How I Manage Cancer-Associated Thrombosis

Abstract

In this concise review, we discuss some common clinical challenges in the management of patients with cancer-associated venous thromboembolism (VTE), a frequent complication in patients with cancer that increases morbidity and mortality. While direct oral anticoagulants (DOACs) have been established in clinical practice for anticoagulation in patients with VTE without cancer, their efficacy and safety in patients with cancer have not been assessed in randomized controlled trials until recently. The choice of the appropriate anticoagulant agent in the era of DOACs to treat patients with cancer-associated VTE is based on balancing the risk of recurrence against the risk of bleeding, and potential drug–drug interactions. However, the management of patients is challenged by special scenarios such as incidentally diagnosed pulmonary embolism and catheter-related thrombosis, and sometimes complicated by concomitant thrombocytopenia. We provide guidance for management of cancer-associated VTE in different clinical scenarios in a case-based manner and briefly review recent clinical studies and guidelines to explain our approach to management of the cases.

Extended anticoagulation treatment for cancer‐associated thrombosis—Rates of recurrence and bleeding beyond 6 months: A systematic review

“…The treatment of cancer‐associated VTE has recently evolved with the introduction of direct oral anticoagulants (DOACs) into clinical practice after demonstration of non‐inferiority compared to low molecular weight heparin (LMWH), the long‐standing mainstay of therapy 4,8‐12 . However, management of VTE in patients with cancer remains challenging as they are at 2‐fold higher risk of major bleeding and 3‐ to 7‐fold higher risk of VTE recurrence during anticoagulation treatment compared to non‐cancer patients with VTE 13‐15 …”

Prevention and Treatment of Side Effects of Immunotherapy for Bladder Cancer

“…In the case of bleeding disorder, prompt supplementation of platelets, vitamin K and other pro-coagulant medications; A blood clot is a serious condition that needs treatment right away, the management of thrombosis consists of anticoagulation with warfarin or rivaroxaban, followed by thrombolytic therapy with urokinase or streptokinase. Besides, extra care should be taken during daily activities to avoid circumstances that may lead to bleeding and thrombosis ( 116 , 117 ). Sepsis, on the other hand, requires the selection of appropriate antibiotics, aggressive anti-infection treatment, increasing resistance, avoiding late nights and exertion, and avoiding the intake of unclean water and food.…”

Survival patterns among venous thromboembolism patients with hematologic malignancies in Alberta, Canada from 2003 to 2015

“…The high risk of VTE recurrence, especially in the early phase after diagnosis of cancer-associated VTE, necessitates the administration of therapeutic anticoagulation for a minimum of 6 months or longer, if the cancer is still active or antineoplastic treatment is continued [16][17][18][19][20]. Until recently, low-molecular weight heparin (LMWH) was the preferred and recommended agent in this setting.…”

“…Especially in patients at high risk for VTE progression in the acute phase (within 30 days), adequate platelet counts should be sustained to enable full dose anticoagulation as of the high risk for VTE recurrence. In patients with platelet counts above the threshold of 50 G/L, a personalized treatment approach should be pursued, with DOAC recommended in patients at low risk of bleeding and in the absence of co-medication with a potential for drug-drug interactions, and LMWH recommended in the case of increase bleeding risk from the gastrointestinal or genitourinary tract [16][17][18][19][20]. Fig.…”