The right antithrombotic strategy for cancer patients is still up in the air, as a pilot study suggested feasibility and safety of testing aspirin as an alternative to low molecular weight heparin.
Cumulative rates of major bleeding, thromboembolic events, and survival were similar between the two treatments at 1 year. With the 10% eligibility rate and 40% enrollment rate, the researchers led by Babak Navi, MD, MS, of Weill Cornell Medicine in New York City, said that a larger trial would be appropriate.
“Larger blinded clinical trials to determine the optimal antithrombotic strategy for these high-risk patients appear feasible and safe,” they suggested. “Comparing aspirin with direct oral anticoagulants instead of injectable heparins should be considered for future clinical trials, assuming the confirmation of preliminary data that suggest that these medicines may be safe and effective for varying manifestations of cancer-associated thrombosis.”
Out of 469 patients recruited from a comprehensive cancer center and two comprehensive stroke centers, only 49 met the inclusion criteria of the TEACH pilot trial, having an active solid or hematological cancer and MRI-confirmed acute ischemic stroke within 4 weeks.
Ultimately, just 21 out of the 49 eligible patients (age 18-85 years) were were randomized to subcutaneous enoxaparin (Lovenox; 1 mg/kg twice daily) or oral aspirin (81-325 mg/day) for 6 months. Navi’s group halted further recruitment for lack of funding, they said in a research letter published in JAMA Neurology.
The top two reasons for trial exclusion were clear indications for anticoagulation (30%) and inactive cancer (20%). Then, eligible patients were not included for several reasons: an aversion to receiving injections (38%), patient/physician preferences for anticoagulation (24%), declined clinical trial participation (24%), and patient/physician preferences for antiplatelet therapy (7%).
Six of those assigned to enoxaparin crossed over to aspirin because they were uncomfortable with the injections (n=4) or drug cost (n=2).
Navi disclosed no relevant conflicts of interest.