Cleveland Clinic Journal of MedicineManagement of Venous Thromboembolism in Patients with Active Cancer (CME)

Navigating the Intersection of Cancer and Venous Thromboembolism: Emerging Paradigms in Anticoagulation

Venous thromboembolism (VTE) significantly impacts patients with cancer, representing a major cause of morbidity and mortality. This CME program instructs professionals on the complex relationship between cancer and VTE, highlighting the increased risk, diagnostic challenges, and evolving treatment strategies that underscore the need for a nuanced approach to patient care. With the introduction of direct oral anticoagulants (DOACs) and the exploration of factor XI inhibitors, the landscape of VTE management in cancer patients is shifting, emphasizing personalized treatment to balance efficacy with safety.

Key Points:

• Epidemiology and Risk: Cancer patients have a substantially higher risk of developing VTE compared to the general population, with certain cancers like pancreatic and brain cancers associated with the highest VTE risk.
• Diagnosis Challenges: VTE diagnosis in cancer patients is complicated by overlapping symptoms and the high prevalence of VTE, which undermines the utility of traditional clinical prediction rules.
• Treatment Shifts: There is a paradigm shift from using vitamin K antagonists to low-molecular-weight heparin (LMWH) and now to DOACs, which are preferred due to ease of use and fixed dosing.
• Factor XI Inhibitors: Emerging treatments, such as factor XI inhibitors, are under study for their potential in managing cancer-associated VTE, indicating a future direction in treatment options.
• Incidental VTE: Incidental VTE, often discovered during routine cancer imaging, requires treatment akin to symptomatic VTE, underscoring the importance of vigilant monitoring.
• Special Populations and Considerations: Treatment must be individualized based on factors such as renal function, presence of metastatic disease, and potential drug-drug interactions, especially with chemotherapy.
• Duration of Anticoagulation: Current guidelines recommend a minimum of 6 months of anticoagulation in patients with active cancer, with considerations for extended therapy based on ongoing cancer activity or therapy.
• Cost and Adherence: The cost and route of administration of anticoagulants, such as the subcutaneous administration of LMWH, can affect patient adherence, highlighting the need for patient-centered care approaches.

A study found that VTE contributes to a 2- to 6-fold increase in healthcare costs for patients with cancer, underscoring the economic burden of this complication beyond its clinical impact.

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