A comprehensive review of DOACs for cancer associated VTE prophylaxis or treatment

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ABSTRACT

Cancer is a leading cause of venous thromboembolism (VTE), which contributes to significant morbidity and mortality in these patients. Increased thrombotic risk in cancer patients is modified by tumor-specific biology, disease-directed interventions, and individual comorbidities. Risk stratification for prophylaxis and treatment requires regular reevaluation of these factors, which can be facilitated by validated prediction tools. This review also discusses large clinical trial data (SELECT-D, HOKUSAI-VTE, ADAM VTE, CARAVAGGIO) demonstrating that direct oral anticoagulants (DOACs) are effective in the treatment of cancer-associated VTE, with comparable efficacy to the traditional choice of low molecular weight heparin. In the prophylactic setting derived from patients with cancer with increased VTE risk, DOACs also reduced the incidence of VTE with only modest increases in bleeding risk. The ease of DOAC administration and acceptable risk profile in the carefully selected patient make them an appealing choice for anticoagulation. In instances where the risk of gastrointestinal bleeding is of concern, apixaban, in particular, may still be a suitable option in place of LMWH. These improvements in our anticoagulation approach to cancer-associated VTE are well-timed to accompany the recent advances in disease-directed therapies that are enabling patients to live longer with cancer and therefore at increased risk of complications such as VTE.

KEYWORDS:

• Hypercoagulability
• anticoagulants
• factor xa inhibitors
• thromboembolism
• venous
• venous thrombosis
• pulmonary embolisms
• medical oncology

Acknowledgments

None stated

Declaration of interest

No potential conflict of interest was reported by the author(s).

Declaration of funding

No funding was received to produce this article

Declaration of financial/other relationships

J.M.C receives personal fees from Bristol-Myer Squibb, Abbott, Portola, Pfizer. Research funding to the institution from CSL Behring

A reviewer on this manuscript has disclosed that they receive honoraria for lectures and ad-board-advice from Apsen, Bayer, BMS, Boehringer-Ingelheim, Daiichi Sankyo, Leo-Pharma, Pfizer. The other peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Author Contributions

Writing and revision of manuscript: All authors