Prof Grigoris Gerotziafas of Paris, France, shares insights on risk assessment and prophylactic management of venous thromboembolism in patients with cancer

Expert Perspectives in Cancer Care with Grigoris Gerotziafas, MD, PhD

Aptitude Health recently spoke with Grigoris Gerotziafas, MD, PhD, from Sorbonne University in Paris, France, to learn his views on risk assessment and prophylaxis for cancer-associated thrombosis. Prof Gerotziafas, a leading expert in the field of thrombosis and hematology, is the director of the . His work focuses on the intricate interplay between cancer cells, blood coagulation, and endothelial cells. His leadership extends to the postgraduate thrombosis and hemostasis in hematology masters program at Sorbonne University, guiding future specialists in this critical field. Internationally recognized, Prof Gerotziafas’ expertise spans cancer-associated thrombosis, antithrombotic treatment, and vascular complications in pregnancy and subfertility. His pioneering work includes leading the ROADMAP-Thrombosis project, which aims to identify crucial biomarkers for hypercoagulability in conditions such as solid tumors, hematologic malignancies, COVID-19, and vascular pregnancy complications. He also heads the , an international collection of experts responsible for developing multiple risk assessment models for diverse medical scenarios including cancer-associated thrombosis. Here is a recap of our conversation.

 

How significant is thrombosis as a complication in patients with cancer?

First, we need to consider recent epidemiologic data to understand the burden of cancer-associated thrombosis. These data help us understand the impact of cancer-associated thrombosis on patients’ quality of life and survival, and the financial impact on the health care system. The first data, from the early 21st century, established that cancer-associated thrombosis is the second leading cause of death in patients with cancer. This is critical because therapeutic advancements in oncology have transformed many cancer types into chronic diseases. Patients live longer but often die from cancer-associated thrombosis, a preventable disease. This must be communicated to oncologists, patients, and society.

The second point is the increased occurrence of thrombosis in patients with cancer, which is 2 to 5 times higher compared with patients without cancer, elevating the risk of death. This increase also concerns cancers considered curable today, such as breast and prostate cancer, and some hematologic malignancies. The occurrence of thrombosis in patients with cancer dramatically changes the natural history of the disease, diminishing the benefits achieved by new anticancer treatments and strategies.

Venous thromboembolism (VTE) in oncologic patients is a major, long-lasting health problem. The frequency of VTE is increasing and expected to continue rising. For example, in 2000, the cumulative incidence of VTE in patients with cancer was about 1.5%. In 2024, it’s approximately 5%, with projections suggesting an increase to about 8% in the coming years. This increase is due to longer patient survival, cancer cell activation of blood coagulation, and patients developing cardiovascular risk factors.

Additionally, new anticancer drugs, including targeted treatments and modern cellular treatments like chimeric antigen receptor T-cell therapy, are effective and better tolerated compared with conventional chemotherapy, but they increase cancer-associated thrombosis risk. This impacts patients’ quality of life and treatment schedules. The financial burden is also significant; each episode of VTE in a patient with cancer costs approximately €11,000 (approximately $11,845 US), with the cost of patients experiencing thrombosis being 4 times higher due to the need for more aggressive and expensive drugs.

 

Has there been any advancement in diagnosis or treatment of cancer-associated thrombosis?

Yes, there has been progress. About 4% to 10% of patients with unprovoked VTE have thrombosis as the first clinical manifestation of cancer. Early cancer diagnosis in these cases is vital. Additionally, the risk of VTE increases 6-fold in the first 6 months after a cancer diagnosis. Awareness of this high-risk period allows for targeted early pharmacologic thromboprophylaxis with low-molecular-weight heparin or direct oral anticoagulants, significantly reducing the incidence of VTE.

Risk assessment models help identify high-risk patients for cancer-associated thrombosis. The recommendation is to assess risk on the day of cancer diagnosis and start pharmacologic thromboprophylaxis in high-risk patients immediately. Postsurgery, the risk of thrombosis increases 5 to 6 times. We have tools to identify patients who, after the initial month of recommended thromboprophylaxis, remain at high risk and need extended prophylaxis. In patients with cancer that is in remission or resistant to treatment, adapted risk assessment models can guide the provision of pharmacologic thromboprophylaxis.

These approaches, recommended in European Society for Medical Oncology guidelines, allow us to effectively manage thrombosis without a high bleeding risk. Clinical trials with orally active anticoagulants like apixaban and rivaroxaban have shown a 60% decrease in the occurrence of VTE. These drugs, along with low-molecular-weight heparin, also positively impact patients’ quality of life.

 

Should oncologists have sole responsibility for diagnosis and management of VTE, or is a multidisciplinary approach necessary?

This is a very pertinent question. Patients with cancer are not seen only by oncologists. They often visit general practitioners more often than oncologists. Increasing oncologists’ awareness is crucial, as only 10% currently apply preventive measures and conduct risk assessments for VTE. General practitioners, who follow patients in daily life, must also be educated to use risk assessment models and prescribe pharmacologic thromboprophylaxis to high-risk patients. Additionally, dedicated outpatient consultations for thrombosis in oncology are vital to help manage anticoagulant treatment, ensuring compatibility with cancer drugs and patient adherence. The third critical aspect is raising public awareness of cancer-associated thrombosis. Targeted education at the societal level can prompt patients to inquire about their thrombosis risk, leading to appropriate prophylactic measures.