Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives

ABSTRACT

Introduction

Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections.

Areas covered

This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives.

Expert opinion

Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient’s preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.

KEYWORDS:

• Cancer
• venous thromboembolism
• anticoagulant treatment
• non-vitamin K antagonist oral anticoagulants
• patients’ preferences

Article highlights

• Cancer-associated venous thromboembolism is a common complication in patients with cancer. Historically, low-molecular-weight-heparin has been the gold standard for treatment and secondary prevention of cancer-associated venous thrombosis.

• Three non-vitamin K antagonist oral anticoagulants (NOACs), rivaroxaban, apixaban, and edoxaban, have proven to be attractive alternatives for cancer patients in this setting.

• Careful patient selection is required, since important drug–drug interactions exist between NOACs and several medical cancer treatments, dose-adjustments may be needed according to renal function, and bleeding risk assessment is challenging in this population.

• The safety and efficacy of NOACs in cancer patients in the long term is unknown.

• Patient preferences are highly diverse in cancer patients and should be routinely incorporated into treatment decisions.

• A formalized inter-disciplinary team approach between surgeons, cardiologists, haematologists and oncologists as well as individual patient preferences are needed to ensure appropriate holistic management of cancer-associated venous thromboembolism.

Declaration of interest

T.B. Larsen has served as an investigator for Janssen Scientific Affairs, LLC and Boehringer Ingelheim; has participated in speaker panels for Bayer, Bristol-Myers Squibb, Pfizer, Roche Diagnostics, and Boehringer Ingelheim; has received honoraria for consulting activities from Bayer, Boehringer Ingelheim, Bristol-Myers Squibb and Pfizer. T.B. Larsen’s institution has received unrestricted funds for investigator-initiated research activities from Bayer, Pfizer, and Daiichi Sankyo. I. E. Albertsen has received speaking fees from Pfizer and Bayer. S. Noble has been on the speakers bureau for Bayer, Leo Pharma, Pfizer/BMS alliance, and Daiichi Sankyo, and advisory board for Pfizer/BMS alliance, Daiichi Sankyo, and Bayer. P. B. Nielsen has received fees for speaking engagements from Boehringer Ingelheim and BMS/Pfizer; fees for consulting from Bayer and Daiichi-Sankyo; and grant support from BMS/Pfizer and Daiichi-Sankyo Europe. Other authors are salaried employees of their institution and report no personal conflicts of interest disclosures.

Reviewer disclosures

A reviewer on this manuscript has disclosed they are a site co-investigator for Janssen & Janssen

And on the advisory board for Bristol-Myers Squibb. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This work was partly supported by the Obel Family Foundation.