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The Excessively Clotting Cancer Patient

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The Coagulation Consult

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Abstract

Active cancer is associated with a hypercoagulable state that is clinically translated into an increased risk of both venous and arterial thromboembolism. This increased risk is seen both with solid tumors and with hematologic malignancies. The thrombosis risk can be further increased by additional risk factors such as extension of disease, type of chemotherapy, performance status, presence of indwelling catheters, and medical comorbidities. There are multiple pathophysiological mechanisms by which cancer cells lead to clinical hypercoagulability. But once venous thrombosis develops in a patient with active cancer, it is associated with poor disease-related prognosis and survival compared to patients with similar malignancy but without venous thrombosis. In addition, patients with active malignancy have a greater risk of both recurrent thromboses and hemorrhage while on antithrombotic therapy than patients without cancer. Best available evidence indicates that cancer-related acute venous thromboembolic events should be treated with low-molecular-weight heparins, which reduce the risk of recurrent venous thromboembolism without increasing the risk of bleeding when compared with oral vitamin K antagonists. There is insufficient data to support the use of new oral anticoagulants in patients with cancer-related venous thrombosis; thus, the use of such drugs cannot be recommended for this patient population at the present time. While primary prophylaxis against venous thrombosis may be recommended in some patients with selected malignancies, it should not be prescribed universally. There are promising research efforts to identify cancer patients who might benefit from primary prophylaxis, through the use of either clinical risk scores or biomarkers.

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Abbreviations

ALL:

Acute lymphoblastic leukemia

AML:

Acute myeloid leukemia

CNS:

Central nervous system

DVT:

Deep venous thrombosis

GI:

Gastrointestinal

GU:

Genitourinary

IU:

International units

IVC:

Inferior vena cava

LMWH:

Low-molecular-weight heparin

NSCLC:

Non-small cell lung cancer

PE:

Pulmonary embolism

SC:

Subcutaneously

SCLC:

Small-cell lung cancer

TF:

Tissue factor

UFH:

Unfractionated heparin

VKA:

Vitamin K antagonist

VTE:

Venous thromboembolic disease

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  1. Section of Vascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Marcelo P. Villa-Forte Gomes M.D.

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    Alan Lichtin

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    John Bartholomew

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Gomes, M.P.VF. (2014). The Excessively Clotting Cancer Patient. In: Lichtin, A., Bartholomew, J. (eds) The Coagulation Consult. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-9560-4_11

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