Therapeutic anticoagulation for oncology patients

Acute Oncology Guidelines
NHS Lothian

Venous thromboembolism (VTE) is a major complication of patients with cancer occurring in 4% to 20% of patients9.  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 cancer1.  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)11.  

The HOKUSAI trial12 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 dalteparin13. 

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 bleeding14. Rivaroxaban has SMC approval for treatment of VTE in adults but is not on the Lothian formulary for this indication. 

Previously the CLOT study found that 6 months of dalteparin was more effective than warfarin in reducing the risk of recurrent thromboembolism (9% v 17%, HR 0.48, p = 0.002) with no difference in major or minor bleeding15. The LITE trial has confirmed the efficacy of tinzaparin compared to Vitamin K antagonists for the treatment of VTE in cancer patients16.  Tinzaparin has SMC approval for this indication but is not on the Lothian formulary. 

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 recommended17-20.   

The conclusions from these studies are:

Patients with an active cancer or receiving SACT, who present with symptomatic or incidental venous thromboembolism, should be commenced on either:
  • Apixaban 10mg bd for 7 days followed by 5mg bd OR
  • LMWH with dalteparin 200 units/kg for 30 days followed by 150 units/kg.

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.

Editorial Information

Last reviewed: 01/12/2021

Next review date: 01/12/2024

Author(s): Dalrymple H.

Version: 2.1

Approved By: CTAC Chair

Reviewer name(s): Stewart J.