Cancer-associated thrombosis

Venous thromboembolic disease (VTE) is an important source of morbidity and mortality in patients with cancer. Activation of coagulation pathways may be a central mechanism for tumor spread and development of aggressive disease. This review will focus on novel risk factors and predictors for the development of VTE in patients with malignancies, as well as approaches for the treatment and prevention of cancer-associated thrombosis.

Individual patient comorbidities, cancer-specific factors such as site and stage, and therapies including angiogenesis inhibitors associated with higher risk of VTE are increasingly being identified. Novel risk stratification approaches focus on the use of predictive biomarkers including P-selectin and markers of coagulation activation such as D-dimer, as well as predictive modeling. Thromboprophylaxis and treatment of VTE with low-molecular-weight heparin, unfractionated heparin, or fondaparinux in hospitalized medical and surgical cancer patients has been found to be well tolerated and effective; the appropriate role of thromboprophylaxis in ambulatory cancer patients, especially those with central venous catheters, remains to be explored.

Routine thromboprophylaxis in all patients with cancer cannot be recommended because only a subgroup of patients develop VTE, and the use of anticoagulants may be associated with unacceptably high risk of bleeding complications. Identification of patients at highest risk for VTE or bleeding who would benefit from careful prophylaxis is an important next step.