Cancer

Venous Thromboembolism (VTE) is a major complication and one of the leading causes of death for patients with cancer. Deep vein thrombosis (DVT) and pulmonary embolism (PE) collectively known as VTE occurs in 4-20% of cancer patients, with those receiving chemotherapy accounting for 13% of those numbers. Prevention of VTE in cancer patients is an important issue. Patients should be evaluated for VTE risk, proper prevention, and treatment options to improve patient outcomes and quality of life.

Talk to your doctor about your risk and ways to prevent VTE.

Cancer Patients at Increased Risk:

Older age
Obesity
Infection
Renal disease
Pulmonary disease
Arterial Thromboembolism
Prior history of VTE
Elevated pre-chemotherapy platelet count
Blood clotting disorders

Cancer Related Factors Increasing Risk:

Hospitalized patients
Primary site of cancer (GI, brain, lung, gynecologic, renal, hematologic)
Initial 3-6 months after diagnosis
Metastasis

Treatment Related Factors Increasing Risk:

Recent surgery
Currently Receiving Chemotherapy
Currently Receiving Hormonal Therapy
Current Anti-Angiogenic Therapy (thalidomide, lenalidomide, bevacizumab)
Current Erythropoiesis agents
Central Venous Catheters in Place

Prevention:

IVC Filters for those with contraindications to anticoagulants
Intermittent compression devices
Compression stockings

References

Alluri, Krishna, et al. Prophylaxis of Venous Thromboembolism in Patients with Cancer: What the Guidelines Say. CME/CE released 5/6/2009.
Caprini, Joseph, et al. Controversial Issues in the Use of VTE Prophylaxis for Patients With Cancer. CME/CE released 5/6/2009.
Lyman, Gary, et al. American Society of Clinical Oncology Guideline: Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer. Journal of Clinical Oncology 2007 Dec. 25(34): 5490-5505.
Lyman, Gary, et al. American Society of Clinical Oncology 2007 Clinical Practice Guideline Recommendations for Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer. Journal of Oncology Practice 2007. 3(6): 326-329.

Drugs available for Prophylaxis of VTE in the United States

Drug

Dose

Comment

Contraindications

UFH

5000 U subcutaneously every 8 hours

Platelet count must be monitored
Preferred agent in renal dysfunction
Inexpensive

HIT

Enoxaparin

40 mg once daily subcutaneously

LMWH
Approved for treatment of DVT with or without PE

Caution with renal dysfunction, obesity, or weight < 50 kg. If creatinine clearance is < 30 mL/min, consider UFH
Contraindicated in HIT

Dalteparin

5000 U once daily subcutaneously

LMWH

Contraindicated in HIT

Tinzaparin

75 IU/kg once daily subcutaneously

LMWH
Approved for the treatment of PE
Not FDA approved for VTE prophylaxis

Contraindicated in HIT

Fondaparinux

2.5 mg subcutaneously once daily

Factor Xa inhibitor
Can be used in HIT
Approved for the treatment of acute PE

Should not be used in patients with severe renal impairment (creatinine < 30 mL/min)

Recommendations based on guidelines from the American College of Chest Physicians (ACCP), American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN)

ACCP

ASCO

NCCN

Hospitalized patients, no contraindications to anticoagulants

UFH
LMWH
- Enoxaparin
- Dalteparin
Fondaparinux

UFH
LMWH
- Enoxaparin
- Dalteparin
Fondaparinux

UFH
LMWH
- Enoxaparin
- Dalteparin
- Tinzaparin
Fondaparinux

Post-surgery

UFH
LMWH
- Enoxaparin
- Dalteparin
Fondaparinux
Mechanical compression devices (IPC, GCS) in combination with pharmacologic agents depending on the type of surgery

UFH
LMWH
- Enoxaparin
- Dalteparin
Fondaparinux
Mechanical compression devices (IPC, GCS) in combination with pharmacologic agents in high-risk patients

UFH
LMWH
- Enoxaparin
- Dalteparin
- Tinzaparin
Fondaparinux
Mechanical compression devices (IPC, GCS) in combination with pharmacologic agents in high-risk patients

Extended postsurgical prophylaxis

No specific recommendation

Up to 4 weeks post-surgery in high-risk patients

Patients with central venous catheters

VTE thromboprophylaxis not recommended

Outpatients without VTE

VTE thromboprophylaxis not recommended

Special Populations

Renal insufficiency

UFH is recommended as the safest option in these individuals. Recommended caution with LMWH and fondaparinux.

UFH is recommended as the safest option in these individuals. Severe renal insufficiency (CrCl < 30 mL/min)

Enoxaparin is the only LMWH with a manufacturer-recommended dose reduction
Fondaparinux is contraindicated Moderate renal insufficiency (CrCl 30-60 mL/min)
LMWH and fondaparinux should be used with caution.

Obesity, weight below 50 kg

UFH is recommended as the safest option in these individuals. Recommended caution with LMWH and fondaparinux.

Active chemotherapy

VTE thromboprophylaxis not recommended

VTE thromboprophylaxis using LMWH or low-dose warfarin (dose adjusted to an INR ~ 1.5) in myeloma patients receiving thalidomide with dexamethasone or chemotherapy

VTE thromboprophylaxis should be considered in highly thrombogenic chemotherapy

Contraindications to anticoagulants

Mechanical compression devices (IPC, GCS)