From the Guidelines
Patients with metastatic cancer are at a significantly increased risk of developing venous thromboembolism (VTE) and bleeding complications, with cancer being an independent risk factor for both conditions 1. The risk of metastatic cancer for VTE and bleeding is a complex issue, with multiple factors contributing to the increased risk of these complications.
- The incidence of VTE recurrence is increasing in patients with cancer, especially those receiving chemotherapy 1.
- Cancer is an independent bleeding risk factor in patients with cancer, with certain cancers such as pancreatic, gastric, and brain carrying particularly high bleeding risks.
- The use of low-molecular-weight heparins (LMWHs) is recommended for the treatment of cancer-associated VTE, with a high-grade recommendation for their use as a 3- to 6-month treatment 1.
- The preferred option for the treatment of cancer-associated VTE is LMWHs, which have been shown to be superior to vitamin K antagonists (VKAs) in reducing VTE recurrence in patients with cancer-associated thrombosis 1. The management of anticoagulation in cancer patients requires regular assessment of both thrombotic and bleeding risks, with treatment decisions individualized based on cancer type, stage, concurrent treatments, and patient preferences.
- Certain situations, such as severe thrombocytopenia or active bleeding, may require temporary interruption of anticoagulation, with consideration of reduced doses or IVC filters in high-risk situations.
- The hypercoagulable state in cancer results from tumor cells activating the coagulation cascade and expressing tissue factor, while bleeding risk stems from tumor invasion, thrombocytopenia from treatments, and organ dysfunction 1.
From the Research
Risk of Metastatic Cancer for VTE and Bleeding
- The risk of metastatic cancer for VTE and bleeding is a significant concern in patients with cancer-associated venous thromboembolism (VTE) 2, 3, 4, 5, 6.
- Studies have shown that patients with cancer are at increased risk for both bleeding and VTE recurrence 2, 3, 4, 5, 6.
- The use of direct oral anticoagulants (DOACs) and low-molecular-weight heparin (LMWH) has been evaluated in patients with cancer-associated VTE, with varying results 2, 3, 4, 5, 6.
Predictors of Recurrent VTE and Major Bleeding
- Significant predictors of recurrent VTE and major bleeding in patients with cancer-associated VTE include active systemic treatment, high Khorana Score, active smoker, pancreatic cancer, and stage IV disease 2.
- The risk of major bleeding is higher in patients with gastrointestinal and possibly genitourinary cancers, and DOACs should be used with caution in these patients 4.
Comparison of Anticoagulation Therapies
- LMWH is probably superior to unfractionated heparin (UFH) in the initial treatment of VTE in people with cancer 6.
- DOACs have been associated with an increased risk of major bleeding in patients with gastrointestinal and possibly genitourinary cancers 4.
- Apixaban has been shown to have generally positive treatment outcomes compared to LMWH and warfarin in high-risk subgroups of VTE cancer patients 5.
Patient Selection and Treatment
- Patient selection for treatment with DOACs should consider factors such as cancer type, metastatic diagnosis, cancer treatment, and index VTE event type 4, 5.
- A personalized approach to treatment is proposed, addressing patient selection for treatment with DOACs, factors that influence efficacy and safety, controversies and caveats, and suggestions for their resolution in clinical practice 4.