Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update 2014

Abstract

Purpose To provide current recommendations about the prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Methods PubMed and the Cochrane Library were searched for randomized controlled trials, systematic reviews, meta-analyses, and clinical practice guidelines from November 2012 through July 2014. An update committee reviewed the identified abstracts. Results Of the 53 publications identified and reviewed, none prompted a change in the 2013 recommendations. Recommendations Most hospitalized patients with active cancer require thromboprophylaxis throughout hospitalization. Routine thromboprophylaxis is not recommended for patients with cancer in the outpatient setting. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low–molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those undergoing major abdominal or pelvic surgery with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term secondary prophylaxis (at least 6 months). Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE because of limited data in patients with cancer. Anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should educate patients about the signs and symptoms of VTE.

Practice Patterns for Prophylaxis and Treatment of Venous Thromboembolism in German Cancer Patients

“…The results of this survey are again in line with this recommendation in that many hematologists/oncologists only offer prophylactic anticoagulation to ambulatory patients with pancreatic cancer or multiple myeloma, as recommended by the ASCO or the National Comprehensive Cancer Network (NCCN) [10,11]. Some also provide prophylaxis for ambulatory lung cancer patients, as has been recommended by the International Society on Thrombosis and Haemostasis (ISTH) [8].…”

“…There is uncertainty whether really all hospitalized cancer patients should be offered prophylaxis. The recent American Society of Clinical Oncology (ASCO) guideline update reflects this discussion and concedes that there is inadequate support for routine thromboprophylaxis in cancer patients admitted for minor procedures or short chemotherapy infusion [9,10]. The discomfort with uniform thromboprophylaxis is also reflected in our survey.…”

“…Several national and international evidence-based guidelines on the prevention and treatment of cancer-associated VTE have been published to support clinicians working in the field [8,9,10,11]. These guidelines uniformly recommend thromboprophylaxis for hospitalized cancer patients, while routine thromboprophylaxis is not recommended for ambulatory patients.…”

Venous Thromboembolism in Primary Nephrotic Syndrome - Is the Risk High Enough to Justify Prophylactic Anticoagulation?

“…Despite this, and accepting 80% power, the required sample size would still be challenging to recruit, especially given the relative rarity of the condition and the expected high prevalence of exclusion criteria (e.g., bleeding tendency). The risk of VTE in NS is similar to the risk of VTE in patients with some active cancers [17], in whom routine anticoagulation is not currently recommended [18]. In contrast, it is also similar to the risk of stroke in patients with AF (a CHA 2 DS 2 -VASc score of 2 carries a risk of stroke of 2.2% per year [19]) in whom anticoagulation is recommended [20].…”

Recurrent brain ischaemia and deep vein thrombosis: the clot thickens

“…Current guidance recommends using low-molecular-weight heparin over warfarin, and there is no evidence for the efficacy of direct acting oral anticoagulants 6. There are no guidelines for secondary prevention of cancer-related stroke, though one study showed reduced cerebral embolic signals and D-dimer levels with anticoagulant use 7.…”