New Guidelines on Management of Venous Thromboembolism

Cancer patients are significantly more likely to develop venous thromboembolism (VTE) than people without cancer. Appropriate risk assessment, prophylaxis, and management of VTEs is essential to prevent the long-term complications and risk of death from deep vein thrombosis and pulmonary embolism. In a new Clinical Practice Guideline released by the American Society for Clinical Oncology (ASCO), an expert panel reviewed current strategies for the prevention and treatment of VTE and recommended updates to these processes based on recent studies. A total of 35 publications on VTE prophylaxis and 18 publications on risk assessment were included in the analysis.

As in previous guidelines, the experts recommended VTE prophylaxis for patients with cancer who are hospitalized for acute medical illness, while patients who are hospitalized for minor procedures or chemotherapy do not require prophylaxis. Patients with restricted mobility or obesity should receive prophylaxis with low-molecular-weight heparin (LMWH) prior to major surgery, including laparoscopic abdominal or pelvic surgery. Furthermore, high-risk patients receiving outpatient chemotherapy should be considered for VTE prophylaxis, as should patients with multiple myeloma receiving an immunomodulatory therapy (IMiD) or dexamethasone.

One major change to the guidelines with this update is the recommendation of direct oral anticoagulant (DOAC) therapy as a treatment strategy. DOACs, including apixaban, edoxaban, and rivroxaban, are rapid-acting anticoagulants that directly inhibit proteins within the coagulation cascade. The expert panel added DOACs as recommended prophylaxis for VTEs in high-risk patients with cancer receiving systemic chemotherapy, as well as for prevention of recurrence in patients with established VTEs. A further update was the addition of recommended treatment regimens for patients with brain metastases. The expert panel recommended that patients with primary or metastatic brain malignancies with established VTEs receive anticoagulation therapy with LMWH or DOACs.

The panel also provided recommendations regarding treatment of VTE and prevention of VTE occurrence, echoing the advice of the 2015 guidelines. Finally, the panel stressed the importance of including the patient in any decision regarding VTE prophylaxis and treatment and considering less expensive treatment alternative when appropriate.

Read more about these guidelines on Medscape Oncology.

J Clin Oncol. 2019 August 5. [Epub ahead of print.]

Clinical Opinion Poll

What frontline therapy would you recommend for a 49 y/o woman diagnosed with low tumor burden metastatic ALK+ NSCLC (lung and liver metastases, normal brain MRI, PS0)?