Management of Cancer-Associated Thrombosis: Unmet Needs and Future Perspectives
Anna Falanga,
Grégoire Le Gal,
Marc Carrier,
Hikmat Abdel-Razeq,
Cihan Ay,
Andrés J. Muñoz Martin,
Ana Thereza Cavalcanti Rocha,
Giancarlo Agnelli,
Ismail Elalamy,
Benjamin Brenner
Affiliations
Anna Falanga
Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Monza, Italy
Grégoire Le Gal
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
Marc Carrier
Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
Hikmat Abdel-Razeq
Department of Medicine, King Hussein Cancer Center, Amman, Jordan
Cihan Ay
Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
Andrés J. Muñoz Martin
Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
Ana Thereza Cavalcanti Rocha
Departamento de Saúde da Família, Faculdade de Medicina da Bahia, Universidade Federal da Bahia – UFBA, Salvador, BA, Brazil
Giancarlo Agnelli
Internal Vascular and Emergency Medicine – Stroke Unit, University of Perugia, Perugia, Italy
Ismail Elalamy
Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
Benjamin Brenner
Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
Patients with cancer are at a high risk of symptomatic venous thromboembolism (VTE), which is a common cause of morbidity and mortality in this patient population. Increased risk of recurrent VTE and bleeding complications are two major challenges associated with therapeutic anticoagulation in these patients. Long-term therapy with low-molecular-weight heparins (LMWHs) has been the standard of care for the treatment of cancer-associated VTE given its favorable risk–benefit ratio in comparison with vitamin K antagonists. Direct oral anticoagulants (DOACs), which offer the convenience of oral administration and have a rapid onset of action, have recently emerged as a new treatment option for patients with cancer-associated thrombosis (CT). Randomized clinical trial data with head-to-head comparisons between DOACs and LMWHs showed that overall, DOACs have a similar efficacy profile but a higher risk of bleeding was observed in some of these studies. This review aims to identify unmet needs in the treatment of CT. We discuss important considerations for clinicians tailoring anticoagulation (1) drug–drug interactions, (2) risk of bleeding (e.g., gastrointestinal bleeding), (3) thrombocytopenia, hematological malignancies, (4) metastatic or primary brain tumors, and (5) renal impairment. Additional research is warranted in several clinical scenarios to help clinicians on the best therapeutic approach.
