Challenges and Advances in Managing Thrombocytopenic Cancer Patients

Abstract

Cancer patients have varying incidence, depth and duration of thrombocytopenia. The mainstay of managing severe chemotherapy-induced thrombocytopenia (CIT) in cancer is the use of platelet transfusions. While prophylactic platelet transfusions reduce the bleeding rate, multiple unmet needs remain, such as high residual rates of bleeding, and anticancer treatment dose reductions/delays. Accordingly, the following promising results in other settings, antifibrinolytic drugs have been evaluated for prevention and treatment of bleeding in patients with hematological malignancies and solid tumors. In addition, Thrombopoeitin receptor agonists have been studied for two major implications in cancer: treatment of severe thrombocytopenia associated with myelodysplastic syndrome and acute myeloid leukemia; primary and secondary prevention of CIT in solid tumors in order to maintain dose density and intensity of anti-cancer treatment. Furthermore, thrombocytopenic cancer patients are often prescribed antithrombotic medication for indications arising prior or post cancer diagnosis. Balancing the bleeding and thrombotic risks in such patients represents a unique clinical challenge. This review focuses upon non-transfusion-based approaches to managing thrombocytopenia and the associated bleeding risk in cancer, and also addresses the management of antithrombotic therapy in thrombocytopenic cancer patients.

Keywords: anticoagulation; antifibrinolytic; antiplatelet; cancer; thrombocytopenia; thrombopoietin receptor agonist; tranexamic acid.

Figure 1

Selected mechanisms of drug induced thrombocytopenia in cancer. Examples of implicated drugs are given for each mechanism. HDAC, histone deacetylase.

Figure 2

Take-home messages. AML, acute myeloid leukemia; EACA, epsilon aminocaproic acid; MDS, myelodysplastic syndrome; TPO-RA, thrombopoietin receptor agonists; TXA, tranexamic acid; VTE, venous thromboembolism.