Impact of venous thromboembolism and anticoagulation on cancer and cancer survival

Abstract

Changes in the hemostatic system and chronic hemostatic activation are frequently observed in patients with cancer, even in the absence of venous thromboembolism (VTE). VTE is a leading cause of death among patients with cancer and contributes to long-term mortality in patients with early as well as advanced-stage cancer. Mounting evidence suggests that components of the clotting cascade and associated vascular factors play an integral part in tumor progression, invasion, angiogenesis, and metastasis formation. Furthermore, there are intriguing in vitro and animal findings that anticoagulants, in particular the low molecular weight heparins (LMWHs), exert an antineoplastic effect through multiple mechanisms, including interference with tumor cell adhesion, invasion, metastasis formation, angiogenesis, and the immune system. Several relatively small randomized controlled clinical trials of anticoagulation as cancer therapy in patients without a VTE diagnosis have been completed. These comprise studies with LMWH, unfractionated heparin, and vitamin K antagonists, with overall encouraging but nonconclusive results and some limitations. Meta-analyses performed for the American Society of Clinical Oncology VTE Guidelines Committee and the Cochrane Collaboration suggest overall favorable effects of anticoagulation on survival of patients with cancer, mainly with LMWH. However, definitive clinical trials have been elusive and questions remain regarding the importance of tumor type and stage on treatment efficacy, the impact of fatal thromboembolic events, optimal anticoagulation therapy, and safety with differing chemotherapy regimens. Although the LMWHs and related agents hold promise for improving outcomes in patients with cancer, additional studies of their efficacy and safety in this setting are needed.

Fig 1.

The tumor cell promotes a hypercoagulable state and activates the hemostatic system, utilizing cell surface proteins such as tissue factor (TF), cancer procoagulant (CP), tissue plasminogen activator (t-PA), urokinase plasminogen activator (uPA), as well as plasminogen activator inhibitor 1 (PAI-1) and 2 (PAI-2). Interaction with other blood cells (eg, monocytes, platelets, endothelial cells) occurs (A) directly by cell-cell interaction; or (B) indirectly by cytokine release promoting prothrombotic endothelial changes. IL, interleukin; P, protein; F, factor; TM, thrombomodulin; TNF, tumor necrosis factor; VEGF, vascular endothelial growth factor; R, receptor; FV-R, factor V receptor. Adapted from Falanga.

Fig 2.

Positive feedback loop between tumor and the hemostatic system: tumor can promote a procoagulant state. Components of the activated hemostatic system, in particular the platelet-fibrin–rich tumor microthrombi, also promote tumor growth, angiogenesis, invasion, and metastasis formation.

Fig 3.

Meta-analysis of anticoagulation studies evaluating the impact on mortality in cancer patients without venous thrombosis: 1-year overall mortality by type of anticoagulation. SCLC, small-cell lung cancer; LMWH, low molecular weight heparin; UFH, unfractionated heparin; NSCLC, non–small-cell lung cancer; CRC, colorectal cancer; HN, head and neck cancer. Adapted from Kuderer et al.

Fig 4.

Meta-analysis of anticoagulation studies evaluating the impact on mortality in cancer patients without venous thrombosis: major bleeding complications by type of anticoagulation. SCLC, small-cell lung cancer; NSCLC, non–small-cell lung cancer; HN, head and neck cancer; CRC, colorectal cancer. Adapted from Kuderer et al.