J.W. is a 55-year-old woman recently admitted to the hospital for worsening shortness of breath (Slide 1).
Relevant Medical History
• Stage 4 estrogen receptor/progesterone receptor–positive breast cancer.
Current Treatment Regimen
• Nab-paclitaxel 100 mg/m2 on day 1, 8, and 15, repeated every 28 days. and denosumab every 28 days for her bone metastasis.
Assessment and Relevant Test Results
• Recent scans have revealed metastases to the bone and lung (Slide 2)
• Weight = 72 kg
• Creatinine clearance (CrCl) = 50 mL/min
• Normal CBC, with the exception of platelet count, which is 65,000
• Eastern Cooperative performance status score is 1
• J.W. was diagnosed with a pulmonary embolism (Slide 3)
Submit your diagnosis to see full explanation.
The correct answer is D: Dalteparin.
Therapeutic anticoagulation in patients with cancer may be challenging, however, given varying patient circumstances and adverse events of treatment. When anticoagulation therapy is needed, multiple factors should be taken into consideration. These factors include a patient’s diagnosis, which will dictate duration of therapy, as well as weight and renal function. One variable that can be particularly challenging in patients with cancer is pre-existing thrombocytopenia, as in the case of J.W. According to the National Comprehensive Cancer Network (NCCN), full anticoagulation is indicated unless patients have platelet counts of less than 50,000.1 Compromised renal function can also be a common adverse event among patients with cancer. Although J.W. does have declining renal function, because her CrCl is greater than 30 mL/min, it does not impact the drug of choice. Drug selection and dosing would be influenced if her CrCl was less than 30 mL/min, which would indicate severe renal insufficiency. NCCN guidelines recommend unfractionated heparin as the preferred agent for CrCl less than 30 mL/min.1
Multiple international organizations, including the Italian Association of Medical Oncology (AIOM), the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), the French National Federation of the League of Centers Against Cancer (FNCLCC), and the European Society of Medical Oncology (ESMO), have issued guidelines for providers regarding the prevention and treatment of venous thromboembolism (VTE; deep venous thrombosis [Slide 4] and pulmonary embolism) in patients diagnosed with cancer. The recommendations of the initial treatment of VTE in patients with cancer vary slightly among these organizations; however, low-molecular-weight heparin (LMWH) is recommended across all organizations. Specifically, ASCO prefers LMWH for the initial 5 to 10 days in patients who do not have severe renal impairment over a vitamin K antagonist, such as warfarin.2 In addition, ASCO guidelines recommend continuing treatment for 6 months and to consider extending therapy indefinitely for select patients with active cancer, such as those with metastatic disease and those receiving chemotherapy.2 New oral anticoagulant therapies, such as rivaroxaban, are currently not recommended for patients with cancer. Both NCCN and ASCO recommend inferior vena cava filter only for patients with contraindication to anticoagulation therapy and in those with recurrent VTE or extension, despite adequate long-term therapy with LMWH.1,2
- National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology™ Venous Thromboembolic Disease V.2.2013. www.nccn.org
- Khorana AA, Streiff MB, Farge D, et al. Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. J Clin Oncol. 2009 Oct 10;27(29):4919-26.