Edward Spangenthal, MD, clinical chief of cardiology at Roswell Park Comprehensive Cancer Center in Buffalo, New York, told Hematology Advisor that previous trials showed LMWH was more effective for preventing VTE compared with placebo but was accompanied by increased bleeding. Subsequently, current recommendations suggest only using LMWH in patients at very high risk, such as those with multiple myeloma.

Moreover, Dr Spangenthal noted, the CASSINI (ClinicalTrials.gov Identifier: NCT02555878) and AVERT (ClinicalTrials.gov Identifier: NCT02048865) trials, which assessed prophylactic therapy in patients with cancer at high risk for VTE, showed a reduced incidence of VTE with DOAC treatment.

“Because of their lower cost and ease of administration, and because of the generally favorable results in the trials that are available, I plan to use DOACs as my treatment of choice in cancer patients with atrial fibrillation or acute VTE who are at low risk for bleeding and when there are no drug-drug interactions [between DOACs and] their chemotherapy,” Dr Spangenthal said. He went on to say cancer patients with acute VTE should receive lifelong anticoagulation unless their malignancy is considered cured with little risk of recurrence. He also stated that in low-risk patients, 6 to 12 months of therapy may be adequate.

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“In cancer patients with the highest risk of VTE, low-dose rivaroxaban or apixaban can be considered rather than LMWH, but a head-to-head trial comparing them would be very helpful,” said Dr Spangenthal. “I feel it is [crucial] for the specialty societies, including the American College of Chest Physicians, American College of Cardiology, American Heart Association, and American Society of Clinical Oncology, to update their guidelines frequently to give clinicians guidance on this very important subject.”

Currently, the American College of Chest Physicians, American Society of Clinical Oncology, British Committee for Standards in Haematology, European Society of Medical Oncology, National Comprehensive Cancer Network, and International Clinical Practice Guidelines all recommend using LMWH for short-term and long-term management of VTE in patients with cancer.

Vlad Zaha, MD, PhD, assistant professor in the department of internal medicine at the University of Texas Southwestern Medical Center in Dallas, told Hematology Advisor that the CASSINI and AVERT trials are not definitive, but many patients would prefer a pill over daily subcutaneous injections. Dr Zaha said this highlights the need for greater emphasis on vascular oncology and not just cardio-oncology.

“All the systems in the body are affected. Cancer patients tend to survive better with early diagnosis, so cardiac issues are a bigger [problem],” Dr Zaha said. “There has been a gap in cardiovascular care. This is a gap in knowledge that needs to be filled.”


  1. Vedovati MC, Giustozzi M, Becattini C. Venous thromboembolism and cancer: Current and future role of direct acting oral anticoagulants [published online February 27, 2019]. Thromb Res. doi: 10.1016/j.thromres.2019.02.031

This article originally appeared on Hematology Advisor