Primary Thromboprophylaxis in Ambulatory Cancer Patients: Where Do We Stand?

Frits I Mulder, Floris T M Bosch, Nick van Es, Frits I Mulder, Floris T M Bosch, Nick van Es

Abstract

Venous thromboembolism (VTE), comprising deep-vein thrombosis and pulmonary embolism, is a frequent complication in ambulatory cancer patients. Despite the high risk, routine thromboprophylaxis is not recommended because of the high number needed to treat and the risk of bleeding. Two recent trials demonstrated that the number needed to treat can be reduced by selecting cancer patients at high risk for VTE with prediction scores, leading the latest guidelines to suggest such an approach in clinical practice. Yet, the interpretation of these trial results and the translation of the guideline recommendations to clinical practice may be less straightforward. In this clinically-oriented review, some of the controversies are addressed by focusing on the burden of VTE in cancer patients, discussing the performance of available risk assessment scores, and summarizing the findings of recent trials. This overview can help oncologists, hematologists, and vascular medicine specialists decide about thromboprophylaxis in ambulatory cancer patients.

Keywords: anticoagulants; cancer-associated venous thromboembolism; coumarins; direct oral anticoagulants; low molecular weight heparins; neoplasms; pulmonary embolism; thrombosis; venous thromboembolism.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
VTE incidence in cancer patients with and without thromboprophylaxis, stratified by Khorana score. Abbreviations: NNT, number needed to treat; VTE, venous thromboembolism. * Calculations based and extrapolated from Mulder et al; The Khorana Score For Prediction Of Venous Thromboembolism In Cancer Patients: A Systematic Review And Meta-Analysis [58], Carrier et al; Apixaban to Prevent Venous Thromboembolism in Patients with Cancer [73], and Li et al, Direct Oral Anticoagulant for the Prevention of Thrombosis in Ambulatory Patients with Cancer: A Systematic Review and Meta-Analysis [22].
Figure 2
Figure 2
The chronological introduction of primary thromboprophylaxis in cancer patients and possible future directions. Abbreviations: NNT, number needed to treat; VTE, venous thromboembolism.

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