Fred Hutchinson Cancer Research Center, Seattle, WA, USA; University of Washington, Seattle, WA, USA.
University of Washington, Seattle, WA, USA; Advanced Cancer Research Group, Seattle, WA, USA.
Thromb Res. 2020 Jul;191 Suppl 1:S79-S84. doi: 10.1016/S0049-3848(20)30402-3.
The risk of venous thromboembolism (VTE) is increased in patients with cancer and is greatest in those with cancers of the pancreas, stomach, brain, lung and ovary, late stage disease and in those undergoing treatment including chemotherapy, hormonal therapy, or surgery. VTE in patients with cancer is associated with a variety of adverse consequences including an increased risk of VTE recurrence, major bleeding, and early mortality. A VTE risk score for ambulatory patients receiving cancer chemotherapy has been extensively validated and has been used to select high risk patients for thromboprophylaxis trials. Several randomized controlled trials (RCTs) and meta-analyses of these trials have confirmed that LMWHs can significantly reduce the risk of VTE in patients with cancer. While the direct oral anticoagulants (DOACs) have been approved for the general population, previous guideline panels discouraged their use due to a lack of cancer-specific data. Recently RCTs for the treatment of established VTE in patients with cancer have demonstrated that the risk of recurrent VTE is lower while the risk of bleeding greater with DOACs compared to LMWH. Two thromboprophylaxis trials comparing low dose DOACs to placebo in high risk patients receiving cancer therapy have recently reported similar rates of VTE occurrence at 6 months in the control arms. A meta-analysis of the pooled results from these trials in higher risk ambulatory patients receiving cancer therapy confirmed a significant reduction in overall VTE incidence as well as pre-planned secondary outcomes on treatment. Several clinical practice guidelines addressing VTE in patients with malignant disease have been updated including those from the American Society of Clinical Oncology (ASCO). The addition of DOACs as an option for the management of VTE in patients with cancer is the latest major change to previous guidelines issued by these organizations. The updated recommendations from these guidelines are summarized in this review.
静脉血栓栓塞症（VTE）的风险在癌症患者中增加，在患有胰腺癌、胃癌、脑癌、肺癌和卵巢癌、晚期疾病以及接受化疗、激素治疗或手术治疗的患者中风险最大。癌症患者的 VTE 与多种不良后果相关，包括 VTE 复发、大出血和早期死亡率增加的风险。针对接受癌症化疗的门诊患者的 VTE 风险评分已得到广泛验证，并已用于选择高风险患者进行血栓预防试验。几项随机对照试验（RCT）和这些试验的荟萃分析证实，低分子肝素（LMWH）可显著降低癌症患者的 VTE 风险。虽然直接口服抗凝剂（DOACs）已被批准用于一般人群，但由于缺乏癌症特异性数据，以前的指南小组不鼓励使用。最近，针对癌症患者已确立的 VTE 治疗的 RCT 表明，与 LMWH 相比，DOAC 治疗的复发 VTE 风险较低，出血风险较高。两项比较高危癌症治疗患者接受低剂量 DOAC 与安慰剂的血栓预防试验最近报告称，在对照组中，6 个月时 VTE 发生的发生率相似。对这些试验中接受癌症治疗的高风险门诊患者的汇总结果进行的荟萃分析证实，总体 VTE 发生率以及治疗中的预先计划的次要结局均显著降低。针对恶性疾病患者的 VTE 的几个临床实践指南已得到更新，包括美国临床肿瘤学会（ASCO）的指南。将 DOAC 作为癌症患者 VTE 管理的一种选择是这些组织以前发布的指南的最新重大变化。这些指南的更新建议在本综述中进行了总结。
