Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update

Nigel S. Key; Alok A. Khorana; Nicole M. Kuderer; Kari Bohlke; Agnes Y.Y. Lee; Juan I. Arcelus; Sandra L. Wong; Edward P. Balaban; Christopher R. Flowers; Charles W. Francis; Leigh E. Gates; Ajay K. Kakkar; Mark N. Levine; Howard A. Liebman; Margaret A. Tempero; Gary H. Lyman; Anna Falanga

doi:10.1200/JCO.19.01461

Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update

Nigel S. Key, Alok A. Khorana, Nicole M. Kuderer, Kari Bohlke, Agnes Y.Y. Lee, Juan I. Arcelus, Sandra L. Wong, Edward P. Balaban, Christopher R. Flowers, Charles W. Francis, Leigh E. Gates, Ajay K. Kakkar, Mark N. Levine, Howard A. Liebman, Margaret A. Tempero, Gary H. Lyman, Anna Falanga

Research output: Contribution to journal › Review article › peer-review

941 Scopus citations

Abstract

PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.

Original language	English (US)
Pages (from-to)	496-520
Number of pages	25
Journal	Journal of Clinical Oncology
Volume	38
Issue number	5
DOIs	https://doi.org/10.1200/JCO.19.01461
State	Published - Feb 10 2020
Externally published	Yes

ASJC Scopus subject areas

Oncology
Cancer Research

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Key, N. S., Khorana, A. A., Kuderer, N. M., Bohlke, K., Lee, A. Y. Y., Arcelus, J. I., Wong, S. L., Balaban, E. P., Flowers, C. R., Francis, C. W., Gates, L. E., Kakkar, A. K., Levine, M. N., Liebman, H. A., Tempero, M. A., Lyman, G. H., & Falanga, A. (2020). Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update. Journal of Clinical Oncology, 38(5), 496-520. https://doi.org/10.1200/JCO.19.01461

Key, NS, Khorana, AA, Kuderer, NM, Bohlke, K, Lee, AYY, Arcelus, JI, Wong, SL, Balaban, EP, Flowers, CR, Francis, CW, Gates, LE, Kakkar, AK, Levine, MN, Liebman, HA, Tempero, MA, Lyman, GH & Falanga, A 2020, 'Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update', Journal of Clinical Oncology, vol. 38, no. 5, pp. 496-520. https://doi.org/10.1200/JCO.19.01461

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title = "Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update",

abstract = "PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.",

author = "Key, {Nigel S.} and Khorana, {Alok A.} and Kuderer, {Nicole M.} and Kari Bohlke and Lee, {Agnes Y.Y.} and Arcelus, {Juan I.} and Wong, {Sandra L.} and Balaban, {Edward P.} and Flowers, {Christopher R.} and Francis, {Charles W.} and Gates, {Leigh E.} and Kakkar, {Ajay K.} and Levine, {Mark N.} and Liebman, {Howard A.} and Tempero, {Margaret A.} and Lyman, {Gary H.} and Anna Falanga",

note = "Publisher Copyright: {\textcopyright} 2019 by American Society of Clinical Oncology",

year = "2020",

month = feb,

day = "10",

doi = "10.1200/JCO.19.01461",

language = "English (US)",

volume = "38",

pages = "496--520",

journal = "Journal of Clinical Oncology",

issn = "0732-183X",

publisher = "American Society of Clinical Oncology",

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TY - JOUR

T1 - Venous thromboembolism prophylaxis and treatment in patients with cancer

T2 - ASCO clinical practice guideline update

AU - Key, Nigel S.

AU - Khorana, Alok A.

AU - Kuderer, Nicole M.

AU - Bohlke, Kari

AU - Lee, Agnes Y.Y.

AU - Arcelus, Juan I.

AU - Wong, Sandra L.

AU - Balaban, Edward P.

AU - Flowers, Christopher R.

AU - Francis, Charles W.

AU - Gates, Leigh E.

AU - Kakkar, Ajay K.

AU - Levine, Mark N.

AU - Liebman, Howard A.

AU - Tempero, Margaret A.

AU - Lyman, Gary H.

AU - Falanga, Anna

PY - 2020/2/10

Y1 - 2020/2/10

N2 - PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.

AB - PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.

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Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update

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