• Maria Cristina Vedovati, Michela Giustozzi, and Cecilia Becattini.
• Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Italy. Electronic address: mariacristina.vedovati@unipg.it.
• Thromb. Res. 2019 May 1; 177: 33-41.

AbstractApproximately one-fifth of all cases of venous thromboembolism (VTE) are related to cancer and anticoagulant treatment in these patients has remained a challenge. Cancer patients with VTE are at increased risk of developing recurrent VTE compared to patients without cancer, but also have a higher risk of major bleeding. In these patients, low molecular weight heparins (LMWHs) have been shown to be more effective and as safe as vitamin K-antagonists (VKAs) for the treatment of VTE. Therefore, the majority of current clinical guidelines recommend LMWHs as the treatment of choice for cancer-associated VTE. However, several issues should be considered regarding the use of LMWHs as daily subcutaneous injections, the costs or risk of heparin-induced thrombocytopenia. In recent years, direct-acting oral anticoagulants (DOACs) have shown similar efficacy and better safety profile compared to VKAs and have become the standard of care for the treatment of VTE in the general population. Because DOACs offer a simple oral treatment regimen without the need for anticoagulation control, they could be an attractive alternative to LMWH. Before DOACs become an accepted treatment option for cancer associated VTE, they have to be evaluated in a head-to-head comparison with LMWH. Data from two randomized trials comparing DOACs vs. LMWH have recently been published. In the present review, we will provide three clinically relevant questions on the use of DOACs in patients with cancer and VTE and provide an overview on recent evidence on this topic: 1) are DOACs a treatment option for the prevention of VTE in cancer patients?; 2) what is the place for DOACs in patients with cancer-associated VTE?; 3) should I use DOACs for the extended treatment of cancer-related VTE?.Copyright © 2019. Published by Elsevier Ltd.

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