Prevent and Treat Venous Thromboembolism in Patients With Cancer

Risk Factors for VTE

APNs must first recognize the clinical risk factors for development of VTE (https://doi.org/10.1007/s11239-015-1313-4):

• Primary brain tumors; pancreatic, stomach, liver, lung, or kidney cancer; lymphoma, or multiple myeloma
• Advanced-stage disease
• Certain therapeutic interventions, including surgery, types of chemotherapy, or of erythropoiesis-stimulating agents
• Devices such as central venous catheters
• Comorbid conditions such as infection or immobility
• Advanced age.

For a more comprehensive list of risk factors, refer to the National Comprehensive Cancer Network guidelines (https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf) for VTE.

Ways to Prevent VTE

Patients with cancer who are hospitalized with acute illness or have decreased mobility should receive pharmacologic thromboprophylaxis (low-molecular-weight heparin [LMWH] and unfractionated heparin [UFH]) unless contraindicated. Also, prophylaxis should begin before any major surgery and continue for at least 7–10 days and up to four weeks for patients at higher risk. Patients with multiple myeloma who are being treated with antiangiogenesis agents (e.g., thalidomide, lenalidomide) and chemotherapy or dexamethasone should receive VTE prophylaxis (https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf) with either LMWH or low-dose aspirin, depending on their risk (https://doi.org/10.1200/JCO.2013.49.1118). 

Thromboprophylaxis is not routinely recommended for outpatients with cancer.

Treatment for VTE

Treatment decisions for VTE are based on many factors, including kidney function, cost and ease of administration for the drug, monitoring, and the ability to easily reverse an agent if necessary. For acute VTE, the treatment of choice is a LMWH (e.g., dalteparin, enoxaparin). Fondaparinux and UFH are possible but less-preferred treatment options, per national guidelines. For patients who refuse LMWH for various reasons (e.g., cost, inconvenience), apixaban and rivaroxaban are acceptable direct oral anticoagulant alternatives. 

For chronic management, LMWH is still the preferred treatment for the first six months. Warfarin is an option for chronic anticoagulation and should be initiated with the parental agent used as acute therapy and continued for at least five days until the international normalized ratio is at least 2 for 24 hours. Chronic VTE treatment should include at least three months of anticoagulation. Indefinite anticoagulation is recommended for VTE not associated with a catheter in patients with active cancer, undertreatment, or ongoing risk factor. For catheter-associated VTE, anticoagulation should continue while the catheter is in place, but at least three months. Hemoglobin, hematocrit, and platelet counts should be monitored every two to three days (https://www.nccn.org/professionals/physician_gls/pdf/vte.pdf) for the initial 14 days of anticoagulation and then every two weeks thereafter or when clinically indicated.

Patient adherence is important for therapeutic success, and education is crucial. APNs are at the forefront of educating patients and their families about their prescribed therapies, including self-injection if necessary. Well-educated patients are more likely to accept efforts (https://doi.org/10.1188/17.CJON.502-505) such as anticoagulation or early mobility after surgery and to understand the rationale for anticoagulation and reporting symptoms to facilitate early intervention (https://doi.org/10.1200/JCO.2013.49.1118).