Prophylactic Anticoagulation in Patients with Cancer: When and How?

Abstract

Purpose of review: Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients.

Recent findings: Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.

Keywords: Anticoagulants; Cancer; Factor Xa inhibitors; Low molecular weight heparin; Preventative care; Venous thromboembolism.

Figure 1)

Flow chart on selecting ambulatory medical oncology patients for pharmacologic venous thromboembolism prophylaxis Flow chart reflecting the use of pharmacologic prophylaxis for ambulatory medical oncology patients. Adapted from guideline recommendations [29] and with permission from the Michigan Anticoagulation Quality Improvement Initiative (anticoagulationtoolkit.org). A. This flow chart applies to patients with active cancer excluding patients with multiple myeloma, myeloproliferative neoplasms, primary or metastatic brain tumors, planned stem cell transplant, hospitalized, or post-operative patients. B. Patients receiving hormonal therapy were excluded from the AVERT trial but not the CASSINI trial. C. See text for discussion of some contraindications to prophylactic anticoagulation. It is recommended providers review the latest guidelines for cancer associated thrombosis, their institutional guidelines, review management with a pharmacist, and assess patient specific bleeding risk. Patients with gastric and gastroesophageal tumors are at increased risk of bleeding with direct oral anticoagulants. D. Low molecular weight heparin is selectively considered for high thrombotic risk not eligible for direct oral anticoagulants.