Direct Oral Anticoagulants in Cancer Patients. Time for a Change in Paradigm

Marek Z Wojtukiewicz,Stephanie C Tucker,Piotr Tokajuk,Barbara Politynska,Kenneth V Honn,Anna M Wojtukiewicz,Piotr Skalij

doi:10.3390/cancers12051144

Abstract

Thrombosis is a more common occurrence in cancer patients compared to the general population and is one of the main causes of death in these patients. Low molecular weight heparin (LMWH) has been the recognized standard treatment for more than a decade, both in cancer-related thrombosis and in its prevention. Direct oral anticoagulants (DOACs) are a new option for anticoagulation therapy. Recently published results of large randomized clinical trials have confirmed that DOAC may be a reasonable alternative to LMWH in cancer patients. The following review summarizes the current evidence on the safety and efficacy of DOAC in the treatment and prevention of cancer-related thrombosis. It also draws attention to the limitations of this group of drugs, knowledge of which will facilitate the selection of optimal therapy.

Highlights

As early as the nineteenth century, Armand Trousseau observed a relationship between the occurrence of venous thromboembolism (VTE) and cancer
The results revealed that the greatest concern to patients was that anticoagulant therapy should not interfere with cancer treatment (39%), which suggests that cancer is perceived as more important than VTE despite the inherent risk of the latter
These considerations lead to the conclusion that Direct oral anticoagulants (DOACs) should not currently be used in this patient population, and in the event of deteriorating quality of life (QoL) symptomatic of cancer-associated thrombosis (CAT), the use of Low molecular weight heparin (LMWH) should remain the treatment of choice

Summary

Introduction

As early as the nineteenth century, Armand Trousseau observed a relationship between the occurrence of venous thromboembolism (VTE) and cancer. A meta-analysis of the results of patients meeting these exclusion criteria from six key phase III clinical studies demonstrated a statistically insignificant increase in the effectiveness and safety of DOAC as compared to VKA [20] Another meta-analysis covering the same sub-population of patients with cancer included in the studies described, showed a significant reduction in the risk of CAT recurrence among patients receiving. A meta-analysis of the above studies has recently been published that confirms the reduced risk of VTE recurrence in cancer patients receiving DOAC as compared to dalteparin, this is at the cost of an increased number of episodes of major bleeding [25].

The Use of DOAC in the Primary Prevention of CAT

Limitations of Direct Oral Anticoagulant Therapy

Patient Preferences and the Route of Administration of Anticoagulants

Anticoagulation Therapy and the Use of DOAC in Hospice patients

Findings

Conclusions