Division of Hematology/Oncology, Columbia University Irving Medical Center, New York, New York, USA.
Oncologist. 2020 Feb;25(2):132-139. doi: 10.1634/theoncologist.2019-0264. Epub 2019 Oct 1.
Venous thromboembolism (VTE) frequently occurs in patients with cancer, and particularly those with pancreatic ductal adenocarcinoma (PDAC). Therapeutic anticoagulation with either low-molecular-weight heparin or a direct oral anticoagulant is clearly beneficial in patients who develop a VTE. However, whether thromboprophylaxis improves patient outcomes remains unclear. Studies assessing this risk show a 10%-25% risk of VTE, with reduction to 5%-10% with thromboprophylaxis but no impact on survival. To aid in the risk stratification of patients, several tools have been developed to identify those at highest risk for a VTE event. However, the clinical application of these risk stratification models has been limited, and most patients, even those at the highest risk, will never have a VTE event. New oral anticoagulants have greatly improved the feasibility of prophylaxis but do show increased risk of bleeding in patients with the underlying gastrointestinal dysfunction frequently found in patients with pancreatic cancer. Recently, several completed clinical trials shed new light on this complicated risk versus benefit decision. Here, we present this recent evidence and discuss important considerations for the clinician in determining whether to initiate thromboprophylaxis in patients with PDAC. IMPLICATIONS FOR PRACTICE: Given the high risk of venous thromboembolism in patients with pancreatic adenocarcinoma (PDAC), whether to initiate prophylactic anticoagulation is a complex clinical decision. This review discusses recent evidence regarding the risk stratification and treatment options for thromboprophylaxis in patients with PDAC, with the goal of providing practicing clinicians with updates on recent developments in the field. This article also highlights important considerations for individualizing the treatment approach for a given patient given the lack of general consensus of uniform recommendations for this patient population.
静脉血栓栓塞症（VTE）经常发生在癌症患者中，尤其是胰腺导管腺癌（PDAC）患者。对于发生 VTE 的患者，低分子量肝素或直接口服抗凝剂的治疗性抗凝显然是有益的。然而，血栓预防是否能改善患者的预后尚不清楚。评估这一风险的研究表明，VTE 的风险为 10%-25%，通过血栓预防可降低至 5%-10%，但对生存没有影响。为了帮助患者进行风险分层，已经开发了几种工具来识别发生 VTE 事件风险最高的患者。然而，这些风险分层模型的临床应用受到限制，大多数患者，甚至是风险最高的患者，都不会发生 VTE 事件。新型口服抗凝剂大大提高了预防的可行性，但在经常发生于胰腺癌患者的基础胃肠道功能障碍患者中，会增加出血风险。最近，几项完成的临床试验为这一复杂的风险与获益决策提供了新的依据。在这里，我们介绍了这一新的证据，并讨论了临床医生在决定是否对 PDAC 患者进行血栓预防时需要考虑的重要因素。临床意义：鉴于胰腺腺癌（PDAC）患者发生静脉血栓栓塞症的风险很高，是否开始预防性抗凝是一个复杂的临床决策。本综述讨论了 PDAC 患者血栓预防的风险分层和治疗选择的最新证据，旨在为临床医生提供该领域最新进展的更新。本文还强调了鉴于缺乏针对这一患者群体的统一建议的共识，在为特定患者制定个体化治疗方案时需要考虑的重要因素。
