American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

Abstract

Background: Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. Results: Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. Conclusions: Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.

Cancer and Thrombosis: New Treatments, New Challenges

“…Consequently, the number needed to treat was reduced, although the relative reduction of VTE was again approximately half. Therefore, current guidelines state that it is necessary to estimate the risk of VTE in cancer patients to decide on thromboprophylaxis [7]. The best validated risk assessment tool is the Khorana score [39], but there are many other suggested scores such as, e.g., the Protecht score or the Vienna Cats score [40,41].…”

“…Although there is little data on thromboprophylaxis in hospitalized cancer patients, there is general agreement that all cancer patients submitted to hospital for a disease other than the cancer, e.g., infection, should be considered for thromboprophylaxis. Additionally, all cancer patients undergoing surgery should be considered for postoperative thromboprophylaxis if the bleeding risk is not very high [7].…”

“…Hence, in anticoagulant treatment of cancer patients it is pivotal to weigh the risk of thrombosis against the risk of bleeding. Recently, several organizations have published guidelines for treatment and prophylaxis of VTE in cancer patients [5][6][7].…”

Illustrated State‐of‐the‐Art Capsules of the ISTH 2021 Congress

“… 12 Hence, the use of primary thromboprophylaxis should be considered to decrease the risk of VTE and tailored to minimize the risk of bleeding. 12 Patients should be educated about signs and symptoms of cancer‐associated thrombosis and stratified according to their underlying risk of VTE and bleeding for potential consideration of primary thromboprophylaxis. Multidisciplinary approaches (nurses, pharmacists and physicians) are successful models for primary thromboprophylaxis implementation in ambulatory patients with cancer initiating systemic chemotherapy.…”

“…Venous thromboembolism (VTE) is associated with significant morbidity, mortality and healthcare utilization among ambulatory patients with cancer initiating systemic chemotherapy. Direct oral anticoagulants and low molecular weight heparins have been shown to be safe and effective to prevent cancer‐associated thrombosis in this patient population 12 . Hence, the use of primary thromboprophylaxis should be considered to decrease the risk of VTE and tailored to minimize the risk of bleeding 12 …”