Antithrombotic therapy for cancer-associated venous thromboembolism

Cancer-associated venous thromboembolism (VTE) is one of the most frequent and life-threatening complications in oncology, representing the second leading cause of death in patients with malignancy. Its pathogenesis is multifactorial, driven by tumor-specific procoagulant activity, systemic inflammation, and the prothrombotic effects of anticancer therapies. The risk is particularly high in pancreatic, gastric, cerebral, and pulmonary cancers and is further amplified by advanced disease stage, comorbidities, and treatment-related factors. Management of cancer-associated VTE requires a careful balance between the risks of thrombosis and bleeding. Low-molecular-weight heparins (LMWHs) were long considered the standard of care, based on superior efficacy over vitamin K antagonists. More recently, direct oral anticoagulants (DOACs) have emerged as effective alternatives, offering the convenience of oral administration and comparable efficacy. However, increased rates of gastrointestinal and genitourinary bleeding, drug-drug interactions, and challenges in patients with renal dysfunction or thrombocytopenia complicate their use. Current international guidelines recommend both LMWHs and DOACs as first-line options, with agent selection guided by tumor type, bleeding risk, comorbidities, and patient preference. Despite these advances, unmet needs persist, including recurrent thrombosis despite anticoagulation, management in thrombocytopenic patients, and adherence to prolonged LMWH therapy. Novel strategies, particularly inhibition of coagulation factor XI, hold promise for dissociating antithrombotic efficacy from bleeding risk. Ongoing phase 3 trials of abelacimab may provide critical evidence to refine anticoagulation strategies in patients with complex clinical profiles. Cancer-associated VTE remains a major clinical challenge requiring individualized decision-making and continuous reassessment. Emerging therapies may further improve outcomes in this vulnerable population.