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Cancer-associated thrombosis

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Updated 2024 BSH guidelines for the prevention and management of cancer-associated thrombosis.

Guidelines

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 British Society for Haematology (BSH 2024), the American Society of Clinical Oncology (ASCO 2023,2013), the American Society of Hematology (ASH 2023,2021), the European Society of Medical Oncology (ESMO 2023,2015), the American Association for Thoracic Surgery (AATS/ESTS 2022), ...
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Screening and diagnosis

Screening for occult malignancy: as per BCSH 2015 guidelines, 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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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.
B
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Diagnostic investigations

Baseline laboratory tests: as per CCG-VTEC 2015 guidelines, obtain a baseline CBC, creatinine, liver function tests, and INR or PTT to rule out severe thrombocytopenia, renal or hepatic impairment, and coagulopathy.
B

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  • Diagnostic imaging

Medical management

Anticoagulant therapy, initiation/treatment phase
As per BSH 2024 guidelines:
Administer a direct oral factor Xa inhibitor or LMWH for 6 months initially in patients with cancer-associated VTE (other than catheter-related).
A
Administer warfarin as an alternative in patients with cancer-associated VTE requiring anticoagulation if direct oral factor Xa inhibitors or LMWH are not available.
B

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  • Anticoagulant therapy (extended phase)

  • Anticoagulant therapy (monitoring)

  • Thrombolytic therapy

Therapeutic procedures

IVC filter placement
As per BSH 2024 guidelines:
Do not use IVC filters routinely in patients with cancer.
D
Consider placing a temporary IVC filter in patients with acute VTE and a contraindication to anticoagulation or when interruption in anticoagulation is required during the 4 weeks after diagnosis of acute VTE.
C

Specific circumstances

Elderly patients
As per CCG-VTEC 2015 guidelines:
Recognize that elderly patients (> 70 years of age) with reduced CrCl could be at greater risk of LMWH-induced complications such as bleeding.
B
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.
I

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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

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.
B

Preventative measures

Thromboprophylaxis, general indications
As per BSH 2024 guidelines:
Initiate pharmacologic thromboprophylaxis with low molecular weigh heparin in patients with active cancer admitted to hospital with an acute medical illness, continued throughout admission unless contraindicated.
A
Consider omitting pharmacologic thromboprophylaxis when the platelet count is < 50×10⁹/L.
C

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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)

Follow-up and surveillance

Follow-up
As per CCG-VTEC 2015 guidelines:
Schedule an initial follow-up at 1-4 weeks.
B
Ensure that SC injections are being administered properly and assess for bleeding and recurrent thrombotic complications.
B

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  • Management of recurrence (anticoagulant therapy)

  • Management of recurrence (IVC filter placement)