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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).


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.
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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.
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.

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

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

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  • Management of recurrence