Cancer VTE in Pancreatic Cancer — RACP Adult Medicine MCQ

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ModerateHaematologyCancer VTE in Pancreatic CancerRACP Adult Medicine

A 50-year-old man with recently diagnosed pancreatic cancer develops acute onset left leg swelling and pain. Doppler ultrasound confirms an ileofemoral DVT. He is too unwell for chemotherapy. His estimated survival is 3 months. What is the preferred anticoagulant?

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Correct answer: B — No anticoagulation – palliative setting only

For cancer-associated VTE, DOACs (apixaban or rivaroxaban) are now preferred first-line based on the Caravaggio and SELECT-D trials, EXCEPT in GI/genitourinary cancers where mucosal bleeding risk is higher. For PANCREATIC cancer (GI primary), LMWH is preferred due to the lower GI bleeding risk. However, the Caravaggio trial (apixaban) showed no significant increase in major GI bleeding even in GI malignancies. The choice between DOAC and LMWH in GI cancers is evolving – current ISTH 2023 guidelines suggest either is acceptable. In a palliative setting with poor prognosis, patient preference and quality of life considerations guide the decision.

Reference: Cancer Council Australia – 2022 – Cancer-Associated VTE; ISTH – 2023