Medical School, University of Malta, Msida, Malta.
Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
Vasc Health Risk Manag. 2022 Oct 13;18:793-807. doi: 10.2147/VHRM.S271411. eCollection 2022.
Cancer is a major risk factor for venous thromboembolism (VTE), and cancer-associated thrombosis (CAT) constitutes approximately 15-25% of all VTE cases. For decades, the standard treatment for CAT used to be daily subcutaneous low molecular weight heparin (LMWH). Data on the safety and efficacy of the direct oral anticoagulants (DOACs) in this population emerged only in recent years and specific DOACs were included into recent guidelines recommendations. In this narrative review of the literature, we reported the results of the phase III randomized controlled trials that evaluated the DOACs for the prevention and the acute treatment of CAT. For the acute phase treatment, the anti-Xa inhibitors (apixaban, edoxaban, rivaroxaban) showed better efficacy than LMWH in preventing VTE recurrence; however, rivaroxaban and edoxaban were also associated with an increased risk of bleeding events. For primary prevention of CAT in ambulatory cancer patients starting chemotherapy, apixaban and rivaroxaban showed better efficacy than placebo but a trend towards higher bleeding rates. Recent guidelines suggest the DOACs for the treatment of CAT in selected cancer patients (eg, low bleeding risk, no luminal gastrointestinal or genitourinary malignancies, no interfering medications). The DOACs are also suggested for primary thromboprophylaxis in selected ambulatory cancer patients at high risk of VTE (eg, Khorana score ≥2 prior to starting new chemotherapy, low bleeding risk, no interfering medications).
癌症是静脉血栓栓塞症（VTE）的主要危险因素，癌症相关血栓形成（CAT）约占所有 VTE 病例的 15-25%。几十年来，CAT 的标准治疗方法一直是每天皮下注射低分子肝素（LMWH）。近年来才出现了关于直接口服抗凝剂（DOACs）在该人群中的安全性和疗效的数据，并且特定的 DOAC 也被纳入了最近的指南建议。在对文献的叙述性综述中，我们报告了评估 DOACs 预防和急性治疗 CAT 的 III 期随机对照试验的结果。在急性阶段治疗中，抗 Xa 抑制剂（阿哌沙班、依度沙班、利伐沙班）在预防 VTE 复发方面比 LMWH 更有效；然而，利伐沙班和依度沙班也与出血事件风险增加相关。对于开始化疗的门诊癌症患者的 CAT 一级预防，阿哌沙班和利伐沙班比安慰剂更有效，但出血率较高的趋势。最近的指南建议在选定的癌症患者（例如低出血风险、无腔胃肠道或泌尿生殖系统恶性肿瘤、无干扰药物）中使用 DOACs 治疗 CAT。在高 VTE 风险的选定门诊癌症患者（例如在开始新化疗前 Khorana 评分≥2、低出血风险、无干扰药物）中，也建议使用 DOACs 进行一级血栓预防。
