Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review

Abstract

Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.

Keywords: ASCO, American Society of Clinical Oncology; ASH, American Society of Hematology; AT, antithrombin; ATE, arterial thromboembolism; CAT, cancer-associated thrombosis; CI, confidence interval; CRNMB, clinically relevant nonmajor bleeding; CVA, cerebrovascular event; DOAC, direct oral anticoagulant; DVT, deep venous thrombosis; ESMO, European Society of Medical Oncology; GI, gastrointestinal; HR, hazard ratio; ICH, intracranial hemorrhage; ISTH, International Society on Thrombosis and Haemostasis; KS, Khorana score; LMWH, low-molecular-weight heparin; MI, myocardial infarction; MM, multiple myeloma; NNT, number needed to treat; PE, pulmonary embolism; PPV, positive predictive value; RAM, risk assessment model; SPE, segmental pulmonary embolism; SSC, Scientific and Standardization Committee; SSPE, subsegmental pulmonary embolism; UHF, unfractionated heparin; VKA, vitamin K antagonist; VTE, venous thromboembolism; VVT, visceral vein thrombosis; arterial thromboembolism; cancer-associated thrombosis; prophylaxis; risk assessment models; treatment; venous thromboembolism.

Graphical abstract

Central Illustration

Prophylaxis and Treatment of Cancer-Associated Thrombosis The choice of pharmacological anticoagulation in patients with cancer should be based on several aspects, which include type of cancer, risk of bleeding, drug-drug interactions, and patient preferences. DOAC = direct oral anticoagulant; LMWH = low molecular weight heparin; VTE = venous thromboembolism.