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Essence of this Article

A number of guidelines have been published for the prevention of venous thromboembolism (VTE) and treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients with cancer. A consensus on guidelines for the use of antithrombotic therapy for VTE in patients with cancer, and their implementation in clinical practice, may assist in improving the care that patients with cancer receive.

Guideline Recommendations

A number of guidelines have been published for the prevention of VTE and treatment of DVT and PE in patients with cancer. The 2012 American College of Chest Physicians (ACCP) guidelines recommend the use of low molecular weight heparin (LMWH), unfractionated heparin (UFH) or fondaparinux for thromboprophylaxis in patients with cancer who are at high risk of VTE.289, 290 LMWH is also recommended over LMWH/VKA for acute and long-term treatment of VTE in patients with cancer (grade 2B recommendation).301 VKAs may, therefore, be appropriate for long-term treatment in some patients, according to preference and other factors such as the stage of the cancer and chemotherapy.301 VKA therapy is preferred to the novel oral anticoagulants (grade 2B recommendation) because of a lack of published evidence on the latter at the time the guidelines were produced. Extended therapy with LMWH for ≥3 months is recommended for treatment of DVT and PE, if the risk of bleeding is not high.301

Guideline recommendations have also been published in recent years by the following bodies:

  • The American Society of Clinical Oncology (ASCO)308
  • National Comprehensive Cancer Network (NCCN)293
  • European Society of Cardiology (ESC)309

A comparison of guideline recommendations for the prevention of VTE and the treatment of DVT and PE in patients with cancer is presented.

Comparison of guidelines for the prevention of VTE and treatment of DVT and PE in patients with cancer.

Guideline NCCN293 ACCP289, 290, 301 ASCO308 ESC*309
Year of publication 2007 2012 2013 2014
Prevention of VTE
Hospitalized medical patients with cancer Anticoagulation from admission to discharge if no contraindication VTE prophylaxis with LMWH, UFH or fondaparinux Anticoagulation if no contraindication or bleeding
Ambulatory patients receiving chemotherapy Not mentioned Not mentioned No routine prophylaxis unless high risk
Surgical cancer patients Anticoagulation if no contraindication Extended LMWH prophylaxis in patients who are not at high risk of bleeding UFH or LMWH if major surgery or laparotomy, laparoscopy or thoracotomy duration >30 minutes
Duration Non-high-risk patients: from admission to discharge
High-risk patients: 4 weeks
4 weeks Non-high-risk patients: 7–10 days
High-risk patients: 4 weeks
Treatment of DVT and PE
Acute VTE treatment LMWH LMWH LMWH LMWH
Long-term VTE treatment LMWH or VKA for 3–6 months for DVT; for 6–12 months for PE Indefinite anticoagulation if active cancer or persistent risk factors Extended anticoagulant therapy for >3 months, using the same anticoagulant as used for acute treatment, unless bleeding risk is very high LMWH for at least 6 months LMWH for 3–6 months or until cancer is cured
*Guidelines cover PE only; Recommended over VKA, but VKA is recommended over novel oral anticoagulants.
ACCP, American college of Chest Physicians; ASCO, American Society of Clinical Oncology; DVT, deep vein thrombosis; LMWH, low molecular weight heparin; NCCN, National Comprehensive Cancer Network; PE, pulmonary embolism; UFH, unfractionated heparin; VKA, vitamin K antagonist; VTE, venous thromboembolism.

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A consensus on guidelines for the use of antithrombotic therapy for VTE in patients with cancer, and their implementation in clinical practice, may assist in improving the care that patients with cancer receive.306


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