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Table 5 Summary of international guidelines regarding thromboprophylaxis in hospitalized cancer patients

From: Venous thromboembolism in cancer patients: an underestimated major health problem

  Medical patient Surgical patient
NCCN Guidelines (2014) [9] -Prophylactic anticoagulation therapy(category 1) -Prophylactic anticoagulation therapy (category 1)
± Intermittent pneumatic venous compression device (IPC)
± Graduated compression stockings (GCS) ± Intermittent pneumatic venous compression device (IPC)
± Graduated compression stockings (GCS)
-Out-of-hospital primary VTE prophylaxis is recommended for up to 4 weeks postoperation (particularly for high-risk abdominal or pelvic cancer surgery patients)
-Mechanical methods are not recommended as monotherapy except when pharmacological methods are contraindicated.
ASCO Guidelines (2015) [8] 1. Hospitalized patients who have active malignancy with acute medical illness or reduced mobility should receive pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications. 1. All patients with malignant disease undergoing major surgical intervention should be considered for pharmacologic thromboprophylaxis with either UFH or LMWH unless contraindicated because of active bleeding or high bleeding risk.
Evidence: strong Evidence: strong
2. Hospitalized patients who have active malignancy without additional risk factors may be considered for pharmacologic thromboprophylaxis in the absence of bleeding or other contraindications. 2. Prophylaxis should be commenced preoperatively. Evidence: moderate
Evidence: moderate 3. Mechanical methods may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because of active bleeding or high bleeding risk.
Evidence: moderate
4. A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest risk patients.
Evidence: moderate
5. Pharmacologic thromboprophylaxis for patients undergoing major surgery for cancer should be continued for at least 7 to 10 days. Extended prophylaxis with LMWH for up to 4 weeks postoperatively should be considered for patients undergoing major abdominal or pelvic surgery for cancer who have high-risk features such as restricted mobility, obesity, history of VTE, or with additional risk factors. In lower-risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-by-case basis considering the individual patient.
Recommendation type, strength: evidence based, strong
3. Data are inadequate to support routine thromboprophylaxis in patients admitted for minor procedures or short chemotherapy infusion or in patients undergoing stem-cell/bone marrow transplantation.
ESMO Guidelines (2011) [10] Prophylaxis with UFH, LMWH or fondaparinux is recommended [I, A]. In cancer patients undergoing major cancer surgery:
Prophylaxis with LMWHs or UFH is recommended. Mechanical methods such as pneumatic calf compression may be added to pharmacological prophylaxis but should not be used as monotherapy unless pharmacological prophylaxis is contraindicated because of active bleeding [I,A].
Cancer patients undergoing elective major abdominal or pelvic surgery:
Should receive in hospital and postdischarge prophylaxis with LMWH for up to 1 month after surgery [I, A].
ISTH Guidelines (2013) [11] 1. We recommend prophylaxis with LMWH, UFH or fondaparinux in hospitalized medical patients with cancer and reduced mobility (grade 1B). 1. Use of LMWH once a day or a low dose of UFH three times a day is recommended to prevent postoperative VTE in cancer patients; pharmacological prophylaxis should be started 12 to 2 h preoperatively and continued for at least 7 to 10 days; there are no data allowing conclusions regarding the superiority of one type of LMWH over another (grade 1A).
Values and preferences: LMWH once a day is more convenient
2. There is no evidence to support fondaparinux as an alternative to LMWH for the prophylaxis of postoperative VTE in cancer patients (grade 2C).
Values and preferences: similar
3. Use of the highest prophylactic dose of LMWH to prevent postoperative VTE in cancer patients is recommended (grade 1A).
Values and preferences: equal
4. Extended prophylaxis (4 weeks) to prevent postoperative VTE after major laparotomy in cancer patients may be indicated in patients with a high VTE risk and low bleeding risk (grade 2B).
Values and preferences: longer duration of injections
5. The use of LMWH for the prevention of VTE in cancer patients undergoing laparoscopic surgery may be recommended in the same way as for laparotomy [best clinical practice, based on a balance between desirable and undesirable effects indicating an increased bleeding risk].
Values and preferences: daily injections
Costs: In some countries, the price of LMWH may influence the choice.
6. Mechanical methods are not recommended as monotherapy except when pharmacological methods are contraindicated (grade 2C).
Values and preferences: no injection
ACCP guidelines [13]   1. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, extended duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis is recommended (grade 1B).
  1. Extended prophylaxis is strongly recommended especially for patients undergoing major abdominal or pelvic surgery [8-13]. This recommendation is based on the results of two randomized trials and one meta-analysis that showed better outcomes with extended postoperative prophylaxis after major laparotomy surgery [75,76]