Anticoagulation during anti-angiogenic cancer therapy: balancing risks of thrombosis and bleeding

Anti-angiogenic therapies, including agents targeting vascular endothelial growth factor or its receptors are widely used for the treatment of different types of cancer. On-target adverse events of anti-angiogenic therapies include an increased risk of bleeding due to impaired endothelial integrity and vascular regeneration. In addition, an increased risk of arterial and venous thromboembolic events has been reported for selected anti-angiogenic agents. Anticoagulation therapy, either due to pre-existing indications or for the treatment of thromboembolic events during anti-angiogenic treatment, therefore, poses a clinical challenge. In the absence of robust evidence-based guidelines and in the context of heterogeneous patient- and treatment-related risk factors, individualized assessment of both thromboembolic and bleeding risk is warranted. High-quality evidence to support clinical management in this setting remains scarce, necessitating personalized risk-benefit evaluations. In the present narrative review, we summarize available data on the risk profiles of thromboembolic and bleeding events associated with different anti-angiogenic therapies and discuss strategies for anticoagulation management in this setting.