIMO study demonstrates that CAT
patients who changed their VTE treatment to
Rivaroxaban experienced :
improved
everyday clinical practice.
reduced anticoagulation burden (patient
reported).
This can improve long term persistence and
clinical outcomes.
References
1) Agnelli G, Verso M. Management of venous
thromboembolism in patients with cancer. J Thromb
Haemost. 2011;9:316-324.
doi:10.1111/j.1538-7836.2011.04346.x
2) Blom JW, Vanderschoot JP, Oostindi r MJ, Osanto S,
van der Meer FJ, Rosendaal FR. Incidence of venous
thrombosis in a large cohort of 66,329 cancer patients:
results of a record linkage study. J Thromb Haemost.
2006;4(3):529-535.
doi:10.1111/j.1538-7836.2006.01804.x
3) Campello E, Henderson MW, Noubouossie DF, Simioni
P, Key NS. Contact system activation and cancer: new
insights in the pathophysiology of cancer-associated
thrombosis. Thromb Haemost. 2018;118 (2):251-265.
doi:10.1160/TH17-08-05962014.59.7351
4) Key NS, Khorana AA, Kuderer NM, et al. Venous
thromboembolism prophylaxis and treatment in patients
with cancer: ASCO clinical practice guideline update. J
Clin Oncol. 2020;38:496-520.
Conclusion 8 treatment 8 satisfaction 8 in