As reported in Blood Advances by Gary H. Lyman, MD, MPH, FASCO, FRCP, and colleagues, the American Society of Hematology (ASH) has issued evidence-based guidelines intended to assist patients, clinicians, and other health-care professionals in decisions regarding the prevention and treatment of venous thromboembolism (VTE) in patients with cancer. The guidelines are summarized below.
ASH guideline panel “strong” recommendations are indicated by “the panel recommends.” Panel “conditional” recommendations are indicated by “the panel suggests.” From the clinician perspective, conditional recommendations acknowledge that different choices are appropriate for individual patients, and that clinicians should assist each patient in coming to a management decision consistent with the patient’s values and preferences.
Gary H. Lyman, MD, MPH, FASCO, FRCP
Primary Prophylaxis for Hospitalized Medical Patients With Cancer
- For patients without VTE, the panel suggests using thromboprophylaxis over no thromboprophylaxis.
- For patients without VTE in whom pharmacologic thromboprophylaxis is used, the panel suggests using low–molecular-weight heparin (LMWH) over unfractionated heparin (UFH).
- For patients without VTE, the panel suggests using pharmacologic thromboprophylaxis over mechanical thromboprophylaxis.
- For patients without VTE, the panel suggests using pharmacologic thromboprophylaxis over a combination of pharmacologic and mechanical thromboprophylaxis.
- The panel suggests discontinuing thromboprophylaxis at the time of hospital discharge rather than continuing thromboprophylaxis beyond the discharge date.
Primary Prophylaxis for Patients With Cancer Undergoing Surgery
- For patients without VTE undergoing a surgical procedure at lower bleeding risk, the panel suggests using pharmacologic rather than mechanical thromboprophylaxis.
- For patients without VTE undergoing a surgical procedure at high bleeding risk, the panel suggests using mechanical rather than pharmacologic thromboprophylaxis.
- For patients without VTE undergoing a surgical procedure at high risk for thrombosis, except in those at high risk of bleeding, the panel suggests using a combination of mechanical and pharmacologic thromboprophylaxis rather than mechanical prophylaxis alone or pharmacologic thromboprophylaxis alone.
- For all patients, the panel suggests using LMWH or fondaparinux for thromboprophylaxis rather than UFH.
- The panel makes no recommendation on the use of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for thromboprophylaxis due to absence of data.
- The panel suggests using postoperative thromboprophylaxis over preoperative thromboprophylaxis.
- For patients who have undergone a major abdominal/pelvic surgical procedure, the panel suggests continuing pharmacologic thromboprophylaxis postdischarge rather than discontinuing at the time of hospital discharge.
Primary Prophylaxis in Ambulatory Patients With Cancer Receiving Systemic Therapy
- For patients at low risk for thrombosis receiving systemic therapy, the panel recommends no thromboprophylaxis over parenteral thromboprophylaxis. For patients at intermediate risk, the panel suggests no prophylaxis over parenteral prophylaxis. For patients at high risk, the panel suggests parenteral thromboprophylaxis (LMWH) over no thromboprophylaxis.
- The panel recommends no thromboprophylaxis over oral thromboprophylaxis with VKAs.
- For patients at low risk for thrombosis, the panel suggests no thromboprophylaxis over oral thromboprophylaxis with a DOAC (apixaban or rivaroxaban). For patients at intermediate risk, the panel suggests thromboprophylaxis with a DOAC (apixaban or rivaroxaban) or no thromboprophylaxis. For patients at high risk, the panel suggests thromboprophylaxis with a DOAC (apixaban or rivaroxaban) over no thromboprophylaxis.
- For patients with multiple myeloma receiving lenalidomide-, thalidomide-, or pomalidomide-based regimens, the panel suggests using low-dose acetylsalicylic acid (ASA) or fixed low-dose VKAs or LMWH.
Primary Prophylaxis for Patients With Cancer and a Central Venous Catheter (CVC)
- The panel suggests not using parenteral thromboprophylaxis.
- The panel suggests not using oral thromboprophylaxis.
Initial Treatment (First Week) for Patients With Active Cancer and VTE
- The panel suggests DOAC (apixaban or rivaroxaban) or LMWH be used for initial treatment of VTE.
- The panel recommends LMWH over UFH for initial treatment of VTE.
- The panel suggests LMWH over fondaparinux for initial treatment of VTE.
Short-Term Treatment for Patients With Active Cancer (Initial 3 to 6 Months)
- The panel suggests DOACs (apixaban, edoxaban, or rivaroxaban) over LMWH.
- The panel suggests DOACs (apixaban, edoxaban, or rivaroxaban) over VKAs.
- The panel suggests LMWH over VKAs.
- For patients with incidental (unsuspected) pulmonary embolism (PE), the panel suggests short-term anticoagulation treatment rather than observation.
- For patients with subsegmental PE (SSPE), the panel suggests short-term anticoagulation treatment rather than observation.
- For patients with visceral/splanchnic vein thrombosis, the panel suggests treatment with short-term anticoagulation or observation.
- For patients with CVC-related VTE receiving anticoagulant treatment, the panel suggests keeping the CVC over removing the CVC.
- For patients with recurrent VTE despite receiving therapeutic LMWH, the panel suggests increasing the LMWH dose to a supratherapeutic level or continuing with a therapeutic dose.
- For patients with recurrent VTE despite anticoagulation treatment, the panel suggests not using an inferior vena cava filter over using a filter.
Long-Term Treatment (> 6 Months) for Patients With Active Cancer and VTE
- The panel suggests long-term anticoagulation for secondary prophylaxis (> 6 months) rather than short-term treatment alone (3–6 months).
- For patients receiving long-term anticoagulation for secondary prophylaxis, the panel suggests continuing indefinite anticoagulation over stopping after completion of a definitive period of anticoagulation.
- For patients requiring long-term anticoagulation (> 6 months), the panel suggests using DOACs or LMWH.
The panel concluded, “Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use LMWH for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or DOACs in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.”
Dr. Lyman, of Fred Hutchinson Cancer Research Center, and Pablo Alonso-Coello, MD, PhD, of Cochrane Iberoamérica, Biomedical Research Institute Sant Pau, Barcelona, are the corresponding authors for the Blood Advances article.
Disclosure: For full disclosures of the study authors, visit ashpublications.org.
