VTE risk assessment in cancer

Summary

Venous thromboembolism (VTE) in patients with cancer is associated with an increased morbidity and mortality, and its prevention is of major clinical importance. However, the VTE rates in the cancer population vary between 0.5–20 %, depending on cancer-, treatment- and patient-related factors. The most important contributors to VTE risk are the tumour entity, stage and certain anticancer treatments. Cancer surgery represents a strong risk factor for VTE, and medical oncology patients are at increased risk of developing VTE, especially when receiving chemotherapy or immunomodulatory drugs. Also biomarkers have been investigated for their usefulness to predict risk of VTE (e.g. elevated leucocyte and platelet counts, soluble P-selectin, D-dimer, etc.). In order to identify cancer patients at high risk of VTE and to improve risk stratification, risk assessment models have been developed, which contain both clinical parameters and biomarkers. While primary thromboprophylaxis with low-molecular- weight-heparin (LMWH) is recommended postoperatively for a period of up to 4 weeks after major cancer surgery, the evidence is less clear for medical oncology patients. Thromboprophylaxis in hospitalized medical oncology patients is advocated, and is based on results of randomized controlled trials which evaluated the efficacy and safety of LMWH for prevention of VTE in hospitalized medically ill patients. In recent trials the benefit of primary thromboprophylaxis in cancer patients receiving chemotherapy in the ambulatory setting has been investigated. However, at the present stage primary thromboprophylaxis for prevention of VTE in these patients is still a matter of debate and cannot be recommended for all cancer outpatients.

Zusammenfassung

Venöse Thromboembolien (VTE) bei Krebserkrankungen führen zu einer erhöhten Morbidität und Mortalität. Daher ist ihre Prävention von großer klinischer Bedeutung. Die VTERate bei Krebspatienten variiert zwischen 0.5–20 % – in Abhängigkeit von Tumor-, Behandlungs- und Patienten-spezifischen Risikofaktoren. Auch die Rolle von verschiedenen Laborparametern und Biomarkern (z.B. erhöhte Thrombozyten und leucozyten, solubles P-Selektin, D-dimer, etc.) für die Vorhersage des Auftretens einer VTE wurde in rezenten Studien untersucht. Um Krebspatienten mit dem höchsten VTE-Risiko zu identifizieren und die Risikostratifizierung zu optimieren, sind Risiko-Scores entwickelt worden, die sowohl klinische Parameter als auch Laborparameter beinhalten. Während eine primäre Thromboseprophylaxe mit niedermolekularen Heparinen (NMH) postoperativ nach großen tumorchirurgischen Operationen für eine Dauer von etwa 4 Wochen empfohlen ist, gibt es keine eindeutige Evidenz für eine routinemäßige medikamentöse Thromboseprophylaxe für “internistische” Krebspatienten. Bei stationären Krebspatienten mit einer akut internistischen Erkrankung ist jedenfalls eine Thromboseprophylaxe zu befürworten. Im ambulanten Setting wird die Durchführung einer primären Thromboseprophylaxe bei Patienten diskutiert, die eine Chemotherapie erhalten.

Keywords

Venous thromboembolism - cancer - hypercoagulability - risk factors - thromboprophylaxis

Schlüsselwörter

Venöse Thromboembolie - Krebs - Hyperkoagulabilität - Risikofaktor - Thromboseprophylaxe

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