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Fast Facts

A brief refresher with useful tables, figures, and research summaries

Venous Thromboembolism in Malignancy

Malignancy is associated with a significantly increased risk of venous thromboembolism (VTE). This risk is particularly elevated in patients with certain cancers; those undergoing surgery, radiation, or chemotherapy; and metastatic disease. In addition, VTE in patients with malignancy is associated with lower survival rates than VTE in patients without cancer.

The following table shows the risk-assessment model for VTE in malignancy, based on the Khorana score:

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(Source: Prophylaxis Against Venous Thromboembolism in Ambulatory Patients with Cancer. N Engl J Med 2014.)

VTE Prophylaxis

There is increasing evidence that direct oral anticoagulants (DOACs) are equivalent to low-molecular-weight heparin (LMWH) in preventing recurrent VTE in cancer patients. Current guidelines suggest that either LMWH or DOACs may be used to treat cancer-associated thrombosis. However, the use of LMWH remains preferred over DOACs in patients with gastrointestinal malignancies due to a higher risk of bleeding with DOACs.

For management of VTE in patients with contraindications to anticoagulation and for information on inferior vena cava (IVC) filter use, see the Venous Thromboembolism section in the Hematology rotation guide.

 

Research

Landmark clinical trials and other important studies

Research

Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer

Agnelli G et al. N Engl J Med 2020.

Oral apixaban was noninferior to subcutaneous dalteparin for the treatment of cancer-associated venous thromboembolism without an increased risk of major bleeding.

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Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism

Raskob GE. N Engl J Med 2018.

This RCT showed noninferiority of edoxaban versus dalteparin in preventing the composite outcome of venous thromboembolism or major bleeding.

Read the NEJM Journal Watch Summary

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Enoxaparin Dose Reduction for Thrombocytopenia in Patients with Cancer: A Quality Assessment Study

Miao Y et al. American Society of Hematology Meeting. December 2015.

A study presented at ASH 2015 that supports the safety of reducing therapeutic enoxaparin in patients with a history of VTE who develop chemotherapy-induced thrombocytopenia

Tinzaparin vs Warfarin for Treatment of Acute Venous Thromboembolism in Patients with Active Cancer: A Randomized Clinical Trial

Lee AYY et al. for the CATCH Investigators. JAMA 2015.

This is another large RCT comparing low-molecular-weight heparin to warfarin for prevention of VTE in cancer patients. Although low-molecular-weight heparin was not more effective than warfarin, it did reduce nonmajor bleeding events.

Read the NEJM Journal Watch Summary

Screening for Occult Cancer in Unprovoked Venous Thromboembolism

Carrier M et al. for the SOME Investigators. N Engl J Med 2015.

This RCT showed that routine screening for cancer in patients with unprovoked VTE did not result in a significant increase in detection of cancer.

Read the NEJM Journal Watch Summary

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Low-Molecular-Weight Heparin versus Coumarin for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer

Lee AYY et al. for the CLOT Investigators. N Engl J Med 2003.

This is the RCT that established that low-molecular-weight heparin is superior to warfarin (Coumarin) for the prevention of recurrent VTE in patients with cancer.

Read the NEJM Journal Watch Summary

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Guidelines

The current guidelines from the major specialty associations in the field

Guidelines

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