Direct Oral Anticoagulants in Cancer Patients

Abstract

Patients with active cancer have an increased risk of arterial occlusion, venous thromboembolism (VTE) and bleeding events. Traditionally, these patients were treated with low-molecular-weight heparins to reduce the risk of VTE, while vitamin K antagonists (VKAs) were used to prevent ischemic stroke in patients with atrial fibrillation (AF). A recent addition to this anticoagulant landscape is the new class of direct oral anticoagulants (DOACs), which not only effectively prevent and treat VTE but also reduce the risk of arterial thromboembolism and stroke in patients with AF. DOACs have several advantages over heparins or VKAs. This includes rapid onset of action, no requirement for routine laboratory monitoring and fewer drug-drug interactions. In this review, we focus on the use of anticoagulants in cancer patients, providing an overview of the available anticoagulants, and discuss coagulation assays, tools for assessing thrombosis/bleeding risk and perioperative considerations. Cancer patients represent an extremely heterogenous and challenging population to treat with anticoagulants. The risk/benefit evaluation has to be individualized for each patient, requiring a thorough understanding of the coagulation system, the available compounds and monitoring tests, as well as the potential influence of the underlying cancer and anti-neoplastic treatments. PEER REVIEWED ARTICLE Peer reviewers: Dr Lukas Graf, Haemostasis and Haemophilia Centre St. Gallen, St. Gallen, Switzerland One anonymous peer reviewer Received on May 30, 2024; accepted after peer review on October 14, 2024; published online on October 30, 2024.