Treating patients with cancer and acute venous thromboembolism

ABSTRACT

Introduction: Cancer and venous thromboembolism (VTE) are closely related, with a high risk of VTE associated with cancer and a strong impact of VTE on cancer prognosis. The management and treatment of cancer-associated VTE are particularly challenging and, in many cases, are not guided by a high level of evidence.

Areas covered: In this review, we present the best therapeutic approach to acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and to some controversial issues, such as home treatment, optimal duration of anticoagulation, management of VTE recurrence during anticoagulant treatment, and of unsuspected PE. Then, the available evidence on other cancer-related VTE manifestations is presented, such as catheter-related thrombosis and splanchnic vein thrombosis.

Expert opinion: While solid evidence exists on the advantage of low molecular weight heparin (LMWH) over vitamin K antagonists (VKAs) during the first 3 to 6 months after acute DVT and/or PE, several issues have not been sufficiently investigated yet. These include the role of LMWH beyond the first 3 to 6 months, whether it is still more effective than VKA and if its intensity could be safely reduced, the strategies to identifying accurate predictors of VTE recurrence and the role of direct oral anticoagulants.

KEYWORDS:

• Anticoagulant therapy
• cancer-associated thrombosis
• catheter-related thrombosis
• splanchnic vein thrombosis
• unsuspected pulmonary embolism

Article highlights

• Cancer and VTE are closely associated, and the treatment of VTE is challenging in this setting.

• LMWH should be preferred over VKAs during the first 3–6 months after acute DVT and/or PE (according to ISTH, ASCO, and ESMO guidelines).

• The optimal duration of anticoagulation needs to be evaluated on a case-by-case basis, and further evidence is needed to identify accurate predictors of recurrent VTE.

• The finding of UPE is not rare during cancer staging. Lobar and segmental PE should receive anticoagulation, whereas uncertainty exists on treating isolated sub-segmental PE.

• CVC-associated thrombosis should be treated with LMWH for at least 3 months.

• Indirect evidence suggests using LMWH as the first option to treat SVT diagnosed in cancer patients. For the long term, indefinite anticoagulant treatment with periodic reassessment of bleeding profile is suggested.

This box summarizes key points contained in the article.

Declaration of interest

Alessandro Squizzato has received lecture fees from Pfizer/Bristol-Myers Squibb and Bayer HealthCare.

Walter Ageno has participated in advisory boards for Pfizer/Bristol-Myers Squibb, Bayer HealthCare, Daiichi-Sankyo, and Boehringer Ingelheim. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.