by 
Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023;41:3063–71. https://ascopubs.org/doi/10.1200/JCO.19.01461
This is a selection of the above mentioned article with recommendation pertinant to acute care surgeons.
Recommendations
1. Should hospitalized patients with cancer receive anticoagulation for VTE prophylaxis?
1.1. Hospitalized patients who have active malignancy and acute medical illness or reduced mobility should be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.
Type: Evidence based
Evidence quality: Intermediate
Strength of recommendation: Moderate
1.2. Hospitalized patients who have active malignancy without additional risk factors may be offered pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications.
Type: Evidence based
Evidence quality: Low
Strength of recommendation: Moderate
1.3. Routine pharmacologic thromboprophylaxis should not be offered to patients admitted for the sole purpose of minor procedures or chemotherapy infusion nor to patients undergoing stem-cell/bone marrow transplantation.
Type: Informal consensus
Evidence quality: Insufficient
Strength of recommendation: Moderate
2. Should ambulatory patients with cancer receive anticoagulation for VTE prophylaxis during systemic chemotherapy?
2.1. Routine pharmacologic thromboprophylaxis should not be offered to all outpatients with cancer
Type: Evidence based
Evidence quality: Intermediate to High
Strength of recommendation: Strong
2.2. High-risk outpatients with cancer (Khorana score of 2 or higher before starting a new systemic chemotherapy regimen) may be offered thromboprophylaxis with apixaban, rivaroxaban, or LMWH provided there are no significant risk factors for bleeding and no drug interactions. Consideration of such therapy should be accompanied by a discussion with the patient about the relative benefits and harms, drug cost, and duration of prophylaxis in this setting
Type: Evidence based
Evidence quality: Intermediate to High for apixaban and rivaroxaban, Intermediate for LMWH
Strength of recommendation: Moderate
3. Should patients with cancer undergoing surgery receive perioperative VTE prophylaxis?
3.1. All patients with malignant disease undergoing major surgical intervention should be offered pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated because of active bleeding, high bleeding risk, or other contraindications.
Type: Evidence based
Evidence quality: High
Strength of recommendation: Strong
3.2. Prophylaxis with UFH or LMWH should be commenced preoperatively
Type: Evidence based
Evidence quality: Intermediate
Strength of recommendation: Moderate
3.3. Mechanical methods may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because of active bleeding or high bleeding risk.
Type: Evidence based
Evidence quality: Intermediate
Strength of recommendation: Strong
3.4. A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest-risk patients.
Type: Evidence based
Evidence quality: Intermediate
Strength of recommendation: Moderat
3.5. Pharmacologic thromboprophylaxis for patients undergoing major surgery for cancer should be continued for at least 7-10 days.
Type: Evidence based
Evidence quality: High
Strength of recommendation: Moderate to Strong
3.6. Extended pharmacologic thromboprophylaxis for up to 4 weeks postoperatively should be offered to patients undergoing major open or laparoscopic abdominal or pelvic surgery for cancer who have high-risk features, such as restricted mobility, obesity, history of VTE, or with additional risk factors. In lower-risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-by-case basis.
Type: Evidence based
Evidence quality: High
Strength of recommendation: Moderate to Strong
3.7. (Updated) Patients who are candidates for extended pharmacologic thromboprophylaxis after surgery may be offered prophylactic doses of LMWH.
Type: Evidence based
Evidence quality: High
Strength of recommendation: Strong
Alternatively, patients may be offered prophylactic doses of rivaroxaban or apixaban after an initial period of LMWH or UFH
Qualifying statement: Evidence for rivaroxaban and apixaban in this setting remains limited. The two available trials differed with respect to type of cancer, type of surgery, and timing of rivaroxaban or apixaban initiation after surgery
Type: Evidence based
Evidence quality: Low
Strength of recommendation: Weak
4. What is the best method for treatment of patients with cancer with established VTE to prevent recurrence?
4.1. (Updated) Initial anticoagulation may involve LMWH, UFH, fondaparinux, rivaroxaban, or apixaban. For patients initiating treatment with parenteral anticoagulation, LMWH is preferred over UFH for the initial 5-10 days of anticoagulation for the patient with cancer with newly diagnosed VTE who does not have severe renal impairment (defined as creatinine clearance ,30 mL/min)
Type: Evidence based
Evidence quality: High
Strength of recommendation: Strong
4.2. (Updated) For long-term anticoagulation, LMWH, edoxaban, rivaroxaban, or apixaban for at least 6 months are preferred over VKAs because of improved efficacy. VKAs may be used if LMWH or direct factor Xa inhibitors are not accessible. There is
reduction in recurrent thrombosis but an increase in clinically relevant nonmajor bleeding risk with direct factor Xa inhibitors compared with LMWH. Caution with direct factor Xa inhibitors is warranted in GI and genitourinary malignancies and other
settings with high risk for mucosal bleeding. Drug-drug interaction should be checked before using a direct factor Xa inhibitor
Type: Evidence based
Evidence quality: High
Strength of recommendation: Strong
4.3. Anticoagulation with LMWH, direct factor Xa inhibitors, or VKAs beyond the initial 6 months should be offered to select patients with active cancer, such as those with metastatic disease or those receiving chemotherapy. Anticoagulation beyond 6
months needs to be assessed on an intermittent basis to ensure a continued favorable risk-benefit profile
Type: Informal consensus
Evidence quality: Low
Strength of recommendation: Weak to Moderate
4.4. On the basis of opinion in the absence of randomized trial data, uncertain short-term benefit, and mounting evidence of longterm harm from filters, the insertion of a vena cava filter should not be offered to patients with established or chronic thrombosis
(VTE diagnosis more than 4 weeks ago), nor to patients with temporary contraindications to anticoagulant therapy (eg, surgery). There also is no role for filter insertion for primary prevention or prophylaxis of PE or DVT because of its long-term harm
concerns. It may be offered to patients with absolute contraindications to anticoagulant therapy in the acute treatment setting (VTE diagnosis within the past 4 weeks) if the thrombus burden was considered life-threatening. Further research is needed
Type: Informal consensus
Evidence quality: Low to Intermediate
Strength of recommendation: Moderate
4.5. The insertion of a vena cava filter may be offered as an adjunct to anticoagulation in patients with progression of thrombosis (recurrent VTE or extension of existing thrombus) despite optimal anticoagulant therapy. This is based on the panel’s expert
opinion given the absence of a survival improvement, a limited short-term benefit, but mounting evidence of the long-term increased risk for VTE
Type: Informal consensus
Evidence quality: Low to Intermediate
Strength of recommendation: Weak
4.7. Incidental PE and DVT should be treated in the same manner as symptomatic VTE, given their similar clinical outcomes compared with patients with cancer with symptomatic events
Type: Informal consensus
Evidence quality: Low
Strength of recommendation: Moderate
4.8. Treatment of isolated subsegmental PE or splanchnic or visceral vein thrombi diagnosed incidentally should be offered on a case-by-case basis, considering potential benefits and risks of anticoagulation
Type: Informal consensus
Evidence quality: Insufficient
Strength of recommendation: Moderate
5. Should patients with cancer receive anticoagulants in the absence of established VTE to improve survival?
5. Anticoagulant use is not recommended to improve survival in patients with cancer without VTE
Type: Evidence based
Evidence quality: High
Strength of recommendation: Strong
Comments
Two RCTs addressed direct factor Xa inhibitors for extended postoperative thromboprophylaxis. The double-blind PROLAPS-II trial compared rivaroxaban with placebo in 582 patients undergoing laparoscopic surgery for colorectal cancer. Exclusion criteria included an increased risk of bleeding (eg, known brain metastases), other indications for anticoagulant therapy, renal insufficiency, and liver failure. Study treatment began 7 days (62 days) after surgery and continued for 3 weeks. From the time of surgery to the start of study treatment, all patients received LMWH. Trial enrollment ended early, after inclusion of 582 of the planned 646 patients, because of study drug expiration. The primary outcome (a composite of symptomatic VTE, asymptomatic DVT, or VTE-related death in the first 28 days after surgery), occurred in 1% of patients in the rivaroxaban arm and 3.9% of patients in the placebo arm (P= .03). Major bleeding occurred in 0.7% of patients in the rivaroxaban arm and zero patients in the placebo arm.
Postoperative thromboprophylaxis with apixaban versus enoxaparin was evaluated in a randomized, open-label trial of 400 patients undergoing surgery for suspected or confirmed gynecologic cancer. Ultimately, 19.6% of patients in the apixaban arm and 18.8% of patients in the enoxaparin armdid not have cancer. Exclusion criteria included history of VTE, long-term use of nonsteroidal anti-inflammatory drugs, concurrent use of selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, history of severe renal or hepatic disease, or history of conditions related to abnormal bleeding or hypercoagulability. Patients received heparin on the first postoperative day, with random assignment to apixaban or enoxaparin within the first week after surgery, when deemed safe by the operating surgeon. Study treatment was provided for 28 days, and patients were followed for a total of 90 days. Major bleeding occurred in one patient in each study arm. Clinically relevant nonmajor bleeding occurred in 5.4% of patients in the apixaban arm and 9.7% of patients in the enoxaparin arm (P= .11). VTE, a secondary outcome, occurred in 1% of patients in the apixaban arm and 1.5% of patients in the enoxaparin arm (P=.68). Although patient satisfaction with ease of taking the medication was significantly higher in the apixaban group compared with enoxaparin, it is interesting to note that the adherence to the prophylactic regimen was similar: 84.8% in the apixaban group and 83.7% in the enoxaparin group.