Clinical Practice Guidelines   







Skip to end of metadata
Go to start of metadata

 This is an original JCO publication from 2014. Please visit the JCO website to access the full article.


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


 

 Authors

Gary H. Lyman, Kari Bohlke, Alok A. Khorana, Nicole M. Kuderer, Agnes Y. Lee, Juan Ignacio Arcelus, Edward P. Balaban, Jeffrey M. Clarke, Christopher R. Flowers, Charles W. Francis, Leigh E. Gates, Ajay K. Kakkar, Nigel S. Key, Mark N. Levine, Howard A. Liebman, Margaret A. Tempero, Sandra L. Wong, Mark R. Somerfield, and Anna Falanga

THE BOTTOM LINE

Intervention

  • Pharmacologic anticoagulation

Target Audience

  • Medical oncologists, surgical oncologists, hospitalists, oncology nurses

Key Recommendations

Methods

  • An update committee was convened to determine whether previous recommendations remain valid based on an updated review of evidence from the medical literature.

SUMMARY OF RECOMMENDATIONS

 

Clinical Question

Recommendation

Strength of Evidence;

Type, Strength of Recommendation

Should hospitalized patients with cancer receive anticoagulation for VTE prophylaxis?

 

1.1 Hospitalized patients who have active malignancy with acute medical illness or reduced mobility should receive pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.

Evidence: Strong;

Type, Strength: evidence-based, strong

1.2 Hospitalized patients who have active malignancy without additional risk factors may be considered for pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.

Evidence: Moderate;

Type, Strength: evidence-based, strong

1.3 Data are inadequate to support routine thromboprophylaxis in patients admitted for minor procedures or short chemotherapy infusion, or in patients undergoing stem cell/ bone marrow transplantation.

Evidence: Insufficient;

Type, Strength: informal consensus, moderate

Should ambulatory patients with cancer receive anticoagulation for VTE prophylaxis during systemic chemotherapy?

 

2.1 Routine pharmacologic thromboprophylaxis is not recommended in cancer outpatients.

Evidence: moderate;

Type, Strength: evidence-based, strong

2.2 Based on limited RCT data, clinicians may consider LMWH prophylaxis on a case-by-case basis in highly selected outpatients with solid tumors receiving chemotherapy. Consideration of such therapy should be accompanied by a discussion with the patient about the uncertainty concerning benefits and harms, as well as dose and duration of prophylaxis in this setting.

Evidence: moderate;

Type, Strength: evidence-based, weak

2.3 Patients with multiple myeloma receiving thalidomide- or lenalidomide-based regimens with chemotherapy and/or dexamethasone should receive pharmacologic thromboprophylaxis with either aspirin or LMWH for lower-risk patients and LMWH for higher-risk patients.

Evidence: moderate;

Type, Strength: evidence-based, strong

Should patients with cancer undergoing surgery receive perioperative VTE prophylaxis?

 

3.1 All patients with malignant disease undergoing major surgical intervention should be considered for pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated because of active bleeding or a high bleeding risk.

Evidence: strong;

Type, Strength: evidence-based, strong

3.2 Prophylaxis should be commenced preoperatively.

Evidence: moderate;

Type, Strength: evidence-based, moderate

3.3 Mechanical methods may be added to pharmacologic thromboprophylaxis, but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because of active bleeding or high bleeding risk.

Evidence: moderate;

Type, Strength: evidence-based, strong

3.4 A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest-risk patients.

Evidence: moderate;

Type, Strength: informal consensus, moderate

3.5 Pharmacologic thromboprophylaxis for patients undergoing major surgery for cancer should be continued for at least 7-10 days. Extended prophylaxis with LMWH for up to 4 weeks postoperatively should be considered for patients undergoing major abdominal or pelvic surgery for cancer who have high-risk features such as restricted mobility, obesity, history of VTE, or with additional risk factors. In lower risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-by-case basis considering the individual patient.

Evidence: strong;

Type, Strength: evidence-based, strong to moderate

What is the best method for treatment of patients with cancer with established VTE to prevent recurrence?

 

4.1 LMWH is preferred over UFH for the initial 5 to 10 days of anticoagulation for the cancer patient with newly diagnosed VTE who does not have severe renal impairment (defined as creatinine clearance < 30 mL/min).

Evidence: strong;

Type, Strength: evidence-based, strong

4.2 For long term anticoagulation, LMWH for at least 6 months is preferred due to improved efficacy over Vitamin K antagonists. Vitamin K antagonists are an acceptable alternative for long-term therapy if LMWH is not available.

Evidence: strong;

Type, Strength: evidence-based, strong

4.3 Anticoagulation with LMWH or Vitamin K antagonist beyond the initial 6 months may be considered for select patients with active cancer, such as those with metastatic disease or those receiving chemotherapy.

Evidence: insufficient;

Type, Strength: informal consensus, weak to moderate

4.4 The insertion of a vena cava filter is only indicated for patients with contraindications to anticoagulant therapy. It may be considered as an adjunct to anticoagulation in patients with progression of thrombosis (recurrent VTE or extension of existing thrombus) despite optimal therapy with LMWH.

Evidence: weak to moderate;

Type, Strength:  informal consensus, moderate

4.5 For patients with CNS malignancies, anticoagulation is recommended for established VTE as described for other patients with cancer. Careful monitoring is necessary to limit the risk of hemorrhagic complications.

Evidence: moderate;

Type, Strength: informal consensus, strong

4.6 Use of novel oral anticoagulants for either prevention or treatment of VTE in cancer patients is not recommended at this time.

Evidence: insufficient;

Type, Strength: informal consensus, strong

4.7 Based on consensus, incidental PE and DVT should be treated in the same manner as symptomatic VTE. Treatment of splanchnic or visceral vein thrombi diagnosed incidentally should be considered on a case-by-case basis, considering potential benefits and risks of anticoagulation.

Evidence: insufficient;

Type, Strength: informal consensus, moderate

Should patients with cancer receive anticoagulants in the absence of established VTE to improve survival?

5.1 Anticoagulants are not recommended to improve survival in patients with cancer without VTE.

Evidence: weak to moderate;

Type, Strength: informal consensus, moderate

5.2 Patients with cancer should be encouraged to participate in clinical trials designed to evaluate anticoagulant therapy as an adjunct to standard anticancer therapies.

What is known about risk prediction and awareness of VTE among patients with cancer?

 

6.1 Based on consensus, the Panel recommends that cancer patients should be assessed for VTE risk at the time of chemotherapy initiation and periodically thereafter. Individual risk factors, including biomarkers or cancer site, do not reliably identify cancer patients at high risk of VTE. In the outpatient setting, risk assessment can be conducted based on a validated risk assessment tool.

Evidence: moderate;

Type, Strength:  informal consensus, strong

6.2 Based on consensus, the Panel recommends that oncologists educate patients regarding VTE, particularly in settings that increase risk such as major surgery, hospitalization, and while receiving systemic anti-neoplastic therapy.

Evidence: insufficient;

Type, Strength: informal consensus, strong

 

 

 

ASCO Guideline Disclaimer: The clinical practice guidelines and other guidance published herein are provided by the American Society of Clinical Oncology, Inc. (“ASCO”) to assist practitioners in clinical decision making. The information therein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating physician, as the information does not account for individual variation among patients. Recommendations reflect high, moderate or low confidence that the recommendation reflects the net effect of a given course of action.  The use of words like “must,” “must not,” “should,” and “should not” indicate that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating physician in the context of treating the individual patient. Use of the information is voluntary.  ASCO provides this information on an “as is” basis, and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information or for any errors or omissions.


You must have an account to comment or submit evidence. Contact the Guidelines Site Administrator for assistance.

  • No labels