Opinion statement
Venous thromboembolism (VTE) is frequently encountered in cancer patients, acts as an important cause of morbidity and mortality, and may be a predictor of worse prognosis. In cancer patient who have a poor life expectancy, preventing death from pulmonary embolism is the mainstay of treatment. Patients who present with severe hypotension or other clinical manifestations suggestive of critical pulmonary embolism and do not have contraindications to thrombolysis should promptly be administered thrombolytic drugs. Except for selected cases requiring aggressive therapy, treatment of VTE in patients with cancer should not differ from that of patients without malignancy; the initial treatment should be conducted with adjusted dose of unfractionated heparin (UH), fixed dose of low-molecular-weight heparins (LMWH), or fondaparinux. LMWHs and fondaparinux have the potential to greatly simplify the initial treatment of VTE, making the management of the pathology feasible in an outpatient setting for selected patients. Traditionally, in cancer as well as in non-cancer patients, UH or LMWH or fondaparinux are overlapped by oral anticoagulation, targeted to reach an International Normalized Ratio (INR) between 2.0 and 3.0, and then followed by oral anticoagulants. However, during oral anticoagulant therapy, cancer patients exhibit a two- to fourfold higher risk of recurrent VTE and major bleeding complications when compared to non-cancer patients. Studies performed during the current decade have demonstrated that LMWHs offer several advantages in terms of efficacy in preventing VTE recurrences without increasing the bleeding risk. According to International Guidelines, the long-term administration of LMWH should be considered an alternative to anti-vitamin K drugs in patients with advanced disease and in those with conditions limiting the use of oral anticoagulants. The targeted policy is to administer LMWH at full therapeutic doses for the first month of treatment and then 75% of the initial dose for at least the following 5 months of therapy. Prolongation of anticoagulation should be considered for as long as the malignant disorder is active. In patients with acute deep venous thrombosis and contraindications to anticoagulation, vena cava filters should be considered. If anticoagulation is temporarily contraindicated, retrievable filters should be considered. Only patients who are actively bleeding or who are at extremely high risk for bleeding should receive a filter without anticoagulation coverage.
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Prandoni P, Falanga A, Piccioli A: Cancer and venous thromboembolism. Lancet Oncol 2005, 6:401–410.
Noble S, Pasi J: Epidemiology and pathophysiology of cancer associated thrombosis. Br J Cancer 2010, 102(Suppl 1):S2–S9.
Blom JW, Doggen CJ, Osanto S, et al.: Malignancy, prothrombotic mutations, and the risk of venous thrombosis. JAMA 2005, 293:715–722.
Prandoni P, Piccioli A, Girolami A: cancer and venous thromboembolism: an overview. Haematologica 1999, 84(5):437–445.
Prandoni P, Lensing AWA, Piccioli A: Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002, 100:3484–3488.
Hutten BA, Prins MH, Gent M, et al.: Incidence of recurrent thromboembolic or bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol 2000, 18:3078–3083.
Kearon C, Kahn SR, Agnelli G, et al.: Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008, 133(Suppl 6):454–545.
Mandala’ M, Falanga A, Roila F, et al.: Venous thromboembolism in cancer patients: ESMO clinical practice guidelines for the management. Ann Oncol 2010, 21(Suppl 5):V275–V276.
Lyman GH, Khorana AA, Falanga A, et al.: American Society of clinical oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007, 25:5490–5505.
Prandoni P: The treatment of venous thromboembolism in patients with cancer. Intern Emerg Med 2010, 5(Suppl 1):S27–S30.
Goldhaber SZ: Advanced treatment strategies for acute PE, including thrombolysis and embolectomy. J Thromb Haemost 2009, 7(Suppl 1):322–327.
Kakkar AK, Levine M, Pinedo HM, et al.: Venous thrombosis in cancer patients: insights from the Frontline survey. Oncologist 2003, 8:381–388.
Van Dongen CJ, van den Belt AG, Prins MH, et al.: Fixed dose subcutaneous low molecular weight heparins versus adjusted dose unfractionated heparin for venous thromboembolism. Cochrane Database Syst Rev 2004, 4:CD001100.
Coleman R, MacCallum P: Treatment and secondary prevention of venous thromboembolism in cancer. Br J Cancer 2010, 102(Suppl 1):S17–S23.
Aki EA, Rohilla S, Barba M, et al.: Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer: a systematic review. Cancer 2008, 113:1685–1694.
Panova-Noema M, Falanga A: Treatment of thromboembolism in cancer patients. Expert Opin Pharmacother 2010, 11(12):2049–2058.
Siragusa S, Arcara C, Malato A, et al.: Home therapy for deep venous thrombosis and pulmonary embolism in patients with cancer. Ann Oncol 2005, 16(Suppl 4):IV136–IV139.
Ageno W, Grimwood R, Limbiati S, et al.: Home treatment of deep venous thrombosis in patients with cancer. Haematologica 2005, 90:220–224.
The Matisse Investigators: Subcutaneous Fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003, 349:1695–1702.
Buller HR, Davidson BL, Decousus H, et al.: Fondaparinux or enoxaparin for the initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann Intern Med 2004, 140:867–873.
van Doormaal FF, Raskob GE, Davidson BL, et al.: Treatment of venous thromboembolism in patients with cancer: Subgroup analysis of the Matisse clinical trials. Thromb Haemost 2009, 101:762–769.
The EINSTEIN investigators, oral rivaroxaban for symptomatic Venous Thromboembolism. N Engl J Med 2010, 363:2499–2510.
Shulman S, Kearon C, Kakkar AK, et al.: Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med 2009, 361:2342–2352.
Prandoni P: How I treat venous thromboembolism in cancer patients. Blood 2005, 106:4027–4033.
PREPIC study group: Eight year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: The PREPIC randomized study. Circulation 2005, 112:416–422.
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):1729–1735.
Lee AY, Levine MN, Baker RI, et al.: Low-molecular weight heparin versus a coumarin for the prevention of venous thromboembolism in patients with cancer. N Engl J Med 2003, 349(2):146–153.
Hull RD, Pineo GF, Brant RF, et al.: For the Lite trial investigators. Long term low-molecular weight heparin versus usual care in proximal vein thrombosis patients with cancer. Am J Med 2006, 119:1062–1072.
Lee AY. Treating venous thromboembolism in cancer patients: the case for low-molecular weight heparins. In Cancer Associated Thrombosis edited by Khorana AA and Francis CW. Informa Healthcare. New York London. 2007. Chapter 16: 231–242.
Merli G, Spiro TE, Olsson CG, et al.: Subcutaneous enoxaparin once or twice daily compared with intravenous heparin for the treatment of venous thromboembolic disease. Ann Intern Med 2001, 134(3):191–202.
Breddin HK, Hach-Wunderle V, Nakov R, et al.: Effects of a low molecular weight heparin on thrombus regression and recurrent venous thromboembolism in patients with DVT. N Engl J Med 2001, 344:626–631.
Prandoni P, Piccioli A, Pagnan A: Recurrent thromboembolism in cancer patients: incidence and risk factors. Semin Thromb Hemost 2003, 29(Suppl 1):3–8.
Prandoni P, Lensing AWA, Cogo A, et al.: The long term clinical course of acute deep venous thrombosis. Ann Intern Med 1996, 125(1):1–7.
Carrier M, Le Gal G, Cho R, et al.: Dose escalation of low molecular weight heparin to manage recurrent venous thromboembolic events despite systemic anticoagulation in cancer patients. J Thromb Haemost 2009, 7:760–765.
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Andrea Piccioli reports no potential conflict of interest relevant to this article. Paolo Prandoni reports no potential conflict of interest relevant to this article.
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Piccioli, A., Prandoni, P. Approach to Venous Thromboembolism in the Cancer Patient. Curr Treat Options Cardio Med 13, 159–168 (2011). https://doi.org/10.1007/s11936-011-0112-2
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DOI: https://doi.org/10.1007/s11936-011-0112-2