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Current Treatment Options in Cardiovascular Medicine

Erschienen in:

01.04.2016 | Vascular Disease (I Weinberg, Section Editor)

Cancer-Associated Venous Thromboembolism

verfasst von: Hazem Elewa, RPh, PhD, BCPS, Riham Elrefai, PharmD, Geoffrey D. Barnes, MD, MSc

Erschienen in: Current Treatment Options in Cardiovascular Medicine | Ausgabe 4/2016

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Opinion statement

Cancer patients are at high risk for venous thromboembolism (VTE) which is considered the second leading cause of death among this population. Both cancer and cancer treatment increase this risk. Since the risk of VTE is not the same in all cancer patients, it is important to understand what factors increase the risk of incident and the risk of recurrent VTE in this patient population. In an effort to combine multiple factors into a single risk stratification system, a scoring system for recurrent VTE risk in cancer patients has been developed and externally validated. While vitamin K antagonists (VKA) or the direct oral anticoagulants (DOACs) are first-line therapies for non-cancer-associated VTE treatment, low-molecular-weight heparin (LMWH) agents are the first-line anticoagulant for treatment of cancer-associated VTE. In this review, we discuss the epidemiology, pathophysiology, and risk stratification used in cancer-associated VTE. We also discuss the current therapies for cancer-associated VTE and the evidence supporting their use from the literature.

Deitcher SR. Cancer-related deep venous thrombosis: clinical importance, treatment challenges, and management strategies. Semin Thromb Hemost. 2003;29(3):247–58. doi:10.1055/s-2003-40963.CrossRefPubMed

Blom JW, Doggen CM, Osanto S, Rosendaal FR. Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA. 2005;293(6):715–22. doi:10.1001/jama.293.6.715.CrossRefPubMed

Lee AYY, Levine MN. Venous thromboembolism and cancer: risks and outcomes. Circulation. 2003;107(23 suppl 1):I-17-I-21. doi:10.1161/01.cir.0000078466.72504.ac.

Lip GYH, Chin BSP, Blann AD. Cancer and the prothrombotic state. Lancet Oncol. 2002;3(1):27–34. doi:10.1016/S1470-2045(01)00619-2.CrossRefPubMed

Greene MT, Flanders SA, Woller SC, Bernstein SJ, Chopra V. The association between PICC use and venous thromboembolism in upper and lower extremities. Am J Med. 2015;128(9):986–993.e981. doi:10.1016/j.amjmed.2015.03.028.CrossRefPubMed

Khorana AA, Francis CW, Culakova E, Kuderer NM, Lyman GH. Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients. Cancer. 2007;110(10):2339–46. doi:10.1002/cncr.23062.CrossRefPubMed

Prandoni P, Lensing AWA, Piccioli A, Bernardi E, Simioni P, Girolami B, et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood. 2002;100(10):3484–8. doi:10.1182/blood-2002-01-0108.CrossRefPubMed

Monreal M, FalgÁ C, ValdÉS M, SuÁRez C, Gabriel F, Tolosa C, et al. Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: findings from the RIETE registry. J Thromb Haemost. 2006;4(9):1950–6. doi:10.1111/j.1538-7836.2006.02082.x.CrossRefPubMed

Trujillo-Santos J, Nieto JA, Tiberio G, Piccioli A, Micco PD, Prandoni P, et al. Predicting recurrences or major bleeding in cancer patients with venous thromboembolism—findings from the RIETE Registry. Thromb Haemost. 2008;100(9):435–9. doi:10.1160/th08-02-0125.PubMed

10.••

Louzada ML, Carrier M, Lazo-Langner A, Dao V, Kovacs MJ, Ramsay TO, et al. Development of a clinical prediction rule for risk stratification of recurrent venous thromboembolism in patients with cancer-associated venous thromboembolism. Circulation. 2012;126(4):448–54. doi:10.1161/circulationaha.111.051920. This study developed and validates a risk scoring system for recurrent VTE in cancer patients.CrossRefPubMed

11.

Douketis J, Tosetto A, Marcucci M, Baglin T, Cushman M, Eichinger S, et al. Patient-level meta-analysis: effect of measurement timing, threshold, and patient age on ability of d-Dimer testing to assess recurrence risk after unprovoked venous thromboembolism. Ann Intern Med. 2010;153(8):523–31. doi:10.7326/0003-4819-153-8-201010190-00009.CrossRefPubMed

12.

Janakiram M, Sullivan M, Shcherba M, Guo S, Billett HH. A systematic review of the utility of residual vein obstruction studies in primary and secondary venous thrombosis. Thrombosis. 2013;2013:9. doi:10.1155/2013/247913.CrossRef

13.

Linkins L-A, Stretton R, Probyn L, Kearon C. Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis. Thromb Res. 2006;117(3):241–7.CrossRefPubMed

14.••

Lee AYY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;349(2):146–53. doi:10.1056/NEJMoa025313. This randomized trial demonstrates that LMWH is superior to warfarin for the prevention of recurrent VTE in cancer patients. The trial also demonstrates no increased risk of bleeding for the LMWH-treated group as compared to the warfarin-treated group.CrossRefPubMed

15.

Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R, et al. Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Medicine. 2006;119(12):1062–72. doi:10.1016/j.amjmed.2006.02.022.CrossRef

16.••

Lee AY, Kamphuisen PW, Meyer G, et al. Tinzaparin vs warfarin for treatment of acute venous thromboembolism in patients with active cancer: a randomized clinical trial. JAMA. 2015;314(7):677–86. doi:10.1001/jama.2015.9243. This randomized trial demonstrates that LMWH is at least as good as warfarin for the prevention of VTE-recurrence in cancer patients. As compared to the earlier CLOT trial, this trial included more diverse enrollment sites and found a lower rate of VTE recurrence in both treatment groups.CrossRefPubMed

17.

Meyer G, Marjanovic Z, Valcke J, et al. Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med. 2002;162(15):1729–35. doi:10.1001/archinte.162.15.1729.CrossRefPubMed

18.

Deitcher SR, Kessler CM, Merli G, Rigas JR, Lyons RM, Fareed J. Secondary prevention of venous thromboembolic events in patients with active cancer: enoxaparin alone versus initial enoxaparin followed by warfarin for a 180-day period. Clin Appl Thromb Hemost. 2006;12(4):389–96. doi:10.1177/1076029606293692.CrossRefPubMed

19.

Lee A, Bauersachs R, Janas M, Jarner M, Kamphuisen P, Meyer G, et al. CATCH: a randomised clinical trial comparing long-term tinzaparin versus warfarin for treatment of acute venous thromboembolism in cancer patients. BMC Cancer. 2013;13(1):284.CrossRefPubMedPubMedCentral

20.•

Carrier M, Cameron C, Delluc A, Castellucci L, Khorana AA, Lee AYY. Efficacy and safety of anticoagulant therapy for the treatment of acute cancer-associated thrombosis: a systematic review and meta-analysis. Thromb Res. 2014;134(6):1214–9. doi:10.1016/j.thromres.2014.09.039. This systematic review demonstrates the superiority of LMWH over warfarin for prevention of VTE recurrence in cancer patients. It also notes that DOAC therapy cannot be recommended over LMWH until head-to-head studies are performed.CrossRefPubMed

21.•

Posch F, Königsbrügge O, Zielinski C, Pabinger I, Ay C. Treatment of venous thromboembolism in patients with cancer: a network meta-analysis comparing efficacy and safety of anticoagulants. Thromb Res. 2015;136(3):582–9. doi:10.1016/j.thromres.2015.07.011. This network meta-analysis suggests that LMWH and DOACs may have similar efficacy and safety for the treatment of cancer-associated VTE. However, only indirect comparisons were made in this analysis, limiting the confidence of its conclusions.CrossRefPubMed

22.

Lee AYY, Peterson EA. Treatment of cancer-associated thrombosis. Blood. 2013;122(14):2310–7. doi:10.1182/blood-2013-04-460162.CrossRefPubMed

23.

Hutten BA, Prins MH, Gent M, Ginsberg J, Tijssen JGP, Büller HR. Incidence of recurrent thromboembolic and bleeding complications among patients with Venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol. 2000;18(17):3078–83.PubMed

24.

Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499–510. doi:10.1056/NEJMoa1007903.CrossRefPubMed

25.

Buller HR, Prins MH, Lensin AW, Decousus H, Jacobson BF, Minar E, et al. Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med. 2012;366(14):1287–97. doi:10.1056/NEJMoa1113572.CrossRefPubMed

26.

Buller HR, Decousus H, Grosso MA, Mercuri M, Middeldorp S, Prins MH, et al. Edoxaban versus warfarin for the treatment of symptomatic venous thromboembolism. N Engl J Med. 2013;369(15):1406–15. doi:10.1056/NEJMoa1306638.CrossRefPubMed

27.

Agnelli G, Buller HR, Cohen A, Curto M, Gallus AS, Johnson M, et al. Oral apixaban for the treatment of acute venous thromboembolism. N Engl J Med. 2013;369(9):799–808. doi:10.1056/NEJMoa1302507.CrossRefPubMed

28.

Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342–52. doi:10.1056/NEJMoa0906598.CrossRefPubMed

29.•

Vedovati MC, Germini F, Agnelli G, Becattini C. Direct oral anticoagulants in patients with VTE and cancer: a systematic review and meta-analysis. Chest. 2015;147(2):475–83. doi:10.1378/chest.14-0402. This meta-analysis of DOAC vs warfarin trials suggests that use of DOACs for VTE treatment in patients with cancer may be safe and effective. However, the cancer patients included in these trials may not be the same as the cancer-associated VTE patients from the CLOT and CATCH trials.CrossRefPubMed

30.

Wu C, Lee AYY. Novel or non-vitamin K antagonist oral anticoagulants and the treatment of cancer-associated thrombosis. Semin Thromb Hemost. 2015;41(2):237–43. doi:10.1055/s-0035-1544160.CrossRefPubMed

31.

Mandala M, Falanga A, Roila F, Group EGW. Management of venous thromboembolism (VTE) in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2011;22 suppl 6:vi85–92.PubMed

32.••

Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):7S–47S. doi:10.1378/chest.1412S3. The American College of Chest Physicians guidelines on management of cancer-associated VTE. They favor the use of LMWH over wafarin without any recommendations on the use of DOACs in this clinical scenario.CrossRefPubMedPubMedCentral

Titel: Cancer-Associated Venous Thromboembolism
verfasst von: Hazem Elewa, RPh, PhD, BCPS
Riham Elrefai, PharmD
Geoffrey D. Barnes, MD, MSc
Publikationsdatum: 01.04.2016
Verlag: Springer US
Erschienen in: Current Treatment Options in Cardiovascular Medicine / Ausgabe 4/2016
Print ISSN: 1092-8464
Elektronische ISSN: 1534-3189
DOI: https://doi.org/10.1007/s11936-016-0445-y

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