What are the guidelines for Deep Vein Thrombosis (DVT) prophylaxis in patients with malignancy?

DVT Prophylaxis Guidelines in Malignancy

All hospitalized cancer patients with acute medical illness or reduced mobility should receive pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications, while high-risk outpatients with cancer (Khorana score ≥2) may be offered thromboprophylaxis with apixaban, rivaroxaban, or LMWH. 1

Hospitalized Cancer Patients

Recommendations:

• Hospitalized patients with active malignancy and acute medical illness or reduced mobility: Pharmacologic thromboprophylaxis strongly recommended 1
• Hospitalized patients with active malignancy without additional risk factors: May be offered pharmacologic thromboprophylaxis 1
• Patients admitted for minor procedures or chemotherapy infusion: Routine prophylaxis NOT recommended 1
• Patients undergoing stem-cell/bone marrow transplantation: Routine prophylaxis NOT recommended 1

Preferred Agents:

• Low molecular weight heparin (LMWH)
• Unfractionated heparin (UFH)
• Fondaparinux (if other options unavailable)

Ambulatory Cancer Patients

Recommendations:

• All outpatients with cancer: Routine pharmacologic thromboprophylaxis NOT recommended 1
• High-risk outpatients (Khorana score ≥2) starting systemic chemotherapy: May be offered thromboprophylaxis with apixaban, rivaroxaban, or LMWH if no significant bleeding risk or drug interactions 1
• Multiple myeloma patients receiving thalidomide/lenalidomide with chemotherapy/dexamethasone: Should receive prophylaxis 1, 2
  • Lower-risk patients: Aspirin or LMWH
  • Higher-risk patients: LMWH

Cancer Surgery Patients

Recommendations:

• All patients undergoing major cancer surgery: Should receive pharmacologic thromboprophylaxis 1
• Timing: Start preoperatively 1
• Duration: Continue for at least 7-10 days postoperatively 1
• Extended prophylaxis: For up to 4 weeks postoperatively in patients undergoing major open or laparoscopic abdominal/pelvic surgery with high-risk features (restricted mobility, obesity, history of VTE) 1

Preferred Agents:

• LMWH (preferred) 1
• UFH 1
• Consider rivaroxaban or apixaban after initial period of LMWH/UFH (weaker evidence) 1

Mechanical Methods:

• May be added to pharmacologic prophylaxis but should NOT be used as monotherapy unless pharmacologic methods are contraindicated 1
• Combined regimen (pharmacologic + mechanical) may improve efficacy in highest-risk patients 1

Risk Assessment

Cancer patients should be periodically assessed for VTE risk, particularly considering:

• Cancer type (highest risk: brain, pancreas, GI tract, ovary, kidney, bladder, lung, hematologic) 2
• Metastatic disease 2
• Immobilization 2
• Recent major surgery 1
• Prior history of VTE 1
• Obesity 1

Special Considerations

Contraindications to Pharmacologic Prophylaxis:

• Active bleeding
• High bleeding risk
• Severe thrombocytopenia (platelet count <50,000/μL) 2
• Recent neurosurgery

Patient Education:

• Oncology professionals should educate patients about signs and symptoms of VTE 1, 2

Implementation Pitfalls

1. Failure to assess VTE risk: Systematic risk assessment should be performed for all cancer patients
2. Underutilization in eligible patients: Despite clear guidelines, prophylaxis is often underutilized in hospitalized cancer patients
3. Overutilization in low-risk settings: Avoid routine prophylaxis in patients admitted only for minor procedures or chemotherapy infusion
4. Inadequate duration: Ensure proper duration, especially extended prophylaxis after major abdominal/pelvic surgery
5. Relying solely on mechanical methods: These should generally supplement, not replace, pharmacologic prophylaxis
6. Overlooking drug interactions: Particularly important when considering oral anticoagulants in patients on chemotherapy

The most recent ASCO guidelines (2023) provide the strongest evidence for these recommendations, emphasizing the importance of appropriate thromboprophylaxis to reduce morbidity and mortality in cancer patients at risk for VTE.