Treatment of Cancer-Associated Venous Thromboembolism with Low-Molecular-Weight Heparin or Direct Oral Anticoagulants: Patient Selection, Controversies, and Caveats

The oncologist

article

Casey O'Connell¹  Carmen P. Escalante²  Samuel Z. Goldhaber³  Robert McBane⁴  Jean M. Connors⁵  Gary E. Raskob⁶ 

[1] Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California;Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center;Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School;Division of Vascular Cardiology, Department of Cardiovascular Medicine, Mayo Clinic;Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School;Hudson College of Public Health, The University of Oklahoma Health Sciences Center

关键词: Cancer-associated thrombosis;    Venous thromboembolism;    Malignancy;    Treatment;   

DOI  :  10.1002/onco.13584

学科分类：地质学

来源: AlphaMed Press Incorporated

【 摘 要 】

The treatment of venous thromboembolism (VTE) in patients with cancer is challenging because these patients have increased risks of both recurrent VTE and major bleeding, along with patient-specific and cancer-related factors that influence the approach to treatment. Historically, anticoagulant therapy with low-molecular-weight heparin (LMWH), given for both initial and long-term treatment, has been the preferred approach recommended by practice guidelines. Most recently, the National Comprehensive Cancer Network (NCCN) guidelines indicate that the direct oral anticoagulants (DOACs) apixaban, edoxaban, or rivaroxaban are preferred for patients without gastric or gastroesophageal lesions. DOACs have been associated with an increased risk of major bleeding in patients with gastrointestinal and possibly genitourinary cancers, and DOACs should either not be used (especially in those with intact intraluminal tumors) or be used with caution in patients with these cancers. Fatal or life-threatening bleeding occurs with similar frequency with DOACs or LMWH, and most major bleeding with DOACs can be managed with transfusion and standard measures. The patient's willingness and ability to comply with LMWH injections, and their treatment preference, should also be considered. Patients with cancer who have VTE should be treated with anticoagulation for a minimum of 6 months. Anticoagulation should be continued indefinitely while cancer is active or under treatment or if there are persistent risk factors for recurrent VTE. This article summarizes the evidence from clinical trials of LMWH and DOACs that underpins the NCCN guideline recommendations, addresses several controversies and caveats regarding anticoagulant treatment, and offers evidence-based, practical suggestions on patient selection for treatment with DOACs. Implications for Practice Several randomized trials support the addition of direct oral anticoagulants (DOACs) to the therapeutic armamentarium for cancer-associated venous thromboembolism (VTE). These agents come with unique risks and patient- and cancer-specific variables that must be evaluated during the course of a patient's cancer care. This narrative review discusses findings from clinical trials of low-molecular-weight heparin and DOACs for the treatment of cancer-associated VTE, evidence that supports the recent National Comprehensive Cancer Network guideline recommendations. A personalized approach to treatment is proposed that addresses patient selection for treatment with DOACs, factors that influence efficacy and safety, controversies and caveats, and suggestions for their resolution in clinical practice.

【 授权许可】

CC BY|CC BY-NC