Approximately one-fifth of all cases of
venous thromboembolism (VTE) are related to
cancer. VTE complications may have a substantial impact on prognosis, quality of life and care in patients with
cancer. Patients with
cancer-related VTE are at increased risk of developing recurrent VTE compared to patients without
cancer, but also have a higher risk of major
bleeding. In the last years, direct oral
anticoagulants (DOACs) have been evaluated in a head-to-head comparison with
low molecular weight heparin (
LMWH) in two randomized trials for the long-term treatment of VTE in patients with advanced
cancer. The results of these trials show that DOACs have a similar efficacy profile, but probably higher risk of
bleeding, compared to
LMWH dalteparin. Because DOACs offer a simple oral treatment regimen without the need for anticoagulation monitoring, they could be attractive alternatives to LMWHs in these setting. The American Society of Clinical Oncology guidelines, published in August 2019, recommend
LMWH,
edoxaban and
rivaroxaban as first-choice
therapies for long-term anticoagulation in
cancer patients with VTE. However, several practical issues should be considered concerning the long-term use of DOAC treatment in patients with
cancer. Major concerns have been highlighted about the gastrointestinal
bleeding risk in patients with
gastrointestinal cancers and the potential drug-drug interactions in combination for some specific anticancer
therapies. Several studies comparing DOACs with
LMWH are currently ongoing to refine our knowledge concerning treatment with DOACs in patients with
cancer-associated VTE.