During the ICTHIC webinar, “Challenges in the management of fragile CAT patients (older patient population & palliative care),” Prof. Simon Noble gave a lecture on some of the challenges facing the elderly with cancer-associated thrombosis (CAT). Here, we summarize the key messages of his speech. You can also watch Simon Noble’s lecture in the video below and the full webinar recording here.
The complex management of frail patients with CAT
Managing patients with cancer who are frail is a highly complex task. This is because there is no clear agreement on what exactly constitutes frailty, inadequate clinical trial data to rely on, and a lack of specific guidelines to follow.
Age carries specific issues, such as an increased risk of VTE (irrespective of cancer), bleeding, and a reduced renal function that complicates anticoagulant excretion. Utilizing a customized approach for administering anticoagulant treatment in this population is important. This can be achieved through an algorithm that factors in the patient’s malignant disease’s unique characteristics and overall physical frailty [1].
Lack of specific guidelines
The current anticoagulant treatment guidelines for managing CAT may not fully apply to frail patients with cancer due to the lack of specific clinical studies. In fact, guidelines are based on randomized control trials, which do not represent the fragile and elderly population.
A study tried to analyze how many patients seen in clinical practice would be eligible for a direct oral anticoagulant randomized controlled trial (RCT) using the inclusion criteria of the CARAVAGGIO study. Results showed that half of the population met one or more criteria for non-inclusion [2].
The same conclusions can be drawn from the inclusion analysis performed in the Select-D trial, where of over the 2000 patients screened for inclusion, approximately 1100 were not eligible for the study [3].
These data indicate that 50% of the patients would not be eligible for an RCT. RCTs serve as the foundation for clinical guidelines, yet a significant knowledge gap remains in guiding clinical practice.
“Data from a German registry [4] show the mean age of cancer patients and patients with CAT is about 72 years, while the clinical studies that we base our knowledge on are in a population much younger than that (median age from 61–67 years),” said Prof. Noble.
Looking at some raw supplementary data from the RCT analyzing the use of apixaban for treating CAT, it seems that in patients aged 75 years and over, when dealing with VTE recurrence, data favors dalteparin rather than apixaban, contrary to what is recommended in the guidelines [5].
Likewise, low-molecular-weight heparins are more favored in major bleeding than apixaban [5].
“These results indicate that different VTE and bleeding rates exist in different age groups, and different therapeutic agents might be best suitable to different age groups,” said Prof. Noble.
“Similarly, guidelines available are suitable for managing a population where every patient is of average age, average renal function, average size cloth in an average size area receiving average chemotherapy, but that’s no help because the real world is much more heterogeneous and most of the patients are excluded from the trials.”
As previously said, age increases the risk of thrombosis, the likelihood of cancer, and frailty. But being a certain age doesn’t mean being frail. Different ages, different people have different finesses, comorbidities, different amounts of drugs, and also different cognitive functions.
Identifying frailty in patients with cancer-associated thrombosis is crucial since it affects the complexity of their anticoagulant treatment.
Conclusion
Managing patients with cancer who are frail can be quite complicated. This is because there is no agreement on what exactly frailty means, limited evidence from clinical trials, and no established clinical guidelines.
When evaluating frailty patients with cancer, it’s important to consider several factors. These include the patient’s overall condition (including nutritional status, body weight, and mobility), the type of cancer (especially gastrointestinal, lung, and multiple myeloma), and any comorbidities. Advanced age is also a crucial factor to consider [1].
It is important to consider the potential negative effects of poly-pharmacotherapy and cognitive impairment, such as drug interactions, compromised adherence to treatment, blood disorders, increased risk of falls, and decreased life expectancy, on a case-by-case basis [1].
Decision-making is quite complex for clinicians in this population vulnerable population. Identifying and assessing frailty in patients with CAT is essential to optimize anticoagulant treatment while maintaining quality of life.
Watch Simon Noble’s lecture:
References
- Scotté F, Leroy P, Chastenet M, Aumont L, Benatar V, Elalamy I. Treatment and Prevention of Cancer-Associated Thrombosis in Frail Patients: Tailored Management. Cancers (Basel). 2019;11(1):48. doi:10.3390/cancers11010048
- Abstracts of the 11th International Conference on Thrombosis and Hemostasis Issues in Cancer Bergamo, Italy May 27–29, 2022. Thromb Res 2022:213(Suppl 2):S1-S46.
- Young AM, Marshall A, Thirlwall J, et al. 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). J Clin Oncol. 2018;36(20):2017-2023. doi:10.1200/JCO.2018.78.8034
- Krebs in Deutschland 2017/2018. 13. Ausgabe. Robert Koch-Institut (Hrsg) und die Gesellschaft der epidemiologischen Krebsregister in Deutschland e.V. (Hrsg). Berlin, 2021. Link: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.krebsdaten.de/Krebs/DE