Cancer and Thrombosis: Implications of Published Guidelines for Clinical Practice

A. A. Khorana

Disclosures

Ann Oncol. 2009;20(10):1619-1630. 

In This Article

ASCO, NCCN, and ESMO Guidelines and Impact on Clinical Practice

Recent guidelines from the ASCO,[14] the NCCN,[16] and the European Society for Medical Oncology (ESMO)[86] recommend consideration of the use of anticoagulants in the following groups:

  • All hospitalized adults (medical or surgical) who have known or suspected cancer, for prophylaxis against VTE.[14,16] The ESMO guidelines, however, restrict this recommendation of prophylactic anticoagulation to hospitalized cancer patients confined to bed. The ASCO guidelines also call for the prophylactic use of anticoagulants in outpatients receiving thalidomide or lenalidomide with chemotherapy or dexamethasone.[14,86]

  • Cancer patients undergoing major cancer surgery. The ESMO guidelines recommend prophylaxis with LMWH or UFH.[86]

  • Patients with cancer and established VTE, to prevent recurrence of thromboembolic events.[14,16,86]

In general, unless there is a contraindication, hospitalized patients with cancer should be considered candidates for VTE prophylaxis with anticoagulants (Table 4).[14,16] Routine prophylaxis during outpatient chemotherapy is not indicated in most cases.[14,86] Mechanical techniques for thromboprophylaxis (e.g. graduated compression stockings, intermittent pneumatic calf compression, and mechanical foot pumps) should be the sole method of prophylaxis only when the patient has a contraindication to pharmacologic anticoagulation.[14]

For cancer patients with established VTE, initial therapy should consist of either LMWH given for 5- 10 days[14,16] or UFH.[86] LMWH should also be used for long-term therapy (≥6 months) to prevent recurrent VTE. A VKA may be used if LMWHs are not available, with the dosage adjusted to achieve an INR of 2.0-3.0. Indefinite anticoagulant prophylaxis should be considered for high-risk patients, such as those with metastatic disease and those receiving chemotherapy.[14,86] The ESMO guidelines also recommend both VKAs and LMWHs for treatment of VTE in patients with cancer, giving the two regimens an equal-strength recommendation.[86] A vena cava filter is indicated only for patients with contraindications to anticoagulants or patients with recurrent VTE despite adequate long-term therapy with LMWH.[14]

It is worth noting that even though guidelines recommending anticoagulant prophylaxis and treatment have been in place for years, only about half of the candidate patients receive appropriate anticoagulation.[17,18] Further, oncologists consider routine thromboprophylaxis for only a minority of their patients (<5% in one survey).[19] Publication of guidelines for thromboprophylaxis, by itself, may not be sufficient to change routine clinical practice; additional interventions may be necessary.[87] In a study by Kucher et al.,[88] the implementation of a hospital-wide computer alert program that warned physicians about patients at risk for DVT increased the use of prophylaxis and significantly reduced the rates of DVT and PE among the hospitalized population. In another study, the use of a formal continuing medical education program for prevention of VTE did lead to some improvement in adherence, although prophylaxis remained underused in the participating hospitals.[89] This same study found that a formal quality assurance program provided no additional benefit. Clearly, other educational interventions are required to improve adherence to thromboprophylaxis guidelines and thereby improve outcomes.

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