Canadian Consensus Recommendations on the Management of Venous Thromboembolism in Patients with Cancer. Part 1: Prophylaxis

Abstract

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy has been shown to prevent vte; however, unique clinical circumstances in patients with cancer can often complicate the decisions surrounding the administration of prophylactic anticoagulation. No national Canadian guidelines on the prevention of cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic.PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations.Low molecular weight heparin can be used prophylactically in cancer patients at high risk of developing vte. Direct oral anticoagulants are not recommended for vte prophylaxis at this time. Specific clinical scenarios, including renal insufficiency, thrombocytopenia, liver disease, and obesity can warrant modifications in the administration of prophylactic anticoagulant therapy. There is no evidence to support the monitoring of anti–factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, factor Xa levels could be checked at baseline and periodically in patients with renal insufficiency. The use of anticoagulation therapy to prolong survival in cancer patients without the presence of risk factors for vte is not recommended.

International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer

“…8 The clinical presentation of VTE-defi ned as deep vein thrombosis, pulmonary embolism, or central venous catheter-associated thrombosis-poses major therapeutic challenges that are further complicated by multiple cancer-related risk factors and comorbidities, which infl uence the choice of anticoagulation. [9][10][11][12] Despite the development of national clinical practice guidelines (CPGs) on VTE treatment, [13][14][15][16][17][18] substantial knowledge gaps remain. 19 Preconceptions about patient tolerance and quality of life with the recommended anticoagulants need to be addressed as they hinder global CPG implementation.…”

High risk of deep vein thrombosis associated with peripherally inserted central catheters in lymphoma

“…Venous thromboembolism (VTE) is the second leading cause of death in cancer patients [5]. PICCs are strongly associated with the risk of developing upper extremity deep vein thrombosis (UEDVT) [6, 7], and patients with cancer, especially those with hematological malignancy [8], are at a high risk of developing VTE [9]. …”

Venous thromboembolism prophylaxis in cancer patients — guidelines focus on surgical patients

“…A number of research on efficacy of low-molecular-weight heparin and unfractionated heparin in patients admitted to the hospital on account of acute internal disease showed that LMWH presents at least comparable effectiveness [258][259][260][261][262][263][264]. Based on the results of the aforementioned studies, most guidelines available thus far recommend administration of thromboprophylaxis with low-molecular--weight heparin, unfractionated heparin, or fondaparinux in hospitalized patients receiving conservative treatment ("medical patients"), including those suffering from cancer, who are immobilized in hospital due to an acute medical illness [15,28,254].…”

“…Cancer itself is an important risk factor for VTE not only in surgical patients, but also in those hospitalized on surgical and non-surgical wards and treated conservatively [4,9,23,28,32,33,254]. Because of the tumor, concomitant risk factors of VTE and factors relating to both patient's condition and treatment itself, most cancer patients admitted to the hospital will require thromboprophylaxis adequate to the risk [15,32,33,36,38,254].…”