Risk of venous thromboembolism (VTE)is elevated in cancer, but individual risk factors cannot identify a sufficiently highrisk group of outpatients for thromboprophylaxis. We developed a simple model for predicting chemotherapy-associated VTE using baseline clinical and laboratory variables. The association of VTE with multiple variables was characterized in a derivation cohort of 2701 cancer outpatients from a prospective observational study. A risk model was derived and validated in an independent cohort of 1365 patients from the same study. Five predictive variables were identified in a multivariate model: site of cancer (2 points for very high-risk site, 1 point for highrisk site), platelet count of 350 ؋ 10 9 /L or more, hemoglobin less than 100 g/L (10 g/dL) and/or use of erythropoiesisstimulating agents, leukocyte count more than 11 ؋ 10 9 /L, and body mass index of 35 kg/m 2 or more (1 point each). Rates of VTE in the derivation and validation cohorts, respectively, were 0.8% and 0.3% in low-risk (score ‫؍‬ 0), 1.8% and 2% in intermediate-risk (score ‫؍‬ 1-2), and 7.1% and 6.7% in high-risk (score > 3) category over a median of 2.5 months (Cstatistic ‫؍‬ 0.7 for both cohorts). This model can identify patients with a nearly 7% short-term risk of symptomatic VTE and may be used to select cancer outpatients for studies of thromboprophylaxis. IntroductionCancer and antineoplastic therapy are frequently complicated by the development of venous thromboembolism (VTE). Several risk factors for cancer-associated VTE have been described in recent studies and include primary site of cancer, presence of metastatic disease, and use of antineoplastic therapy including chemotherapy, hormonal therapy, surgery, and erythropoiesis-stimulating agents. [1][2][3][4] Cancer patients on active therapy are at greatest risk for development of VTE. In a population-based study, cancer was associated with a 4.1-fold greater risk of thrombosis, whereas the use of chemotherapy increased the risk 6.5-fold. 5,6 In women with stage II breast cancer, the risk of VTE decreases dramatically after chemotherapy is completed. 7,8 The occurrence of VTE has important implications for the cancer patient including requirement for chronic anticoagulation, possible delays in delivering chemotherapy, a high risk of recurrent VTE, risk of bleeding complications on anticoagulation, decreased quality of life, and consumption of health care resources. 9,10 Furthermore, cancer patients with VTE have a 2-fold or greater increase in mortality compared with cancer patients without VTE, even after adjusting for stage. 11,12 Indeed, thromboembolism is a leading cause of death in cancer patients. 13 Primary VTE prophylaxis can reduce deep vein thrombosis (DVT), pulmonary embolism (PE), and fatal PE in several highrisk populations such as hospitalized patients or in the postoperative setting. [14][15][16][17][18] In the cancer population, identification of patients most at risk for VTE followed by institution of effective prophylaxis could improve morbidity, m...

PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE. Additional information is available at www.asco.org/supportive-care-guidelines .

Background: VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. Methods: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. Results: In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava fi lter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lowerextremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). Conclusions: Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches. CHEST 2012; 141(2)(Suppl):e278S-e325SAbbreviations: DUS 5 Doppler (or duplex) ultrasonography; GCS 5 graduated compression stockings; HFS 5 hip fracture surgery; INR 5 international normalized ratio; IPCD 5 intermittent pneumatic compression device; IVC 5 inferior vena cava; LDUH 5 low-dose unfractionated heparin; LMWH 5 low-molecular-weight heparin; PE 5 pulmonary embolism; PEP 5 Pulmonary Embolism Prevention trial; RCT 5 randomized controlled trial; RR 5 risk ratio; THA 5 total hip arthroplasty; TKA 5 total knee arthroplasty; UFH 5 unfractionated heparin; VFP 5 venous foot pump; VKA 5 vitamin K antagonist

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Recommendations of the American Society of Clinical Oncology VTE Guideline Panel include (1) all hospitalized cancer patients should be considered for VTE prophylaxis with anticoagulants in the absence of bleeding or other contraindications; (2) routine prophylaxis of ambulatory cancer patients with anticoagulation is not recommended, with the exception of patients receiving thalidomide or lenalidomide; (3) patients undergoing major surgery for malignant disease should be considered for pharmacologic thromboprophylaxis; (4) low molecular weight heparin represents the preferred agent for both the initial and continuing treatment of cancer patients with established VTE; and (5) the impact of anticoagulants on cancer patient survival requires additional study and cannot be recommended at present.

BACKGROUND.Venous thromboembolism (VTE) contributes to morbidity and mortality in cancer patients and is a frequent complication of anticancer therapy. In the current study, the frequency, risk factors, and trends associated with VTE were examined among hospitalized cancer patients.METHODS.A retrospective cohort study was conducted using the discharge database of the University HealthSystem Consortium. This included 1,824,316 hospitalizations between 1995 and 2003 at 133 U.S. medical centers.RESULTS.Among 1,015,598 cancer patients, 34,357 (3.4%) were diagnosed with deep venous thrombosis and 11,515 with pulmonary embolism (PE) (1.1%) for an overall VTE rate of 4.1%. Subgroups of cancer patients with the highest rates included black ethnicity (5.1% per hospitalization) and those receiving chemotherapy (4.9%). Sites of cancer with the highest rates of VTE included pancreas (8.1%), kidney (5.6%), ovary (5.6%), lung (5.1%), and stomach (4.9%). Among hematologic malignancies, myeloma (5%), non‐Hodgkin lymphoma (4.8%), and Hodgkin disease (4.6%) had the highest rates of VTE. The rate of VTE increased by 28%, secondary to a near‐doubling of PE rates from 0.8% to 1.5% (P < .0001). Among patients receiving chemotherapy, the rates of VTE rose from 3.9% to 5.7%, an increase of 47% (P < .0001). In multivariate analysis, risk factors associated with VTE included age ≥65 years, female sex, black ethnicity, use of chemotherapy, primary site of cancer, presence of comorbidities, and year of admission.CONCLUSIONS.VTE, particularly PE, is an increasingly frequent complication of hospitalization in cancer patients. Patients with black ethnicity, specific sites of cancer, or those receiving chemotherapy are disproportionately at risk. Cancer 2007. © 2007 American Cancer Society.

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