Management of Venous Thromboembolism: Prevention and Treatment in Patients with Cancer

Publication Date: February 11, 2021

Recommendations

Primary prophylaxis for hospitalized medical patients with cancer

1. For hospitalized medical patients with cancer without VTE, the American Society of Hematology (ASH) guideline panel suggests using thromboprophylaxis over no thromboprophylaxis. (Conditional, Very low)
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2. For hospitalized medical patients with cancer without VTE, in which pharmacological thromboprophylaxis is used, the ASH guideline panel suggests using LMWH over UFH. (Conditional, Low)
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3. For hospitalized medical patients with cancer without VTE, the ASH guideline panel suggests using pharmacological thromboprophylaxis over mechanical thromboprophylaxis. (Conditional, Very low)
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4. For hospitalized medical patients with cancer without VTE, the ASH guideline panel suggests using pharmacological thromboprophylaxis over a combination of pharmacological and mechanical thromboprophylaxis. (Conditional, Very low)
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5. For hospitalized medical patients with cancer, the ASH guideline panel suggests discontinuing thromboprophylaxis at the time of hospital discharge rather than continuing thromboprophylaxis beyond the discharge date. (Conditional, Very low)
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Primary prophylaxis for patients with cancer undergoing surgery

6. For patients with cancer without VTE undergoing a surgical procedure at lower bleeding risk, the ASH guideline panel suggests using pharmacological rather than mechanical thromboprophylaxis. (Conditional, Low)
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7. For patients with cancer without VTE undergoing a surgical procedure at high bleeding risk, the ASH guideline panel suggests using mechanical rather than pharmacological thromboprophylaxis. (Conditional, Low)
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8. For patients with cancer without VTE undergoing a surgical procedure at high risk for thrombosis, except in those at high risk of bleeding,
  • the ASH guideline panel suggests using a combination of mechanical and pharmacologic thromboprophylaxis rather than mechanical prophylaxis alone
(Conditional, Low)
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  • or pharmacologic thromboprophylaxis alone.
(Conditional, Very low)
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9. For patients with cancer undergoing a surgical procedure, the ASH guideline panel suggests using LMWH or fondaparinux for thromboprophylaxis rather than UFH. (Conditional, Low)
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10. For patients with cancer undergoing a surgical procedure, the ASH guideline panel makes no recommendation on the use of VKA or DOAC for thromboprophylaxis, because there were no studies available. (, )
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11. For patients with cancer undergoing a surgical procedure, the ASH guideline panel suggests using postoperative thromboprophylaxis over preoperative thromboprophylaxis. (Conditional, Low)
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12. For patients with cancer who had undergone a major abdominal/pelvic surgical procedure, the ASH guideline panel suggests continuing pharmacological thromboprophylaxis postdischarge rather than discontinuing at the time of hospital discharge. (Conditional, Very low)
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Primary prophylaxis in ambulatory patients with cancer receiving systemic therapy

13. For ambulatory patients with cancer at low risk for thrombosis receiving systemic therapy, we recommend no thromboprophylaxis over parenteral thromboprophylaxis. (Strong, Moderate)
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For ambulatory patients with cancer at intermediate risk for thrombosis receiving systemic therapy, the ASH guideline panel suggests no prophylaxis over parenteral prophylaxis. (Conditional, Moderate)
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For ambulatory patients with cancer at high risk for thrombosis receiving systemic therapy, the ASH guideline panel suggests parenteral thromboprophylaxis (LMWH) over no thromboprophylaxis. (Conditional, Moderate)
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14. For ambulatory patients with cancer receiving systemic therapy, the ASH guideline panel recommends no thromboprophylaxis over oral thromboprophylaxis with VKA. (Strong, High)
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15. For ambulatory patients with cancer at low risk for thrombosis receiving systemic therapy, the ASH guideline panel suggests no thromboprophylaxis over oral thromboprophylaxis with a DOAC (apixaban or rivaroxaban). (Conditional, Moderate)
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For ambulatory patients with cancer at intermediate risk for thrombosis receiving systemic therapy, the ASH guideline panel suggests thromboprophylaxis with a DOAC (apixaban or rivaroxaban) or no thromboprophylaxis. (Conditional, Moderate)
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For ambulatory patients with cancer at high risk for thrombosis receiving systemic therapy, the ASH guideline panel suggests thromboprophylaxis with a DOAC (apixaban or rivaroxaban) over no thromboprophylaxis. (Conditional, Moderate)
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16 & 17. For multiple myeloma patients receiving lenalidomide, thalidomide, or pomalidomide-based regimens, the ASH guideline panel suggests using low-dose acetylsalicylic acid (ASA) or fixed low-dose VKA or LMWH. (Conditional, Low)
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Primary prophylaxis for patients with cancer with central venous catheter

18. For patients with cancer and a central venous catheter (CVC), the ASH guideline panel suggests not using parenteral thromboprophylaxis. (Conditional, Low)
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19. For patients with cancer and a CVC, the ASH guideline panel suggests not using oral thromboprophylaxis. (Conditional, Low)
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Initial treatment (first week) for patients with active cancer and VTE

20. For patients with cancer and VTE, the ASH guideline panel suggests DOAC (apixaban or rivaroxaban) or LMWH be used for initial treatment of VTE for patients with cancer. (Conditional, Very low)
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21. For patients with cancer and VTE, we recommend LMWH over UFH for initial treatment of VTE for patients with cancer. (Strong, Moderate)
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22. For patients with cancer and VTE, the ASH guideline panel suggests LMWH over fondaparinux for initial treatment of VTE for patients with cancer. (Conditional, Very low)
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Short-term treatment for patients with active cancer (initial 3-6 months)

23. For the short-term treatment of VTE (3-6 months) for patients with active cancer, the ASH guideline panel suggests DOAC (apixaban, edoxaban, or rivaroxaban) over LMWH. (Conditional, Low)
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24. For the short-term treatment of VTE (3-6 months) for patients with active cancer, the ASH guideline panel suggests DOAC (apixaban, edoxaban, or rivaroxaban) over VKA. (Conditional, Very low)
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25. For the short-term treatment of VTE (3-6 months) for patients with active cancer, the ASH guideline panel suggests LMWH over VKA. (Conditional, Moderate)
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26. For patients with cancer and incidental (unsuspected) pulmonary embolism (PE), the ASH guideline panel suggests short-term anticoagulation treatment rather than observation. (Conditional, Very low)
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27. For patients with cancer and subsegmental PE (SSPE), the ASH guideline panel suggests short-term anticoagulation treatment rather than observation. (Conditional, Very low)
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28. For patients with cancer and visceral/splanchnic vein thrombosis, the ASH guideline panel suggests treating with short-term anticoagulation or observing. (Conditional, Very low)
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29. For patients with cancer with CVC-related VTE receiving anticoagulant treatment, the ASH guideline panel suggests keeping the CVC over removing the CVC. (Conditional, Very low)
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30. For patients with cancer and recurrent VTE despite receiving therapeutic LMWH, the ASH guideline panel suggests increasing the LMWH dose to a supratherapeutic level or continuing with a therapeutic dose. (Conditional, Very low)
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31. For patients with cancer and recurrent VTE despite anticoagulation treatment, the ASH guideline panel suggests not using an inferior vena cava (IVC) filter over using a filter. (Conditional, Very low)
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Long-term treatment (>6 months) for patients with active cancer and VTE

32. For patients with active cancer and VTE, the ASH guideline panel suggests long-term anticoagulation for secondary prophylaxis (>6 months) rather than short-term treatment alone (3-6 months). (Conditional, Very low)
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33. For patients with active cancer and VTE receiving long-term anticoagulation for secondary prophylaxis, the ASH guideline panel suggests continuing indefinite anticoagulation over stopping after completion of a definitive period of anticoagulation. (Conditional, Very low)
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34. For patients with active cancer and VTE requiring long-term anticoagulation (>6 months), the ASH guideline panel suggests using DOACs or LMWH. (Conditional, Very low)
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Patients with cancer are at increased risk for VTE, as well as major bleeding. Any consideration of thromboprophylaxis or treatment for patients with cancer should be based on an assessment of the patient’s individual risk for thrombosis and major bleeding after full discussion of the potential benefits and harms. (, )
(Good practice statement)
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Recommendation Grading

Disclaimer

Overview

Title

Management of Venous Thromboembolism: Prevention and Treatment in Patients with Cancer

Authoring Organization

Publication Month/Year

February 11, 2021

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospice, Hospital

Intended Users

Social worker, physician, nurse, nurse practitioner, physician assistant

Scope

Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism

Keywords

Venous Thromboembolism, Clinical guidelines, Cancer patients, thromboprophylaxis, hemorrahage, eustachian tube disorders, low-molecular-weight heparin, direct oral anticoagulants

Source Citation

Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, Leavitt AD, Lee AYY, Macbeth F, Morgan RL, Noble S, Sexton EA, Stenehjem D, Wiercioch W, Kahale LA, Alonso-Coello P. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5(4):927-974. doi: 10.1182/bloodadvances.2020003442. Erratum in: Blood Adv. 2021 Apr 13;5(7):1953. PMID: 33570602; PMCID: PMC7903232.