Management of Cancer-Associated Thrombosis

Anticoagulation options remain the same in those with or without cancer. It is used for the prevention and/or treatment of thrombus in those with low bleeding risk. No anticoagulation is recommended in active bleeding, recent surgery, pre-existing bleeding disorders, coagulopathy, or platelet count <50,000/microL. The immediate treatment options include low molecular weight heparin (LMWH) or unfractionated heparin (UFH) plus long-term management with LMWH, vitamin K antagonists, or direct oral anticoagulants. The acute VTE with malignancy requires initial anticoagulation therapy for 5-10 days, LMWH is the medication of choice unless contraindicated. The patient characteristics such as renal function, compliance, diet adherence determine drug selection. Fondaparinux and direct oral anticoagulants can also be initial treatment choices. UFH is preferred if a rapid anticoagulation reversal is required in circumstances such as renal disease, high bleeding risk, and for patients undergoing procedures. The factor Xa inhibitors are currently approved for initial DVT and acute PE treatment. They eliminate the need to monitor anticoagulation effectiveness. For those who are poor candidates for long-term LMWH, indirect oral anticoagulant (warfarin) is acceptable for chronic management. DOACs can be an alternative for those unable to use LMWH for reasons such as renal impairment (creatinine clearance less than 30mL/min), cost, non-compliance, or fear of needles. The duration of anticoagulation treatment is a minimum of 3 months. For those with malignancy and VTE with contraindications to anticoagulants, the only therapeutic option can sometimes be mechanical devices such as inferior vena cava filter (IVCF).

Keywords: Acute VTE, Cancer-associated thrombosis, Chronic anticoagulant malignancy, IVC filter, LMWH in malignancy, Management of VTE in malignancy, Oral anticoagulants, Rivaroxaban, Thrombosis in malignancy.