VTE prophylaxis for patients with active cancer

Patients in hospital with active cancer1 are at high risk of developing venous thromboembolism (VTE) (ie deep vein thrombosis [DVT] or pulmonary embolism [PE]). Their risk can be increased because of the malignancy, the cancer therapy (eg chemotherapy, hormonal treatments), immobility and indwelling central venous catheters. For patients with active cancer, balance the risk of developing VTE against the risk of bleeding when considering prophylaxis for nonsurgical patients or surgical patients.

A validated risk assessment tool (such as the Khorana score) should be used to stratify the VTE risk of patients with active cancer, while also considering the patient’s risk of bleeding and any possible drug interactions.

For ambulatory patients with active cancer who are receiving systemic cancer therapy and are stratified to have a high risk of VTE, pharmacological VTE prophylaxis is recommended. For other patients the decision is complex; for comprehensive information, see the American Society of Hematology 2021 guidelines for VTE prevention and treatment in patients with cancer.

If VTE prophylaxis is appropriate, consider low molecular weight heparin (LMWH), apixaban or rivaroxaban23; data on the use of dabigatran for patients with active cancer are lackingLyman, 2021Lyon, 2022Stevens, 2021.

Continue pharmacological VTE prophylaxis for patients with active cancer at least until hospital discharge. It may be continued for longer, depending on the VTE risk and as determined by the specialistKey, 2020Lyman, 2021.

Prolonged prophylaxis is recommended for patients undergoing abdominal or pelvic surgery for active cancer because the risk of VTE is increased and the development of VTE can be delayed by more than 21 days postoperatively (see VTE prophylaxis for surgical patients in hospital).

1 Active cancer is defined as patients receiving cancer treatment, those diagnosed with cancer in the past 6 months, or with progressive or advanced diseaseLyon, 2022.Return
2 At the time of writing, apixaban or rivaroxaban are not available on the Pharmaceutical Benefits Scheme (PBS) for VTE prophylaxis for patients with active cancer unless the patient has previously had a VTE (ie for the prevention of recurrent VTE). See the PBS website for current information.Return
3 At the doses used for VTE treatment, rivaroxaban (in comparison to LMWH) has been associated with an increased bleeding risk in patients with active luminal gastrointestinal cancer and may increase the risk of haematuria in patients with genitourinary cancer. Return