The treatment of cancer associated thrombosis: does one size fit all? Who should get LMWH/warfarin/DOACs?

• The term cancer associated thrombosis encompasses a diverse heterogeneity of disease primaries, stage, co morbidities and treatment histories
• Once daily weight adjusted LMWH remains the gold standard treatment for uncomplicated cancer associated thrombosis
• Patient’s should be given sufficient information to make informed decisions about their anticoagulation
• In clinical cases where strong evidence is lacking decisions should be guided by the best evidence available, an understanding of pharmacokinetics/ dynamics of available anticoagulants and informed patient choice

ABSTRACTWhilst the term cancer associated thrombosis (CAT) offers an overarching term for all thrombotic events encountered during the cancer journey, the reality is that this is a far too simplistic reflection of a complex multifactorial process occurring within a heterogeneous population. The management of CAT needs to consider factors beyond the thrombus itself: patients must be treated as individuals within the context of their own cancer journey and their preferences for different treatment options. The breath of pathological, pharmacological and psychosocial variants means it is highly unlikely that one treatment regime will be appropriate for all patients. It is inevitable that regimes may need to be modified and anticoagulant agents changed according to clinical and patient preference needs. There is strong evidence supporting the use of low molecular weight heparin first line in the treatment of acute CAT. The evidence for warfarin and the direct acting oral anticoagulants is not as strong but, as oral agents, may be preferred by some patients. This paper shall identify the various treatment options available, factors which will influence the decision making process and when it is justifiable to treat patients differently to the established protocol.