The following are key points to remember from this review article about anticoagulation strategies in patients with cancer:

1. Patients with active cancer are at increased risk of arterial and venous thromboembolism (VTE) and bleeding events. This results from cancer-specific impacts on all three elements of Virchow’s triad (stasis, endothelial injury, and hypercoagulability).
2. Certain cancers are associated with high or very high risk of thrombosis (especially VTE), including pancreatic, stomach, metastatic, gynecological, lung, brain, hematologic, and genitourinary cancers (excluding prostate).
3. Certain cancer therapies are associated with a high risk of atrial arrhythmias (e.g., atrial fibrillation [AF]), including anthracyclines, alkylating agents, antimetabolites, interleukins, Bruton’s tyrosine kinase TKIs, and immune checkpoint inhibitors.
4. Historically, in patients with cancer, low molecular weight heparin (LMWH) has been the primary treatment choice for patients with VTE, while warfarin has been used for stroke prevention in AF.
5. Recently completed studies in patients with cancer-associated VTE have demonstrated efficacy with edoxaban and rivaroxaban as compared to dalteparin. Subanalyses of the RE-COVER, EINSTEIN PE/DVT, AMPLIFY, and Hokusai-VTE studies also show efficacy of dabigatran, rivaroxaban, apixaban, and edoxaban as compared to warfarin. Bleeding rates with the direct oral anticoagulants (DOACs) have been variable across different studies.
6. Several ongoing studies comparing DOACs to LMWH for treatment of cancer-associated VTE are ongoing and will provide further insight into both efficacy and safety of DOAC therapy.
7. Use of DOAC therapy in cancer patients may be limited by potential drug-drug interactions. These include P-glycoprotein interactions (all DOACs) and CYP3A4 interactions (most strongly impacting rivaroxaban and apixaban).
8. Renal impairment and thrombocytopenia are both common in patients with active cancer and may impact the safety of DOAC therapy. Using a DOAC with less renal clearance may be preferable. Avoiding anticoagulation when platelet counts are <50,000-70,000/μL is often recommended.
9. Although one retrospective study of patients with brain metastases showed no increased risk of intracranial hemorrhage risk with LMWH versus no anticoagulation, it is not clear if this is generalizable to all patients with brain metastases. Nonetheless, DOAC therapy is associated with lower intracranial hemorrhage risk than warfarin broadly, and availability of reversal agents may swing the risk:benefit ratio in favor of treatment for many patients.
10. Most patients with cancer-associated thrombosis will require treatment as long as the cancer is active (until remission or resection). Extended treatment may be considered based on overall risk:benefit assessment.
11. Hospitalized patients with active cancer are at high risk for thrombosis and should receive aggressive thromboprophylaxis as long as there is not a prohibitively high risk of bleeding.
12. Patients with cancer and AF should be treated according to standardized risk stratification scores (e.g., CHA₂DS₂-VASc).

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardio-Oncology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Anticoagulants, Alkylating Agents, Anthracyclines, Antimetabolites, Arrhythmias, Cardiac, Atrial Fibrillation, Brain Neoplasms, Cardiotoxicity, Drug Interactions, Hemorrhage, Heparin, Low-Molecular-Weight, Intracranial Hemorrhages, Platelet Count, Risk Assessment, Secondary Prevention, Stroke, Thrombocytopenia, Thrombophilia, Thrombosis, Urogenital Neoplasms, Vascular Diseases, Venous Thromboembolism, Warfarin

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