Updated ASCO guidelines for VTE in cancer

Tuesday, September 17, 2019

Alok Khorana, MD, of the Cleveland Clinic joins Blood & Cancer host David H. Henry, MD, of Pennsylvania Hospital, Philadelphia, to break down the latest recommendations from the American Society of Clinical Oncology on venous thromboembolism (VTE) prophylaxis in cancer patients.

Plus, in Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, shares her answer to a frequent question from cancer patients: What should I eat?

This Week in Oncology

What is the role of thromboprophylaxis in patients with cancer in the outpatient setting?

  • Key change in ASCO recommendations: Thromboprophylaxis with apixaban, rivaroxaban, or low-molecular-weight heparin (LMWH) may be offered to select high-risk outpatients with cancer.
  • Prophylactic anticoagulation should not be given to every patient with malignancy.
  • Khorana score predicts the venous thromboembolism in patients with malignancy.
    • Influenced by type of malignancy, hemoglobin, platelet count, leukocyte count, and BMI.
    • High risk = Khorana score of 2 or higher may be offered prophylaxis.
  • Patients with pancreatic cancer and gastric cancer are particularly coagulopathic.
  • Does the presence of a CNS lesion(s) preclude anticoagulation for a DVT/PE?
    • All CNS lesions have a risk of hemorrhage.
    • A CNS lesion hemorrhage is not significantly greater when anticoagulated
  • Among high-risk cancer patients who undergo surgery, is there a role for postoperative prophylaxis with LMWH?
    • Data show a persistent risk of VTE up to 4 weeks following abdominal/pelvic surgery.

Show notes by Emily Bryer, DO, resident in the department of internal medicine, University of Pennsylvania, Philadelphia.

References:

Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO Clinical Practice Guideline Update ascopubs.org/doi/pdf/10.1200/JCO.19.01461

Rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814630

Apixaban to prevent venous thromboembolism in patients with cancer nejm.org/doi/full/10.1056/NEJMoa1814468

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Podcast Participants

David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd.
Ilana Yurkiewicz, MD
Ilana Yurkiewicz, MD, is a fellow in hematology and oncology at Stanford University, where she also completed her internal medicine residency. Dr. Yurkiewicz holds an MD from Harvard Medical School and a BS from Yale University. She went into hematology and oncology because of the high-stakes decision-making, meaningful relationships with patients, and opportunity to help people through some of the toughest challenges of their lives. Dr. Yurkiewicz is also a medical journalist. She is a former AAAS Mass Media Fellow and Scientific American blog columnist, and her writing has appeared in numerous media outlets including Hematology News, where she writes the monthly column Hard Questions. Dr. Yurkiewicz is on Twitter: @ilanayurkiewicz.