Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update.

PURPOSE: To conduct an update of the ASCO venous thromboembolism (VTE) guideline. METHODS: After publication of potentially practice-changing clinical trials, identified through ASCO's signals approach to updating, an updated systematic review was performed for two guideline questions: perioperative thromboprophylaxis and treatment of VTE. PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) published between November 1, 2018, and June 6, 2022. RESULTS: Five RCTs provided information that contributed to changes to the 2019 recommendations. Two RCTs addressed direct factor Xa inhibitors (either rivaroxaban or apixaban) for extended thromboprophylaxis after surgery. Each of these postoperative trials had important limitations but suggested that these two oral anticoagulants are safe and effective in the settings studied. An additional three RCTs addressed apixaban in the setting of VTE treatment. Apixaban was effective in reducing the risk of recurrent VTE, with a low risk of major bleeding. RECOMMENDATIONS: Apixaban and rivaroxaban were added as options for extended pharmacologic thromboprophylaxis after cancer surgery, with a weak strength of recommendation. Apixaban was also added as an option for the treatment of VTE, with high quality of evidence and a strong recommendation.Additional information is available at www.asco.org/supportive-care-guidelines.

Overview of VTE treatment in cancer according to clinical guidelines.

Evidence-based clinical practice guidelines are available to provide guidance to clinicians in managing patients living with cancer-associated venous thromboembolism (VTE). While most are developed using rigorous methods and grounded by systematic reviews of the literature, their recommendations do differ because of differences in their grading criteria and interpretation of the data. This can be confusing to practicing clinicians. Also, guidelines are often out of date and cannot keep pace with publications because of the lengthy processes and extensive resources required for completion. The most recent updates of major guidelines in the management of cancer-associated VTE were published in 2015-2016. They broadened the topics addressed in earlier versions but, similar to that in earlier documents, the quality of evidence remains weak in many important clinical scenarios, such as management of recurrent VTE, choice of anticoagulants for long-term and extended treatment, and duration of anticoagulant therapy. Consequently, many recommendations continue to reflect expert opinion and extrapolation from indirect data in non-cancer populations. This review summarizes and comments on the most recent guideline updates from the American College of Chest Physicians, the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the International Initiative on Thrombosis and Cancer. A new round of revisions is expected to incorporate the emerging data on the efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated VTE.

Clinical practice guidelines on cancer-associated thrombosis: a review on scope and methodology.

Cancer-associated thrombosis is a well-recognized complication in patients with cancer. It imposes significant patient morbidity and anxiety, increases personal and societal financial burden, and is the second-leading cause of death in this population. There have been increasing research efforts to reduce the incidence of venous thromboembolism (VTE) and optimize its treatment but the quality of evidence is diverse. To assist clinicians in providing care based on best-available evidence, many international and national organizations have issued clinical practice guidelines. Among these, the most highly cited resources include those developed by the American College of Chest Physicians, the American Society of Clinical Oncology and the European Society of Medical Oncology. Nationally-based guidelines have also been published by various groups, including the Italian Association of Medical Oncology, the National Comprehensive Cancer Network, the French National Federation of the League of Centers Against Cancer, and the British Committee for Standards in Haematology. This review will cover fundamental aspects of clinical practice guideline development and evaluation, summarize the scope and methodology of published guidelines on the management of cancer-associated thrombosis and assess the quality of selected, international guidelines using the validated Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Areas of consensus and uncertainties will be briefly highlighted.