Management of Cancer-Associated Thrombosis
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Cardio-Oncology (M Fradley, Section Editor)
Management of Cancer-Associated Thrombosis Adam J. Nelson, BMedSc (hons) MBBS PhD Chiara Melloni, MD MHS* Address * Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA Email: [email protected]
Published online: 10 October 2020 * Springer Science+Business Media, LLC, part of Springer Nature 2020
This article is part of the Topical Collection on Cardio-Oncology Keywords Cancer I Thrombosis I DVT I PE I DOAC
Abstract Purpose of review Low molecular weight heparin (LMWH) has been the standard of care for patients with cancer-associated thrombosis (CAT) for over 10 years; however, its adoption has been limited. The appearance of direct acting oral anticoagulants (DOACs) revolutionized the treatment of non-cancer venous thromboembolism (VTE) through their attractive fixed dose regimens; however, a lack of dedicated trial experience had relegated their position to off-label use in patients with cancer. The goal of this review is to review the evidence that has been generated over the last 3 years for factor Xa inhibitors, summarize their current position in the guidelines, and highlight areas of ongoing uncertainty with respect to the management of CAT. Recent findings Four dedicated trials of patients with CAT have been published comparing edoxaban, rivaroxaban, or apixaban with the LMWH, dalteparin. While these trials all have differences in sample size and inclusion/exclusion criteria, the totality of evidence suggests these agents have similar (if not superior) efficacy for reducing the risk of VTE recurrence without a significant excess in major bleeding. These overall favorable results have translated to guideline recommendations with caveats for patients at high bleeding risk or those with anticipated drug-drug interactions. Summary Direct-oral anticoagulants now feature prominently in the treatment guidelines for patients with CAT. These agents are, however, not for everyone and ongoing research will need to identify which patients are most, and least likely to benefit from a DOAC-based regimen, and the optimal duration. Furthermore, the incorporation of these data with emerging results from patient-preference research is required to personalize decisions in these patients.
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Curr Treat Options Cardio Med (2020) 22: 41
Background Approximately 20–30% of all cases of venous thromboembolism (VTE) are considered cancer-associated thrombosis (CAT) [1]. Patient, cancer, and treatment factors all influence the risk of developing VTE which is 5 to 8 times more common than in patients without cancer [2, 3]. The overall rates of CAT appear to be increasing through a combination of increasing oncological treatment thrombogenicity (e.g., hormonal therapy, immunomodulators, erythropoiesis stimulating drugs), increasing use of central venous catheters for chemotherapy, prolonged cancer survivorship with an overall aging population, and greater detection through widespread CT imaging [1, 2, 4]. Compared with the gene
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