From the Guidelines
Anticoagulants play a crucial role in the management of cancer-associated thrombosis, with low molecular weight heparins (LMWHs) being the preferred initial treatment and extended therapy option for cancer patients with venous thromboembolism (VTE) 1.
Key Considerations
- Cancer patients have a hypercoagulable state due to tumor cells activating the coagulation cascade, impairing anticoagulant mechanisms, and promoting platelet aggregation 1.
- When selecting an anticoagulant, consider drug-drug interactions with chemotherapy agents, renal function, gastrointestinal absorption issues, and bleeding risk, especially in patients with gastrointestinal or genitourinary malignancies 1.
- Direct oral anticoagulants (DOACs) such as apixaban, rivaroxaban, or edoxaban are also effective options for many cancer patients, but their use should be guided by individual patient risk factors and bleeding risk assessment 1.
Treatment and Prophylaxis
- For initial treatment of VTE, LMWHs like enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily) are recommended, with treatment duration typically ranging from 3-6 months, but often continued as long as the cancer is active or the patient is receiving anti-cancer therapy 1.
- For prophylaxis in hospitalized cancer patients, enoxaparin 40 mg daily, dalteparin 5000 units daily, or fondaparinux 2.5 mg daily can be used 1.
- In patients with a high risk of bleeding, an individualized assessment of bleeding risk is necessary, and anticoagulation may need to be adjusted or withheld 1.
Recent Guidance
- The American Society of Clinical Oncology recommends routine thromboprophylaxis for most hospitalized patients with active cancer, but not for ambulatory patients with cancer unless they have a high risk of VTE 1.
- The International Society on Thrombosis and Haemostasis provides guidance on the use of DOACs in cancer-associated thrombosis, emphasizing the need for individualized decision-making and careful consideration of bleeding risk 1.
From the Research
Role of Anticoagulants in Cancer Management
- Anticoagulants play a key role in the treatment of cancer-associated thrombosis (CAT) 2, 3, 4, 5, 6
- Cancer patients have an increased risk of venous thromboembolism (VTE), and VTE is the second most common cause of death among them 2, 4
- Low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) are effective and generally safe options for cancer-associated VTE 2, 3, 4, 6
Treatment Options for Cancer-Associated VTE
- LMWH is recommended for both initial and long-term management of cancer-related VTE 3, 4, 5
- DOACs are preferred for patients without gastric or gastroesophageal lesions, but should be used with caution in patients with gastrointestinal and possibly genitourinary cancers 3, 6
- Treatment options for recurrent VTE include bridging to LMWH, LMWH dose escalation, and considering inserting a vena cava filter 2, 4
Patient Selection and Monitoring
- Patient selection for treatment with DOACs should consider factors such as cancer type, treatment, and patient-specific variables 3, 6
- Patients receiving anticoagulant therapy should be monitored for signs of pulmonary embolism or bleeding 5
- Regular patient contact and extensive patient education are integral elements for the nursing care of patients with cancer-associated thrombosis treated in the outpatient setting 5
Controversies and Caveats
- The use of DOACs in complex clinical situations, such as metastatic or primary brain disease, comorbid conditions, and elevated bleeding risk, requires special precautions 6
- The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials makes their use complex in certain situations in health care 6