Therapeutic anticoagulation for oncology patients
Acute Oncology Guidelines
Information in this section of the RightDecisions app has been taken from the corresponding antithrombotic guidelines in OOQS. These guidelines are fully referenced and are available to review on the NHS Lothian intranet, should there be any queries.
Venous thromboembolism (VTE) is a major complication of patients with cancer occurring in 4% to 20% of patients. For most patients in SCAN, apixaban will be the preferred first choice of anticoagulant.
The CARAVAGGIO trial compared apixaban to dalteparin for the treatment of VTE in patients with active cancer. Apixaban was non-inferior for recurrent VTE (5.6% v 7.9% with low molecular weight heparin (LMWH), p=<0.001 for non-inferiority) with similar risks of major bleeding observed on both arms (3.8% v 4.0%). The risk of haemorrhage from the GI tract was not increased with apixaban. Patients with CNS tumours or brain metastases were excluded from this trial. These findings were consistent with the smaller ADAM trial, which reported lower rates of recurrent VTE with apixaban compared to dalteparin (0.7% v 6.3%, p=0.0281), with low rates of major bleeding in both arms (0% v 1.4%, p=0.138).
The HOKUSAI trial demonstrated edoxaban was non-inferior to dalteparin for the treatment of VTE in patients with active cancer. There was a trend towards lower rates of recurrent VTE with edoxaban (7.9 v 11.3%, p=0.09), but increased rates of major bleeding with edoxaban (6.9 v 4.0%, p=0.04). A subsequent sub-group analysis reported a higher number of upper GI haemorrhages in patients with GI cancers treated with edoxaban compared to dalteparin.
The SELECT-D trial has reported the efficacy of rivaroxaban compared to dalteparin for the treatment of VTE in cancer patients, but with an increased risk of clinically relevant non-major bleeding. Rivaroxaban has SMC approval for treatment of VTE in adults but is not on the Lothian formulary for this indication.
In clinical trials with limited number of patients, reported rates of recurrent VTE in patients treated with enoxaparin given once or twice daily for 3 to 6 months appear comparable to those with warfarin.
Effectiveness in real-life setting was assessed in a cohort of 4,451 patients with symptomatic VTE and active cancer from the multinational registry RIETE of patients with VTE and other thrombotic conditions [16]. 3,526 patients received SC enoxaparin up to 6 months and 925 patients received tinzaparin or dalteparin SC. There was no significant difference for VTE recurrence rate between the two treatments groups. There was no statistically significant difference between the two treatment groups with regards to the relative risks of major (fatal or non-fatal) bleeding and all-cause death
Incidental VTE
Incidental findings of VTE are common, accounting for up to half of all VTE events in cancer patients. Rates of VTE recurrence, bleeding and mortality are similar compared to symptomatic VTE, and the same initial and long-term anticoagulation strategies are recommended.
The conclusions from these studies are:
- Apixaban 10mg bd for 7 days followed by 5mg bd OR
- LMWH with enoxaparin 1mg/kg BD for 5 days followed by 1.5mg/kg OD.
For patients with primary brain tumours or brain metastases, there is limited data for the safety of direct oral anticoagulants (DOACs) - any proposed use of a DOAC should be discussed with the patient's oncologist.