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Cancer-associated thrombosis

Key sources
The following summarized guidelines for the evaluation and management of cancer-associated thrombosis are prepared by our editorial team based on guidelines from the American Society of Clinical Oncology (ASCO 2023; 2013), the European Society of Medical Oncology (ESMO 2023; 2015), the American Society of Hematology (ASH 2023; 2021), the International Initiative on Thrombosis and Cancer (ITAC 2022), the American Association for Thoracic Surgery (AATS/ESTS 2022), the American College of Chest Physicians (ACCP 2021), the European Society for Vascular Surgery (ESVS 2021), the Canadian Consensus Group on Venous Thromboembolism in Cancer (CCG-VTEC 2015), the British Committee for Standards In Haematology (BCSH 2015), the Canadian Consensus Group on Cancer-Associated Thrombosis (CCG-CAT 2015), and the International Society on Thrombosis and Haemostasis (ISTH 2014).
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Guidelines

1.Screening and diagnosis

Screening for occult malignancy: consider obtaining CT (and mammography in females) for screening of cancer in > 40 years old patients with unprovoked VTE. Set a lower threshold for screening patients with bilateral DVT, very high D-dimers, or an early recurrence of VTE.
C
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2.Classification and risk stratification

Risk assessment: as per ASCO 2023 guidelines, assess patients with cancer for VTE risk initially and periodically thereafter, particularly when starting systemic antineoplastic therapy or at the time of hospitalization.
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3.Diagnostic investigations

Baseline laboratory tests: obtain a baseline CBC, creatinine, liver function tests, and INR or PTT to rule out severe thrombocytopenia, renal or hepatic impairment, and coagulopathy.
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  • Diagnostic imaging

4.Medical management

Anticoagulant therapy, initiation/treatment phase, ASCO: consider administering LMWH, UFH, fondaparinux, rivaroxaban, or apixaban for initial anticoagulation. Prefer LMWH over UFH for the initial 5-10 days of anticoagulation in patients with newly diagnosed VTE, in the absence of severe renal impairment (CrCl < 30 mL/min).
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  • Anticoagulant therapy (extended phase)

  • Anticoagulant therapy (monitoring)

  • Thrombolytic therapy

5.Therapeutic procedures

Inferior vena cava filter placement: as per ASCO 2023 guidelines, do not place vena cava filters in patients with established or chronic thrombosis (VTE diagnosis > 4 weeks ago), nor in patients with temporary contraindications to anticoagulant therapy (for example, surgery).
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6.Specific circumstances

Elderly patients
Recognize that elderly patients (> 70 years of age) with reduced CrCl could be at greater risk of LMWH-induced complications such as bleeding.
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Insufficient evidence to recommend one LMWH or UFH over another in elderly patients with active malignancy. Consider preferring tinzaparin for a favorable biologic profile using therapeutic dosing in the setting of renal insufficiency.
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  • Pregnant patients

  • Pediatric patients

  • Patients with obesity

  • Patients with COVID-19 infection

  • Patients with impaired renal function

  • Patients with thrombocytopenia (thromboprophylaxis)

  • Patients with thrombocytopenia (anticoagulant therapy)

  • Patients with heparin-induced thrombocytopenia

  • Patients with brain tumor (thromboprophylaxis)

  • Patients with brain tumor (anticoagulant therapy)

  • Patients with incidental thrombosis

  • Patients with catheter-related thrombosis (thromboprophylaxis)

  • Patients with catheter-related thrombosis (catheter insertion techniques)

  • Patients with catheter-related thrombosis (catheter flushing)

  • Patients with catheter-related thrombosis (catheter removal)

  • Patients with catheter-related thrombosis (anticoagulation)

  • Patients with catheter-related thrombosis (thrombolysis)

  • Patients with visceral thrombosis

7.Patient education

General counseling: as per ASCO 2023 guidelines, educate patients regarding VTE, particularly in settings increasing the risk, such as major surgery, hospitalization, and while receiving systemic antineoplastic therapy.
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8.Preventative measures

Thromboprophylaxis, general indications, ASCO: initiate pharmacologic thromboprophylaxis in hospitalized patients with active malignancy and acute medical illness or reduced mobility in the absence of bleeding or other contraindications.
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  • Thromboprophylaxis (improving survival)

  • Thromboprophylaxis (choice of anticoagulation)

  • Thromboprophylaxis (patients receiving anticancer therapy)

  • Thromboprophylaxis (patients undergoing surgery, general principles)

  • Thromboprophylaxis (patients undergoing surgery, thoracic: lobectomy/segmentectomy)

  • Thromboprophylaxis (patients undergoing surgery, thoracic: pneumonectomy)

  • Thromboprophylaxis (patients undergoing surgery, thoracic: esophagectomy)

  • Thromboprophylaxis (patients undergoing surgery, abdominopelvic)

  • Thromboprophylaxis (patients undergoing other procedures)

  • Thromboprophylaxis (monitoring)

9.Follow-up and surveillance

Follow-up
Schedule an initial follow-up at 1-4 weeks.
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Ensure that SC injections are being administered properly and assess for bleeding and recurrent thrombotic complications.
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  • Management of recurrence