Table 6 Summary of international guidelines related to thromboprophylaxis in ambulatory cancer patients

NCCN (2014) [9]

1. Multiple myeloma patients receiving thalidomide or lenalidomide:

 -High risk: Recommend anticoagulant VTE prophylaxis

 -Low risk: Recommend aspirin

2. Other outpatient settings:

 No routine VTE prophylaxis recommended outside of a clinical trial setting

ASCO (2015) [8]

1. Routine pharmacologic thromboprophylaxis is not recommended in cancer outpatients.

Evidence: moderate.

2. Based on limited RCT data, clinicians may consider LMWH prophylaxis on a case-by-case basis in highly selected outpatients with solid tumors receiving chemotherapy.

Consideration of such therapy should be accompanied by a discussion with the patient about the uncertainty concerning benefits and harms as well as dose and duration of prophylaxis in this setting.

Evidence: moderate

3. Patients with multiple myeloma receiving thalidomide- or lenalidomide-based regimens with chemotherapy and/or dexamethasone should receive pharmacologic thromboprophylaxis with either aspirin or LMWH for lower-risk patients and LMWH for higher-risk patients.

ESMO (2011) [10]

1. Extensive, routine prophylaxis for advanced cancer patients receiving chemotherapy is not recommended, but may be considered in high-risk ambulatory cancer patients [II, C].

2. Consider LMWH, aspirin or adjusted-dose warfarin (INR 1.5) in myeloma patients receiving thalidomide plus dexamethasone or thalidomide plus chemotherapy [II, B].

ISTH (2013) [12]

1. For children with ALL treated with L-asparaginase, depending on local policy and individual patient characteristics (platelet count, kidney function, fibrinogen and antithrombin III levels, etc.), prophylaxis may be considered in some patients; the same therapeutic option can be considered for adults [best clinical practice, based on evidence of very low quality].

2. In patients receiving chemotherapy, prophylaxis is not recommended routinely [grade 1B].

3. Primary pharmacological prophylaxis of VTE may be indicated in patients with locally advanced or metastatic pancreatic cancer treated with chemotherapy and having a low bleeding risk [grade 1B].

ACCP [13]

1. In outpatients with cancer who have no additional risk factors for VTE, routine prophylaxis with LMWH or LDUH is not suggested (grade 2B) and the prophylactic use of VKAs is not recommended (grade 1B).

2. In outpatients with cancer and indwelling central venous catheters, routine prophylaxis with LMWH or LDUH is not suggested (grade 2B), neither is the prophylactic use of VKAs (grade 2C).