Practice Guidelines

VTE in Patients with Cancer: Guidelines from the American Society of Clinical Oncology

 

Am Fam Physician. 2020 Aug 1;102(3):188-189.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• Universal outpatient prophylactic anticoagulation of patients with cancer is not recommended.

• Patients with cancer who are at high risk of VTE benefit from low-dose anticoagulation during chemotherapy.

• Anticoagulation should be continued at least six months after VTE in patients with cancer. Continuing anticoagulation for 12 months reduces VTE recurrence similar to the increase in major bleeding.

From the AFP Editors

Patients with cancer experience more anticoagulant bleeding complications, making prevention and treatment decisions challenging. The American Society of Clinical Oncology has updated recommendations for the prevention and treatment of venous thromboembolism (VTE) in patients with cancer.

Universal VTE Prevention in Cancer

Routine anticoagulation for outpatients who have cancer without VTE is not recommended because it has not yielded improved survival. Risk factors such as cancer site or biomarker levels are unhelpful in identifying increased risk in ambulatory patients.

VTE Prevention During Chemotherapy

Systemic chemotherapy increases the risk of VTE. Prophylactic therapy with apixaban (Eliquis), rivaroxaban (Xarelto), or low-molecular-weight heparin (LMWH) should be considered for high-risk outpatients with cancer, providing there are no significant risk factors for bleeding and no drug interactions. LMWH has been shown to reduce the VTE rate by about one-half, but with more clinically relevant bleeding and unchanged mortality. Two recent trials showed low-dose direct oral anticoagulant (DOAC) treatment reduced symptomatic VTE in patients with cancer at higher risk of VTE. In one trial, apixaban at 2.5 mg twice daily prevented VTE with a number needed to treat of 17 and number needed to harm of 59 for major bleeding. In these studies, higher VTE risk was defined as a Khorana risk score of 2 or more (Table 1).

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TABLE 1.

Khorana Score for VTE Risk in Cancer

Risk factorPoints

Very high-risk cancer (e.g., pancreas, stomach)

2

High-risk cancer (e.g., bladder, gynecologic, lung, lymphoma, renal, testicular)

1

Leukocyte count ≥ 11,000 per μL (11.00 × 109 per L) before chemotherapy

1

Hemoglobin < 10 g per dL (100 g per L) or taking red cell–stimulating agents

1

Platelet count ≥ 350,000 per μL before chemotherapy

1

Body mass index 35 kg per m2 or greater

1


Note: A Khorana score of 2 or more is an indication for low-dose VTE prophylaxis during chemotherapy.

VTE = venous thromboembolism.

Adapted with permission from Key NS, Khorana AA, Kuderer NM, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. J Clin Oncol. 2020;38(5):502.

TABLE 1.

Khorana Score for VTE Risk in Cancer

Risk factorPoints

Very high-risk cancer (e.g., pancreas, stomach)

2

High-risk cancer (e.g., bladder, gynecologic, lung, lymphoma, renal, testicular)

1

Leukocyte count ≥ 11,000 per μL (11.00 × 109 per L) before chemotherapy

1

Hemoglobin < 10 g per dL (100 g per L) or taking red cell–stimulating agents

1

Platelet count ≥ 350,000 per μL before chemotherapy

1

Body mass index 35 kg per m2 or greater

1


Note: A Khorana score of 2 or more is an indication for low-dose VTE prophylaxis during chemotherapy.

VTE = venous thromboembolism.

Adapted with permission from Key NS, Khorana AA, Kuderer NM, et al. Venous

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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