Cancer-associated thrombosis prevention and treatment
Blood clots are the second commonest cause of death in people with cancer. Risk scores identify who should take preventive blood thinners during chemotherapy, and direct oral anticoagulants have largely replaced injections for treatment.
Cancer raises venous thromboembolism risk 4-7-fold (highest in pancreatic, gastric, brain, lung cancers and myeloma on IMiDs). The Khorana score (2008) identifies high-risk outpatients; AVERT (apixaban) and CASSINI (rivaroxaban) trials (2019) showed primary thromboprophylaxis roughly halves VTE in Khorana ≥2 patients with acceptable bleeding, now recommended by ASCO/ITAC/NCCN. Treatment: LMWH was standard after CLOT (2003); Hokusai VTE Cancer (edoxaban), SELECT-D (rivaroxaban), Caravaggio (apixaban) established DOACs, with LMWH preferred for luminal GI tumours (bleeding) and drug interactions. Duration ≥6 months while cancer active. Central venous catheter thrombosis, arterial events with VEGF inhibitors and BTK inhibitors, and incidental PE are common management problems. Anticoagulation in brain tumours and thrombocytopenia requires individualisation.
How it works
Stratify VTE risk (tumour type, chemotherapy, biomarkers) to target prophylaxis; treat established thrombosis with anticoagulation weighed against tumour-specific bleeding risk.
- Validated risk score and two positive prophylaxis RCTs
- Oral DOACs simplify treatment
- Guidelines aligned across ASCO, ESMO, ITAC
- Bleeding in GI and GU tumours and with thrombocytopenia
- Prophylaxis uptake remains low
- Arterial thrombosis less studied
Latest papers
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