title: Long-term treatment of cancer-associated thrombosis: the choice of the optimal anticoagulant.
abstract: Patients with cancer-associated thrombosis (CAT) carry a higher risk of recurrence, bleeding and mortality as compared with non-cancer patients. The specific profiles of cancer patients, combining frequent co-morbidities, the use of anti-tumoral therapies and the cancer progression itself, represent a major therapeutic challenge for choosing a long-term anticoagulant treatment. This review discusses the practical basis of making a choice between the available drugs for a long-term antithrombotic strategy, linked to their pharmacology, mechanism of action, evidence of clinical benefits, and advantages and limitations in such a complex clinical context. In patients with cancer, low-molecular-weight heparins (LMWHs) are the preferred option for the secondary prevention of venous thromboembolism according to current guidelines, because their efficacy is significantly superior to vitamin K antagonists (VKAs). Even though LMWHs are effective and safe in cancer patients, they require daily subcutaneous injections, which may be problematic for a long-term therapy that may exceed 6 months' duration. Compared with VKAs, non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) are more target specific and do not require laboratory monitoring, whereas the oral route of administration makes them potentially attractive alternatives to LMWH. In randomized controlled trials in the general population DOACs have been shown to be non-inferior to VKAs in terms of efficacy with a lower rate of clinically relevant or major bleeding. However, given the limited number of cancer patients enrolled in these studies (with poorly defined active cancer), available trials are inconclusive regarding the usefulness of DOACs in the cancer setting. Ongoing head-to-head comparisons vs. LMWH in patients with CAT may allow an informed choice to be made regarding the DOAC option.
authors.affiliation: Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien, INSERM UMRS 938 Université Pierre et Marie Curie, Paris 6, Paris, France.
authors.forename: I
authors.initials: I
authors.lastname: Elalamy
authors.affiliation: Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France.|Université Paris-Diderot Paris 7, EA 7334, Sorbonne Paris Cité, Paris, France.
authors.forename: I
authors.initials: I
authors.lastname: Mahé
authors.affiliation: Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy.
authors.forename: W
authors.initials: W
authors.lastname: Ageno
authors.affiliation: Respiratory and Intensive Care, Hôpital Européen Georges Pompidou, APHP, Paris, France.|Université Paris Descartes Paris 5, Sorbonne Paris Cité, Paris, France.|INSERM UMRS 970, CIC 1418, Paris, France.
authors.forename: G
authors.initials: G
authors.lastname: Meyer
mesh_terms: D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects; D001777:Blood Coagulation / Q000187:drug effects*; D000066491:Clinical Decision-Making; D004334:Drug Administration Schedule; D006470:Hemorrhage / Q000139:chemically induced; D006801:Humans; D009369:Neoplasms / Q000097:blood / Q000150:complications* / Q000628:therapy; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D054556:Venous Thromboembolism / Q000097:blood / Q000188:drug therapy* / Q000209:etiology
chemical_list: D000925:Anticoagulants
keywords: antithrombotic; cancer; low-molecular-weight heparin; treatment; venous thromboembolism