Cancer and its associated treatments are well recognized risk factors for venous thromboembolism (VTE), which can lead to substantial morbidity and mortality. VTEs are significantly more likely to occur in patients with cancer compared with the general population. Patients with cancer also experience higher rates of VTE recurrence and bleeding complications during VTE treatment.

Patient management includes identifying those who are most likely to benefit from pharmacologic prophylaxis and administering the optimal treatment to reduce the risk of VTE recurrence and mortality. The American Society of Clinical Oncology (ASCO) published its first set of guidelines on VTE management in 2007 and subsequently updated those guidelines in 2013 and 2015. This year a new update has been published in the Journal of Clinical Oncology. The latest guidelines includes revisions to  several previous recommendations and many changes in practice.

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“Most notably, direct oral anticoagulants (DOACs) have been added as options for VTE prophylaxis and treatment,” said guideline author Nigel S Key, MB ChB, chief of the section of hematology in the division of hematology and oncology at the University of North Carolina (UNC) and Director of the UNC Hemophilia and Thrombosis Center in Chapel Hill.

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As per the updated recommendations, clinicians may offer select high-risk patients with cancer thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH) in the outpatient setting. Rivaroxaban and edoxaban are now considered options for VTE treatment. Furthermore, VTE treatment for patients with brain metastases is now addressed, and the recommendation for long-term use of postoperative LMWH has been expanded.

“Oncologists and members of the [patient’s] oncology team should educate patients regarding VTE, particularly in settings that increase the risk such as [undergoing] major surgery, [being] hospitalized, and receiving systemic antineoplastic therapy,” said Dr Key.

Perhaps the key recommendation is that hospitalized patients who “have active malignancy and acute medical illness or reduced mobility should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.” That said, routine use of pharmacologic thromboprophylaxis should not be offered to all outpatients. Outpatients at high risk for VTE, such as those with a  Khorana score of 2 or higher prior to initiating a new systemic chemotherapy regimen, may be offered thromboprophylaxis with apixaban, rivaroxaban, or LMWH if they do not have any significant risk factors for bleeding and no potential drug interactions. The authors noted that the benefits, harms, costs, and duration of this treatment should be discussed with the patient.