Thromboprophylaxis (patients undergoing surgery, thoracic: pneumonectomy): consider administering parenteral anticoagulation with subcutaneous LMWH or UFH for VTE prevention in patients undergoing pneumonectomy or extended lung resection. C Consider preferring LMWH over UFH. C Show 6 more Thromboprophylaxis (patients undergoing surgery, thoracic: esophagectomy): consider administering parenteral anticoagulation with subcutaneous LMWH or UFH for VTE prevention in patients undergoing esophagectomy. C Consider preferring LMWH over UFH. C Show 6 more Thromboprophylaxis, patients undergoing surgery, abdominopelvic: As per ASCO 2023 guidelines, continue thromboprophylaxis with LMWH for up to 4 weeks postoperatively in patients after a major open or laparoscopic abdominal or pelvic surgery for cancer and having high-risk features, such as restricted mobility, obesity, history of VTE, or with additional risk factors. B As per ESMO 2023 guidelines, administer extended postoperative VTE prophylaxis for 4 weeks with LMWH after open abdominal or pelvic surgery or laparoscopic colorectal cancer surgery. A As per ITAC 2022 guidelines, administer extended prophylaxis (4 weeks) for the prevention of postoperative VTE after major abdominal or pelvic surgery (either laparotomy or laparoscopy) in patients with cancer not at high risk of bleeding. A As per ASH 2021 guidelines, consider continuing pharmacological thromboprophylaxis after hospital discharge in patients with cancer after a major abdominal/pelvic surgical procedure. C As per BCSH 2015 guidelines, consider administering extended thromboprophylaxis in patients undergoing abdominal or pelvic surgery for cancer. C As per CCG-VTEC 2015 guidelines: Administer prophylactic anticoagulant therapy in outpatients undergoing major abdominal or pelvic cancer surgery. A Consider administering extended prophylaxis for deep vein thrombosis for up to 4 weeks postoperatively in patients undergoing major abdominal or pelvic cancer surgery, especially in patients at high risk. C Thromboprophylaxis, patients undergoing other procedures: As per ASCO 2023 guidelines, do not administer routine pharmacologic thromboprophylaxis in patients admitted for the sole purpose of minor procedures or chemotherapy infusion, nor in patients undergoing stem-cell/BMT. D https://web.pathway.md/diseases/recIVmB3RkdyvcT1J 14/18 6/29/23, 3:25 AM Cancer-associated thrombosis Pathway As per CCG-VTEC 2015 guidelines, insufficient evidence to recommend prophylactic anticoagulation in outpatients undergoing lower-risk surgeries (such as biopsies, cutaneous excisions). I Thromboprophylaxis (monitoring): do not obtain routine monitoring of anti-factor Xa levels in most patients receiving prophylactic anticoagulation. D 9. Follow-up and surveillance Follow-up: Schedule an initial follow-up at 1-4 weeks. B Ensure that SC injections are being administered properly and assess for bleeding and recurrent thrombotic complications. B Management of recurrence: As per ITAC 2022 guidelines: Consider offering the following options in patients with VTE recurrence: increase LMWH by 20-25% or switch to direct OACs switch to LMWH if on direct OACs switch to LMWH or direct OACs if on vitamin K antagonists. C Consider placing an IVC filter in patients with PE recurrence occurring under optimal anticoagulation. C Landmark trials: CLOT In patients with cancer who had acute, symptomatic proximal deep vein thrombosis, PE, or both, subcutaneous dalteparin was superior to oral anticoagulation with respect to recurrent VTE at 6 months. Lee AY et al. N Engl J Med. 2003 Jul 10. As per ASH 2021 guidelines: Consider increasing the LMWH dose to a supratherapeutic level or continuing with a therapeutic dose in patients with cancer and recurrent VTE despite receiving therapeutic LMWH. C Avoid using IVC filters in patients with cancer and recurrent VTE despite anticoagulation treatment. D As per CCG-VTEC 2015 guidelines: Increase the dose of LMWH by 20-25% in patients with recurrent VTE while on LMWH. B Extend anticoagulation therapy (> 3 months) in patients with recurrent VTE. B https://web.pathway.md/diseases/recIVmB3RkdyvcT1J 15/18 6/29/23, 3:25 AM Cancer-associated thrombosis Pathway Clinical findings Past medical history Past obstetric history CKD Pregnancy Catheter-related thrombosis Social history Cerebral venous thrombosis DVT Tobacco use Exposure to chemotherapy Immobility Inserted central venous catheter Malignancy Migratory thrombophlebitis Obesity PE Splanchnic vein thrombosis Superficial vein thrombosis Trousseau's syndrome Past surgical history Recent surgery Lab findings serum D-dimer serum lactate Studies 2022 AVERT (subgroup analysis) In patients with cancer-initiating chemotherapy who were at intermediate-to-high risk of VTE, apixaban was superior to placebo with respect to VTE at 180 days. Willem Brandt et al. Thromb Res. 2022 May 29. 2019 CASSINI In high-risk ambulatory adults with cancer, rivaroxaban was not superior to placebo with respect to thrombotic events at 6 months. Alok A Khorana et al. N Engl J Med. 2019 Feb 21. Show 7 more References https://web.pathway.md/diseases/recIVmB3RkdyvcT1J 16/18 6/29/23, 3:25 AM Cancer-associated thrombosis Pathway 1. Henry G Watson, David M Keeling, Mike Laffan et al. Guideline on aspects of cancer-related venous thrombosis. Br J Haematol. 2015 Sep;170 5 640 8. Open 2. Dominique Farge, Corinne Frere, Jean M Connors et al. 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID 19. Lancet Oncol. 2022 Jul;23 7):e334-e347. Open 3. M Carrier, A Lazo-Langner, S Shivakumar et al. Clinical challenges in patients with cancer-associated thrombosis: Canadian expert consensus recommendations. Curr Oncol. 2015 Feb;22 1 49 59. Open 4. J C Easaw, M A Shea-Budgell, C M J Wu et al. Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 1 prophylaxis. Curr Oncol. 2015 Apr;22 2 133 43. Open 5. Stavros K Kakkos, Manjit Gohel, Niels Baekgaard et al. Editor's Choice European Society for Vascular Surgery ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis. Eur J Vasc Endovasc Surg. 2021 Jan;61 1 9 82. Open 6. Gary H Lyman, Marc Carrier, Cihan Ay et al. American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer. Blood Adv. 2021 Feb 23;5 4 927 974. Open 7. A Falanga, C Ay, M Di Nisio et al. Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline. Ann Oncol. 2023 Jan 3;S0923 7534 22 04786 X. Open 8. Nigel S Key, Alok A Khorana, Nicole M Kuderer et al. Canadian Urological Association consensus guideline: Management of testicular germ cell cancer. J Clin Oncol. 2023 Apr 19;JCO2300294. Open 9. J I Zwicker, G Connolly, M Carrier et al. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost. 2014 May;12 5 796 800. Open 10. Schiffer CA, Mangu PB, Wade JC et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013 Apr 1;31 10 1357 70. Open 11. J C Easaw, M A Shea-Budgell, C M J Wu et al. Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2 treatment. Curr Oncol. 2015 Apr;22 2 144 55. Open 12. Yaron Shargall, Wojtek Wiercioch, Alessandro Brunelli et al. Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer- associated venous thromboembolism in thoracic surgery. Eur J Cardiothorac Surg. 2022 Dec 2;63 1):ezac488. Open 13. Sousa B, Furlanetto J, Hutka M et al. Central venous access in oncology: ESMO Clinical Practice Guidelines. Ann Oncol. 2015 Sep;26 Suppl 5:v152 68. Open 14. Saskia Middeldorp, Robby Nieuwlaat, Lisa Baumann Kreuziger et al. American Society of Hematology 2023 Guidelines for Management of Venous Thromboembolism: Thrombophilia Testing. Blood Adv. 2023 May 17;bloodadvances.2023010177. Open 15. Scott M Stevens, Scott C Woller, Lisa Baumann Kreuziger et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160 6):e545- e608. Open https://web.pathway.md/diseases/recIVmB3RkdyvcT1J 17/18 6/29/23, 3:25 AM Cancer-associated thrombosis Pathway 16. Dominique Farge, Corinne Frere, Jean M Connors et al. 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol. 2019 Oct;20 10):e566-e581. Open https://web.pathway.md/diseases/recIVmB3RkdyvcT1J 18/18