**7.1 Prophylaxis in surgical cancer patients**

In general, surgery for cancer increases the risk of VTE and adequate prophylaxis has been shown to reduce VTE rates significantly [99,100]. A number of studies have shown that patients with cancer who undergo a specific type of major surgery have a 2-4 fold higher incidence of postoperative VTE compared with patients without cancer. The risk of venographically proven DVT varies from 20% to 40% and the risk of fatal PE is approximately 1%. Therefore, routine prophylaxis with anticoagulant therapy is strongly recommended, both in the immediate post-operative setting and in the extended period following major surgery.

The agents used most widely for prophylaxis in surgical patients are unfractionated heparin (UFH) and low-molecular- weight heparin (LMWH). Meta-analysis of randomized trials evaluating anticoagulant prophylaxis in general surgery, Mismetti et al. (211), found no significant difference between LMWH and UFH in symptomatic VTE, major bleeding, transfusion and death. This finding is supported by the ENOXACAN study (212). The

Venous Thromboembolism in Cancer Patients 97

(Palliative Medicine June 2010). The authors pointed that primary thromboprophylaxis with LMWH is under utilized in the palliative setting although it is supported by level 1A evidence. The authors stated that studies examined practice in specialist patient care units and attitude held by a total of 32 palliative care physicians and 198 patients for thromboprophylaxis revealed that patient perception of LMWH is based on physician's concern regarding the negative impact on quality life and lack of evidence to support such practice. The authors concluded that LMWH prophylaxis in palliative patients with

The recommendation of the American College of Chest Physicians (ACCP) guidelines on prevention of VTE recommends prophylaxis for acutely ill hospitalized medical/surgical patients with cancer (215). However, the compliance of oncologists with the recommendations remains low (216) and this may be due to lack of awareness or unfounded fear of bleeding within the oncology community. Institution-based VTE prophylaxis guidelines with risk for VTE stratification followed by effective monitoring and auditing policy by the institution and sustained awareness campaigns could have a significant

1. ACCP guidelines is an evidence-based on antithrombotic and thrombolytic therapy covering both prevention and treatment with selected issues related to cancer patients

2. National Comprehensive Cancer Network (NCCN), a non-profit, alliance of 20 leading National Cancer Institute-designated Cancer Centers. The NCCN develops and disseminates clinical practice guidelines in oncology. The latest version of recommendations on VTE management can be found on-line at

3. Italian Guidelines on Management of VTE in patients with cancer published on-line by the Italian Association of Medical Oncologists for Italian oncologists. The guideline covers different aspects of VTE and cancer (a) VTE associated with occult malignancies (b) prophylaxis in cancer surgery, during chemotherapy, during hormonal therapy (c) VTE prophylaxis of VTE associated central venous catheters (d) treatment of VTE in cancer patients (e) anticoagulation and prognosis of cancer. The Italian

4. The American Society of Clinical Oncology Guidelines published its latest recommendations for VTE prophylaxis and treatment in patients with cancer in Dec 2007, JCD volume 25, No. 34 (5490-5505). Our reader is encouraged to refer to this informative and comprehensive document. The ASCO recommendations are depicted

1. Should hospitalized patients with cancer receive anticoagulation for VTE

2. Should ambulatory patients with cancer receive anticoagulation for VTE during

in a user-friendly practical approach in a format of practical questions.

previous good performance status needs further studies.

**7.5 Guidelines for VTE prophylaxis in cancer patients** 

The reader is referred to the following rich evidence-based guidelines:

nccn.org/professionals/physicians\_gls/PDF/vte.pdf.

(http://www.chestnet.org/accp/)

recommendations are updated annually.

prophylaxis?

systematic chemotherapy?

positive impact. **The Guidelines** 

ENOXACAN II study was conducted to examine the effect extended prophylaxis i.e. 21 days, significantly reduced the incidence of DVT from 12% to 4.8% (p= 0.02).
