Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update

Abstract

PURPOSE To conduct an update of the ASCO venous thromboembolism (VTE) guideline. METHODS After publication of potentially practice-changing clinical trials, identified through ASCO's signals approach to updating, an updated systematic review was performed for two guideline questions: perioperative thromboprophylaxis and treatment of VTE. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) published between November 1, 2018, and June 6, 2022. RESULTS Five RCTs provided information that contributed to changes to the 2019 recommendations. Two RCTs addressed direct factor Xa inhibitors (either rivaroxaban or apixaban) for extended thromboprophylaxis after surgery. Each of these postoperative trials had important limitations but suggested that these two oral anticoagulants are safe and effective in the settings studied. An additional three RCTs addressed apixaban in the setting of VTE treatment. Apixaban was effective in reducing the risk of recurrent VTE, with a low risk of major bleeding. RECOMMENDATIONS Apixaban and rivaroxaban were added as options for extended pharmacologic thromboprophylaxis after cancer surgery, with a weak strength of recommendation. Apixaban was also added as an option for the treatment of VTE, with high quality of evidence and a strong recommendation. Additional information is available at www.asco.org/supportive-care-guidelines .

Expression and Release of Tumor Cell Tissue Factor Triggers Recurrent Thromboembolism in a Patient with Endometrial Cancer

“…1 6 Thus, extended anticoagulation beyond 6 months is recommended, especially in patients whose cancer is still active and who carry a high thromboembolic risk. 31 32 33 34 35 In this population, current treatment guidelines recommend anticoagulation with LMWH or direct oral FXa inhibitors (i.e., apixaban, edoxaban, and rivaroxaban). 31 32 33 34 In addition, effective treatment of the underlying malignancy is of utmost importance as it addresses the primary cause of the coagulopathy.…”

“…31 32 33 34 35 In this population, current treatment guidelines recommend anticoagulation with LMWH or direct oral FXa inhibitors (i.e., apixaban, edoxaban, and rivaroxaban). 31 32 33 34 In addition, effective treatment of the underlying malignancy is of utmost importance as it addresses the primary cause of the coagulopathy.…”

Primary Thromboprophylaxis in People With Cancer—Where Next?

“…These findings also further support current American Society of Clinical Oncology and other guideline recommendations for offering thromboprophylaxis to high-risk outpatients. 6 The biggest question in the field, then, is not which riskbased approach or which anticoagulant is the best for primary prevention. Rather, it is this: what is stopping patients with cancer from being offered thromboprophylaxis in the first place?…”

“…Others may point to the lack of regulatory authority approval for outpatient thromboprophylaxis, but oncology guidelines are often used as an alternative for insurance approval and, in this case, guidelines are widely consistent in their recommendations. 6 What is urgently needed is implementation science: systematically closing the gap between what we know and what we do. Findings from one such approach, pioneered at the University of Vermont, are quite encouraging in this regard.…”

“…Overall, however, the findings of the TARGET-TP trial are both consistent with and meaningfully add to the existing evidence base: patients with cancer at high risk for VTE can be identified, and benefit substantially, from primary thromboprophylaxis while preserving safety for the most part. These findings also further support current American Society of Clinical Oncology and other guideline recommendations for offering thromboprophylaxis to high-risk outpatients …”