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Treatment of venous thromboembolism in patients with malignancy

Author
Kenneth A Bauer, MD
Section Editors
Lawrence LK Leung, MD
Jess Mandel, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

The close relationship between malignancy and venous thromboembolism (VTE) is well established. Patients with malignancy are in a hypercoagulable state and are more likely to develop VTE during the course of their illness compared to those without malignancy. Thrombotic events are the second leading cause of death in cancer patients after death from cancer itself.

The treatment of VTE (deep venous thrombosis and pulmonary embolism) in patients with malignancy will be discussed here. The treatment of VTE in patients without malignancy, the pathogenesis and epidemiology, and prevention of VTE in patients with malignancy are discussed separately. (See "Risk and prevention of venous thromboembolism in adults with cancer", section on 'Prevention of VTE in patients with cancer' and "Overview of the causes of venous thrombosis", section on 'Malignancy' and "Overview of the treatment of lower extremity deep vein thrombosis (DVT)" and "Venous thromboembolism: Initiation of anticoagulation (first 10 days)".)

ANTICOAGULATION THERAPY

The indications and contraindications to treatment of acute venous thromboembolism (VTE) in patients with cancer are the same for patients without cancer. The goal of therapy is to prevent recurrence, extension, and embolism while minimizing the risk of bleeding. However, treatment of VTE in cancer is complicated due to higher than usual rates of recurrent VTE as well as a higher risk of bleeding with anticoagulation treatment (table 1) [1-8].

In general, the same options for initial (immediate) anticoagulation (low molecular weight [LMW] heparin and unfractionated heparin [UFH]) and long-term anticoagulation (LMW heparin, vitamin K antagonists [VKAs], and direct oral anticoagulants [rivaroxaban, apixaban, edoxaban, dabigatran]) are similar for patients with cancer and without cancer. Provided renal function is normal (creatinine clearance >30 mL/min), LMW heparin is preferred over UFH for initial therapy (up to 10 days); and LMW heparin is preferred over VKAs (warfarin) or direct oral anticoagulants for long-term anticoagulation (at minimum three months) beyond the initial period. (See 'Initial therapy' below and 'Long term therapy' below.)

Evidence-based society guidelines have been issued in 2012 and 2016 by the American College of Chest Physicians (ACCP) and in 2013 by the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN), for the management of acute VTE in patients with cancer [9-12]. These and other guidelines are in general agreement with our recommendations as discussed below [13-15].

                       

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Literature review current through: Nov 2016. | This topic last updated: Wed Nov 02 00:00:00 GMT+00:00 2016.
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