Management of cancer-associated venous thromboembolism – a case-based practical approach

Abstract

Summary:In patients with solid tumours or haematological malignancies, venous thromboembolism (VTE) is a leading cause of death and signifi cantly contributes to morbidity and healthcare resource utilization. Current practice guidelines recommend long-term anticoagulation with low-molecular-weight heparin (LMWH) as the treatment of choice for cancer-associated VTE, based on clinical trial data showing an overall improved safety and effi cacy profi le of LMWH compared to vitamin K antagonists.However, several open questions remain, e. g. with regard to the intensity and duration of LMWH therapy; moreover, recent realworld evidence indicates that adherence to parenteral anticoagulation with LMWH over the course of treatment is poor in clinical practice. In this regard, the direct oral factor Xa or thrombin inhibitors (DOACs) have emerged as potential alternatives in the management of patients with cancer-associated VTE, albeit fi ndings from randomized controlled studies with a direct head-tohead comparison of DOACs with LMWH, the current standard of care, are still lacking. Based on the case of a lymphoma patient experiencing symptomatic pulmonary embolism during immunochemotherapy, this article aims at both highlighting the current state-of-the-art approach to cancer-associated VTE and pointing out some of the unresolved, controversial issues clinicians have to face when taking care of haematology and oncology patients with already established or with high risk of developing VTE. These issues include the management of patients with incidental pulmonary embolism or thrombocytopenia, the use of DOACs, and the initiation of pharmacological thromboprophylaxis in non-surgical cancer patients.

Venous Thromboembolic Disease and Cardio Oncology

“…The Danish Cancer Registry indicated an increased risk of mortality in tumor patients with VTE compared to those without VTE. Possibly, patients with malignancies and VTE represent a cohort of more aggressive tumors accompanied with clotting system deregulation [4,21].…”

“…Rivaroxaban, apixaban and edoxaban as well as the direct thrombin inhibitor dabigatran, (NOACs) may offer a precious therapeutic alternative to LMWH in special subgroups of cancer patients, albeit until now no clinical trial has presented a head-to-head comparison of NOACs vs LMWH in cancer patients with acute VTE [21,22].…”

“…To date, no study has specifically evaluated the optimal duration of anticoagulation in the setting of cancerassociated VTE in order to avoid recurrences [21]. The CANTHANOX and LITE studies presented their results with three months anticoagulation treatment, while in the CLOT, ONCENOX, and CATCH trials, anticoagulant treatment lasted six months [33,34].…”

“…As the risk of recurrences is higher for the period 1-3 months post VTE diagnosis and diminishes thereafter to insignificant percentages, discontinuation of anticoagulation must be considered, if treatment has already been given for a 3 months period. The management of thrombocytopenic cancer patients with dose-adjusted LMWH is the only choice and recommendations should be based on experts' opinion and empirical knowledge [21].…”

“…Routine imaging tests for cancer staging reveals a small percentage of asymptomatic VTEs (8% on cisplatin-based chemotherapy).If peripheral vessels are involved, there is a question, whether these patients would benefit from anticoagulation treatment, the same as in patients with symptomatic VTE. However guidelines recommend standard anticoagulant treatment for all cancer patients diagnosed with incidental VTE, for at least three months [21].…”