Extended anticoagulation in patients with cancer-associated venous thromboembolism

Cancer‑associated thrombosis (CAT) presents a major clinical burden, impacting both survival and quality of life in patients with malignancy. While direct oral anticoagulants (DOACs) and low‑molecular‑weight heparin are recommended for initial treatment, decisions on extending anticoagulation beyond 6 months remain complex due to variable recurrence and bleeding risks. This comprehensive review explores contemporary strategies for long‑term CAT management, focusing on risk stratification, guideline evolution, and individualized patient‑centered care. We highlight the importance of cancer type, disease status, and patient comorbidities-such as renal dysfunction and thrombocytopenia-in guiding therapy duration. Recent studies suggest that reduced‑dose DOAC regimens, particularly apixaban, may have favorable safety profiles without compromising efficacy, offering a potential shift in secondary prevention paradigms. Nonetheless, bleeding risks remain significant, and validated tools for predicting long‑term venous thromboembolism recurrence or hemorrhagic complications are lacking. We advocate for the creation of dedicated cancer thrombosis clinics to support shared decision‑making and tailored management, particularly for frail or high‑risk populations. Finally, we propose a research agenda targeting challenging subgroups-such as patients with brain tumors, gastrointestinal malignancies, or extremes of weight-to refine anticoagulation strategies and improve outcomes. The future of CAT care demands more precise, patient‑centered approaches grounded in evolving science, clinical nuance, and patient preference.