**7.3 Thromboprophylaxis in ambulatory cancer patients**

Much less is known about prevention of VTE in ambulatory cancer patients. The incidence of symptomatic VTE observed in ambulatory patients with advanced or metastatic malignancies in a recent clinical trial of 3% is considered low (26). Multiple recent studies have evaluated the potential benefit of thromboprophylaxis in ambulatory patients selected on the basis of one or two risk factors but have been unable to definitively identify patients who would benefit from prophylaxis

In the double-blind study by Levine et al (213) evaluated the anticoagulant effect of very low-dose warfarin (INR1.3-1.9) in Stage IV breast cancer while they were receiving chemotherapy. However, more recent trials have failed to confirm the benefit of primary prophylaxis in the ambulatory setting.

In summary, routine anticoagulant prophylaxis in medical oncology patients is not practiced because (a) the incidence of symptomatic VTE observed in ambulatory patients with advanced or metastatic malignancies is considered low. (b), the risk of bleeding remains a significant concern in most patients with cancer. (c) extended periods of primary prevention with an anticoagulant can be unattractive to most patients with cancer and (d) the optimal period of prophylaxis has not been identified.

One established high-risk group in the ambulatory setting is multiple myeloma patients receiving combination therapy. All newly diagnosed patients treated with thalidomide/lenalidomide- containing regimens should receive thromboprophylaxis as detailed in chapter 5.

#### **7.4 Primary VTE prophylaxis in palliative care settings**

Sarah Mclean and James S O'Donnell (214) published a qualitative systemic review that covered the period (1960-2010) on this important aspect of management of cancer patients Pathophysiology and Clinical Aspects of 96 Venous Thromboembolism in Neonates, Renal Disease and Cancer Patients

ENOXACAN II study was conducted to examine the effect extended prophylaxis i.e. 21

As the incidence of VTE in cancer patients who require hospitalization is very high, therefore they would benefit from primary anticoagulant prophylaxis. However, it is likely that the absolute and relative benefit of primary thromboprophylaxis will vary greatly amongst different patient groups because of the heterogeneity of cancer patient. It appears that the greatest potential impact of primary prophylaxis would be in patients initially diagnosed with advanced disease particularly those who are candidates for chemotherapy. Another subgroup of patients who may warrant primary thromboprophylaxis are patients initially diagnosed with local, or regional-stage cancer who progress and develop metastatic cancer or when they are admitted to hospital with an acute illness. Those patients should always be considered for primary pharmacological as well as mechanical thromboprophylaxis. Although none of the clinical studies evaluated a cancer-specific population, consensus statements and guidelines unanimously support the use of

Much less is known about prevention of VTE in ambulatory cancer patients. The incidence of symptomatic VTE observed in ambulatory patients with advanced or metastatic malignancies in a recent clinical trial of 3% is considered low (26). Multiple recent studies have evaluated the potential benefit of thromboprophylaxis in ambulatory patients selected on the basis of one or two risk factors but have been unable to definitively identify patients

In the double-blind study by Levine et al (213) evaluated the anticoagulant effect of very low-dose warfarin (INR1.3-1.9) in Stage IV breast cancer while they were receiving chemotherapy. However, more recent trials have failed to confirm the benefit of primary

In summary, routine anticoagulant prophylaxis in medical oncology patients is not practiced because (a) the incidence of symptomatic VTE observed in ambulatory patients with advanced or metastatic malignancies is considered low. (b), the risk of bleeding remains a significant concern in most patients with cancer. (c) extended periods of primary prevention with an anticoagulant can be unattractive to most patients with cancer and (d)

One established high-risk group in the ambulatory setting is multiple myeloma patients receiving combination therapy. All newly diagnosed patients treated with thalidomide/lenalidomide- containing regimens should receive thromboprophylaxis as

Sarah Mclean and James S O'Donnell (214) published a qualitative systemic review that covered the period (1960-2010) on this important aspect of management of cancer patients

days, significantly reduced the incidence of DVT from 12% to 4.8% (p= 0.02).

**7.2 Thromboprophylaxis in hospitalized or bedridden cancer patients** 

prophylaxis in cancer patients admitted to hospitals.

who would benefit from prophylaxis

prophylaxis in the ambulatory setting.

detailed in chapter 5.

**7.3 Thromboprophylaxis in ambulatory cancer patients** 

the optimal period of prophylaxis has not been identified.

**7.4 Primary VTE prophylaxis in palliative care settings** 

(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 previous good performance status needs further studies.
