Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update Gary H. Lyman, Alok A. Khorana, Nicole M. Kuderer, Agnes Y. Lee, Juan Ignacio Arcelus, Edward P. Balaban, Jeffrey M. Clarke, Christopher R. Flowers, Charles W. Francis, Leigh E. Gates, Ajay K. Kakkar, Nigel S. Key, Mark N. Levine, Howard A. Liebman, Margaret A. Tempero, Sandra L. Wong, Ann Alexis Prestrud, and Anna Falanga Gary H. Lyman, Nicole M. Kuderer, and Jeffrey M. Clarke, Duke University and Duke Cancer Institute, Durham; Nigel S. Key, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC; Alok A. Khorana, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH; Agnes Y. Lee, University of British Colum- bia, Vancouver, British Columbia; Mark N. Levine, McMaster University, Hamilton, Ontario, Canada; Juan Ignacio Arcelus, Hospital Universitario Virgen de las Nieves, University of Granada, Granada, Spain; Edward P. Balaban, University of Pittsburgh Cancer Centers Network, Pittsburgh, PA; Christopher R. Flowers, Emory University School of Medicine and Winship Cancer Institute, Atlanta, GA; Charles W. Francis, James P. Wilmot Cancer Center and University of Rochester, Rochester, NY; Leigh E. Gates, patient representative, Denver, CO; Ajay K. Kakkar, Thrombosis Research Institute, London, United King- dom; Howard A. Liebman, Keck School of Medicine, University of Southern California, Los Angeles; Margaret A. Tempero, University of California–San Francisco Pancreas Center, San Francisco, CA; Sandra L. Wong, University of Michigan, Ann Arbor, MI; Ann Alexis Prestrud, Ameri- can Society of Clinical Oncology, Alexan- dria, VA; and Anna Falanga, Hospital Papa Giovanni XXIII, Bergamo, Italy. Published online ahead of print at www.jco.org on May 13, 2013. Clinical Practice Guidelines Committee Approval: Pending Editor’s note: This American Society of Clinical Oncology Clinical Practice Guideline Update provides recommendations with comprehensive discussion of the relevant literature for each recommendation. The Data Supplement, including evidence tables, is available at http://www.asco.org/ guidelines/vte. Authors’ disclosures of potential conflicts of interest and author contributions are found at the end of this article. Corresponding author: American Society of Clinical Oncology, 2318 Mill Rd, Suite 800, Alexandria, VA 22314; e-mail: guidelines@asco.org. © 2013 by American Society of Clinical Oncology 0732-183X/13/3117w-2189w/$20.00 DOI: 10.1200/JCO.2013.49.1118 A B S T R A C T Purpose To provide recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. Prophylaxis in the outpatient, inpatient, and perioperative settings was considered, as were treatment and use of anticoagulation as a cancer-directed therapy. Methods A systematic review of the literature published from December 2007 to December 2012 was completed in MEDLINE and the Cochrane Collaboration Library. An Update Committee reviewed evidence to determine which recommendations required revision. Results Forty-two publications met eligibility criteria, including 16 systematic reviews and 24 randomized controlled trials. Recommendations Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization. Thrombopro- phylaxis is not routinely recommended for outpatients with cancer. It may be considered for selected high-risk patients. Patients with multiple myeloma receiving antiangiogenesis agents with chemotherapy and/or dexamethasone should receive prophylaxis with either low–molecular weight heparin (LMWH) or low-dose aspirin. Patients undergoing major cancer surgery should receive prophylaxis, starting before surgery and continuing for at least 7 to 10 days. Extending prophylaxis up to 4 weeks should be considered in those with high-risk features. LMWH is recommended for the initial 5 to 10 days of treatment for deep vein thrombosis and pulmonary embolism as well as for long-term (6 months) secondary prophylaxis. Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE. Anticoagulation should not be used for cancer treatment in the absence of other indications. Patients with cancer should be periodically assessed for VTE risk. Oncology professionals should provide patient education about the signs and symptoms of VTE. J Clin Oncol 31:2189-2204. © 2013 by American Society of Clinical Oncology INTRODUCTION The American Society of Clinical Oncology (ASCO) first published an evidence-based clinical practice guideline on prophylaxis and treatment of venous thromboembolism (VTE) in 2007. 1 ASCO guide- lines are updated at intervals determined by an Up- date Committee; this is a full guideline update. Table 1 provides a summary of the 2007 and 2012 guide- line recommendations. GUIDELINE QUESTIONS 1. Should hospitalized patients with cancer re- ceive anticoagulation for VTE prophylaxis? 2. Should ambulatory patients with cancer re- ceive anticoagulation for VTE prophylaxis during systemic chemotherapy? 3. Should patients with cancer undergoing sur- gery receive perioperative VTE prophylaxis? 4. What is the best method for treatment of pa- tients with cancer with established VTE to pre- vent recurrence? 5. Should patients with cancer receive anticoagu- lants in the absence of established VTE to im- prove survival? 6. What is known about risk prediction and awareness of VTE among patients with cancer? METHODS Panel Composition An Update Committee was formed (Appendix Table A1, online only) to review data published since the initial JOURNAL OF CLINICAL ONCOLOGY A S C O S P E C I A L A R T I C L E VOLUME 31  NUMBER 17  JUNE 10 2013 © 2013 by American Society of Clinical Oncology 2189 Downloaded from ascopubs.org by 3.225.221.80 on June 5, 2022 from 003.225.221.080 Copyright © 2022 American Society of Clinical Oncology. All rights reserved.