The Link Between DOACs and Cancer

​A middle-aged woman was started on a direct oral anticoagulant (DOAC) for an upper-extremity deep venous thrombosis two weeks before presenting to the emergency department. She reported that she had coughed up some blood. She had never had blood clots before and had no other testing.​The whole thing was strange and concerning.Only about 10 percent of DVTs are in the upper extremity. (Circulation 2012;126[6]:768.) One can divide them into primary (or provoked), secondary, or idiopathic. Primary ones are usually related to effort, particularly those who are performing repetitive overhead movement or have thoracic outlet syndrome. Secondary upper extremity DVTs are usually associated with intravascular catheters/wires or malignancy. Those with no known cause usually have a less revealing workup than patients with lower-extremity DVTs, but one has a better chance of finding an abnormality in patients without vascular catheters or known exertional risks.On the other hand, studies have shown that extensive screening for cancer in patients with idiopathic or unprovoked DVTs do not necessarily detect more occult cancers and do not change overall survival.​Still, she was coughing up blood. She was going to need a chest x-ray. In addition, some experts have commented that bleeding on a DOAC might be a red flag for cancer.One study showed that the subset of cancer patients with upper-extremity DVTs and no vascular catheters was 28 percent at three months. (Vasc Med 2011;16[3]...
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