From the Guidelines
NOACs should not be used as a substitute for LMWH for postoperative thrombosis prevention in patients who have undergone hemicolectomy for a NET tumor, due to the lack of sufficient evidence supporting their use in this context, as stated in the most recent guidelines 1. When considering thromboprophylaxis for patients with cancer, including those who have undergone hemicolectomy for a neuroendocrine tumor (NET), the primary goal is to prevent venous thromboembolism (VTE) while minimizing the risk of bleeding complications.
- The current guidelines, as outlined in the 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer 1, and further supported by the 2023 ESMO clinical practice guideline for venous thromboembolism in cancer patients 1, recommend the use of low-molecular-weight heparin (LMWH) as the preferred option for pharmacological VTE prophylaxis in surgically treated patients with cancer.
- These guidelines emphasize the importance of starting pharmacological prophylaxis 2-12 hours preoperatively and continuing it for at least 7-10 days, with the option for extended prophylaxis up to 4 weeks in patients undergoing major abdominal or pelvic surgery who do not have a high risk of bleeding.
- The use of direct oral anticoagulants (DOACs or NOACs) as an alternative to LMWH for the prophylaxis of postoperative VTE in patients with cancer is not supported by sufficient evidence, as indicated by the guidelines 1.
- Therefore, in the context of a patient who has undergone hemicolectomy for a NET tumor, LMWH remains the recommended choice for thromboprophylaxis, given its established efficacy and safety profile in the cancer population, as opposed to NOACs which lack sufficient evidence to support their use in this specific context 1.
From the Research
Thrombosis Prevention in Patients with Cancer
- The use of direct oral anticoagulants (DOACs) as an alternative to low-molecular-weight heparin (LMWH) for thrombosis prevention in patients with cancer has been studied in several trials 2, 3, 4, 5.
- These studies have shown that DOACs are effective in preventing recurrent venous thromboembolism (VTE) in patients with cancer, with a significant reduction in VTE recurrence compared to LMWH 3, 5.
- However, DOACs have also been associated with an increased risk of major bleeding and clinically relevant non-major bleeding compared to LMWH 2, 3, 4, 5.
Comparison of DOACs and LMWH
- A systematic review and meta-analysis of randomized controlled trials found that DOACs had a lower risk of recurrent VTE (RR 0.62,95% CI 0.43-0.91) but a higher risk of major bleeding (RR 1.31,95% CI 0.83-2.08) compared to LMWH 3.
- Another study found that DOACs were non-inferior to LMWH in preventing VTE recurrence, but were associated with an increased risk of major bleeding and clinically relevant non-major bleeding 4.
- A 2022 updated systematic review and meta-analysis found that DOACs significantly decreased the risk of CAT recurrence (RR, 0.67; 95%CI, 0.52-0.85) with a non-significant increase in the risk of major bleeding (RR, 1.17; 95%CI, 0.82-1.67) compared to LMWH 5.
Real-World Evidence
- Real-world studies have also been conducted to evaluate the effectiveness and safety of DOACs in patients with VTE, including those with cancer 6.
- These studies have provided valuable insights into the use of DOACs in everyday clinical practice, but more research is needed to fully understand their benefits and risks in different patient populations.