Abstract
In the general population, the incidence of thromboembolic events is 117 cases/100,000 inhabitants/year, while in cancer patient incidence, it is four-fold higher, especially in patients who receive chemotherapy and who are affected by pancreatic, lung or gastric cancer. At the basis of venous thromboembolism (VTE) there is the so-called Virchow triad, but tumor cells can activate coagulation pathway by various direct and indirect mechanisms, and chemotherapy can contribute to VTE onset. For these reasons, several studies were conducted in order to assess efficacy and safety of the use of anticoagulant therapy in cancer patients, both in prophylaxis setting and in therapy setting. With this review, we aim to record principal findings and current guidelines about thromboprophylaxis in cancer patients, with particular attention to subjects with additional risk factors such as patients receiving chemotherapy or undergoing surgery, hospitalized patients for acute medical intercurrent event and patients with central venous catheters. Nonetheless we added a brief insight about acute and maintenance therapy of manifested venous thromboembolism in cancer patients.
Highlights
The correlation between cancer and venous thromboembolism (VTE), which comprehends deep vein thrombosis (DVT) and pulmonary embolism (PE), is well known
The first data about the incidence of venous thromboembolism in oncological patients on active anticancer treatment come from NSABP-14 and NSABP-20 trials; in these trials, estrogen and progesterone receptors positive-nodes negative breast cancer patients treated with tamoxifen and chemotherapy had a higher incidence of VTE compared with patients receiving tamoxifen alone or placebo
Anti-thrombotic prophylaxis should not be offered routinely in all unselected cancer patients on active oncological therapy; In high-risk patients with multiple myeloma and in therapy with lenalidomide or thalidomide, prophylaxis with low-molecular-weight heparin (LMWH) should always be practiced unless specific clinical contraindications. In patients in this setting, but at low risk of VTE, aspirin prophylaxis can be practiced instead of LMWH; In general, prophylaxis with LMWH, apixaban or rivaroxaban should be considered for cancer outpatients who receive chemotherapy and who are at high thromboembolic risk
Summary
The correlation between cancer and venous thromboembolism (VTE), which comprehends deep vein thrombosis (DVT) and pulmonary embolism (PE), is well known. In 2014 Matzdorff and colleagues outlined pathophysiology of VTE in cancer patients and reported the most recent indications about VTE therapy and prophylaxis, as well as the use of new oral anticoagulants (but concluded that DOACs were not recommended according to 2014 international guidelines) [6]. Singh et al in 2017 outlined pathophysiology and diagnosis of venous thromboembolism in patients with cancer, as well as pharmacological and mechanical prophylaxis [7]; Imberti and colleagues, the subsequent year, reported the most important findings about VTE treatment, focusing on the results of Hokusai VTE-cancer trial about the comparison between low-molecular-weight heparin (LMWH) and the direct oral anticoagulant edoxaban, which showed that edoxaban is non-inferior to dalteparin with a trend toward fewer recurrent venous thromboembolic events, but with higher major bleeding risk [8]. We aim to summarize the latest evidence on VTE prophylaxis and treatment in patients with cancer, based on the newest guidelines and papers published in the last few months, as well as synthesize the major clinical trials and meta-analyses that have been conducted until now and highlight the most clinically relevant unmet needs
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