A 64 year old male on chemotherapy for colon cancer if referred for a painful calf x 24 hours that on Doppler imaging shows a popliteal DVT. What is the standard of care for a patient with a DVT in the setting of active cancer?
The CLOT trial was a multi-center RCT that randomized over 670 cancer patients to either dalteparin (month one: 200 u/kg sc od, months 2-6: 150 ug/kg sc od) or warfarin with a target INR of 2-3. Following 6 months of therapy the cumulative rate of recurrent VTE was 9 vs 17% in favour of the dalteparin arm which was statistically significant. Although there was no documented survival advantage, it is recommended that patients with cancer related clots be treated with a LMWH derivative for the duration of their chemotherapy.
Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349:146.