Treatment of Cancer-Associated Venous Thromboembolism in the Age of Direct Oral Anticoagulants

C. Ay; J. Beyer-Westendorf; I. Pabinger


Ann Oncol. 2019;30(6):897-907. 

In This Article

Clinical Guideline Recommendations

The clinical guideline recommendations for LMWH for long-term treatment of cancer-associated VTE are largely based on four clinical trials.[14,15,22,23] The largest of these, CLOT, found a significantly lower rate of VTE recurrence and numerically lower rate of any bleeding in patients treated long-term with dalteparin versus VKAs.[14] The most recently published study, CATCH, enrolled a lower-risk population with lower-than-expected VTE recurrence and found a numerically lower VTE recurrence rate compared with CLOT.[15] CATCH reported a similar rate of major bleeding events in patients treated with tinzaparin versus warfarin, but a significantly lower rate of clinically relevant nonmajor (CRNM) bleeding.[15]

Despite clinical consensus, LMWH treatment of cancer-associated VTE is underused relative to clinical guideline recommendations.[24–27] This is attributed in part to disadvantages related to patient preference, convenience, and cost,[20] which may also contribute to poor treatment persistence. Despite high risk for VTE recurrence, patients with cancer-associated VTE have higher anticoagulation interruption and discontinuation rates relative to patients with other VTE risk factors,[28] and they are more likely to switch anticoagulant agents and less likely to persist on therapy when treated with LMWH versus warfarin or rivaroxaban.[25] There is thus a need for oral anticoagulant options with demonstrated efficacy and safety comparable to LMWH in patients with cancer-associated VTE.