Anticoagulation in Cancer Associated Thrombosis (CAT)

[DrMetal]

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Most of you would turn OFF the anticoagulation after 6 months, right? [say in a patient with an index PE at the time of her CA diagnosis. Now 6 months later, she is 'cured' of CA, surgically complete, rads/chemo complete, has had no further VTEs and is otherwise healthy.]

Do you believe in checking D-Dimers/hs-CRP? Link: D-dimer and high-sensitivity C-reactive protein levels to predict venous thromboembolism recurrence after discontinuation of anticoagulation for cancer-associated thrombosis

 

[gutonc]

Most of you would turn OFF the anticoagulation after 6 months, right? [say in a patient with an index PE at the time of her CA diagnosis. Now 6 months later, she is 'cured' of CA, surgically complete, rads/chemo complete, has had no further VTEs and is otherwise healthy.]

Do you believe in checking D-Dimers/hs-CRP? Link: D-dimer and high-sensitivity C-reactive protein levels to predict venous thromboembolism recurrence after discontinuation of anticoagulation for cancer-associated thrombosis

I do. That study is hypothesis generating only and hasn't entered standard practice, or guidelines. It also included 40% patients with mets (who never get to go off anticoag unless there are other absolute contraindications) and only used LMWH, not DOACs which are SOC now. Also, I like to punch hospitalists that get D-Dimers on patients with active/recent cancer.

Patients as you describe can go off anticoag after 6 months, assuming all curative intent treatment is complete and any indwelling catheters are removed. Patients with metastatic disease, or those treated non-operatively for a Stage III unresectable (anatomically, or medically) cancer, get to stay on it.

 

[DrMetal]

Also, I like to punch hospitalists that get D-Dimers on patients with active/recent cancer.

I totally agree.

But what about checking D-Dimers in the outpatient setting, when the patient is far removed (say > 6 months) from any treatments, lines, etc. No one has touched her. Reasonable to check a D-Dimer when turning off the AC, then again 1-2 months later? x2 negative D-Dimers, has a pretty good negative predictive value, some justification for turning off the AC? Or don't bother: just turn off the AC?

 

[gutonc]

I totally agree.

But what about checking D-Dimers in the outpatient setting, when the patient is far removed (say > 6 months) from any treatments, lines, etc. No one has touched her. Reasonable to check a D-Dimer when turning off the AC, then again 1-2 months later? x2 negative D-Dimers, has a pretty good negative predictive value, some justification for turning off the AC? Or don't bother: just turn off the AC?

This is the thing. At that point, you've already turned it off. Are you going to turn it back on again 4-12 weeks later just based on the D-Dimer? I wouldn't. In someone with a clear provoking factor that you've removed, you're done. You wouldn't do it for a smoker on OCPs who stopped both of them and finished their anticoag, so why do it for cancer?

 

[DrMetal]

This is the thing. At that point, you've already turned it off. Are you going to turn it back on again 4-12 weeks later just based on the D-Dimer? I wouldn't. In someone with a clear provoking factor that you've removed, you're done. You wouldn't do it for a smoker on OCPs who stopped both of them and finished their anticoag, so why do it for cancer?

yeah, makes sense, thanks.

 

[bobow98]

ASH guidelines

Long-term treatment (>6 months) for patients with active cancer and VTE.​

Recommendation 32.​

For patients with active cancer and VTE, the ASH guideline panel suggests long-term anticoagulation for secondary prophylaxis (>6 months) rather than short-term treatment alone (3-6 months) (conditional recommendation, low certainty in the evidence of effects ⊕⊕◯◯).

Recommendation 33.​

For patients with active cancer and VTE receiving long-term anticoagulation for secondary prophylaxis, the ASH guideline panel suggests continuing indefinite anticoagulation over stopping after completion of a definitive period of anticoagulation (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).

Recommendation 34.​

For patients with active cancer and VTE requiring long-term anticoagulation (>6 months), the ASH guideline panel suggests using DOACs or LMWH (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

Background:. Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for

ashpublications.org

 

[DrMetal]

ASH guidelines

Long-term treatment (>6 months) for patients with active cancer and VTE.​

Recommendation 32.​

For patients with active cancer and VTE, the ASH guideline panel suggests long-term anticoagulation for secondary prophylaxis (>6 months) rather than short-term treatment alone (3-6 months) (conditional recommendation, low certainty in the evidence of effects ⊕⊕◯◯).

Recommendation 33.​

For patients with active cancer and VTE receiving long-term anticoagulation for secondary prophylaxis, the ASH guideline panel suggests continuing indefinite anticoagulation over stopping after completion of a definitive period of anticoagulation (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).

Recommendation 34.​

For patients with active cancer and VTE requiring long-term anticoagulation (>6 months), the ASH guideline panel suggests using DOACs or LMWH (conditional recommendation, very low certainty in the evidence of effects ⊕◯◯◯).

American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

Background:. Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for

ashpublications.org

I agree with 32 (>6 months) and 34.

33 (indefinite) doesn't sit well with me. A 42-yo that had a small DCIS and a DVT at the same time, many months/years after all treatments and no further VTEs needs to be AC indefinitely?

 

[gutonc]

I agree with 32 (>6 months) and 34.

33 (indefinite) doesn't sit well with me. A 42-yo that had a small DCIS and a DVT at the same time, many months/years after all treatments and no further VTEs needs to be AC indefinitely?

Note that these are all for "active cancer". Your resected DCIS patient doesn't have active cancer.