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  • Version 1.2019, 02/28/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

    NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)

    Cancer-Associated Venous Thromboembolic

    Disease Version 1.2019 — February 28, 2019

    Continue

    NCCN.org

    http://www.nccn.org/default.aspx

  • NCCN Guidelines Version 1.2019 Cancer-Associated Venous Thromboembolic Disease

    Version 1.2019, 02/28/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

    NCCN Guidelines Index Table of Contents

    Discussion

    *Michael B. Streiff, MD/Chair ‡ The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins

    Bjorn Holmstrom, MD/Vice-Chair Þ Moffitt Cancer Center

    Dana Angelini, MD ‡ Case Comprehensive Cancer Center/ University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute

    Aneel Ashrani, MD ‡ Mayo Clinic Cancer Center

    Paula L. Bockenstedt, MD ‡ University of Michigan Rogel Cancer Center

    Carolyn Chesney, MD ‡ St. Jude Children’s Research Hospital/ The University of Tennessee Health Science Center

    John Fanikos, RPH, MBA Σ Dana-Farber/Brigham and Women’s Cancer Center

    Randolph B. Fenninger, JD ¥ National Blood Clot Alliance

    Annemarie E. Fogerty, MD ‡ † Massachusetts General Hospital Cancer Center

    Shuwei Gao, MD Þ The University of Texas MD Anderson Cancer Center

    Samuel Z. Goldhaber, MD λ Dana-Farber/Brigham and Women’s Cancer Center

    Krishna Gundabolu, MD ‡ Fred & Pamela Buffett Cancer Center

    Paul Hendrie, MD, PhD ‡ Fred Hutchinson Cancer Research Center/ Seattle Cancer Care Alliance

    Alfred Lee, MD, PhD ‡ Yale Cancer Center/Smilow Cancer Hospital

    Jason T. Lee, MD ¶ λ Stanford Cancer Institute

    Janelle Mann, PharmD Σ Siteman Cancer Center at Barnes-Jewish Hospital and Washington Unviersity School of Medicine

    Brandon McMahon, MD ‡ University of Colorado Cancer Center

    Colleen Morton, MD ‡ Vanderbilt-Ingram Cancer Center

    Thomas L. Ortel, MD, PhD ‡ Duke Cancer Institute

    Sadat Ozair, MD ‡ Roswell Park Comprehensive Cancer Center

    Rita Paschal, MD ‡ University of Alabama at Birmingham Comprehensive Cancer Center

    Sanford Shattil, MD ‡ UC San Diego Moores Cancer Center

    Tanya Siddiqi, MD ‡ City of Hope National Medical Center

    Kristi J. Smock, MD ‡ ≠ Huntsman Cancer Institute at the University of Utah

    Gerald Soff, MD ‡ Memorial Sloan Kettering Cancer Center

    Tzu-Fei Wang, MD ‡ The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute

    Eliot Williams, MD ‡ University of Wisconsin Carbone Cancer Center

    Anaadriana Zakarija, MD ‡ Robert H. Lurie Comprehensive Cancer Center of Northwestern University

    Continue NCCN Guidelines Panel Disclosures

    λ Cardiology ‡ Hematology/

    Hematology oncology Þ Internal medicine † Medical oncology ≠ Pathology ¥ Patient advocacy

    Σ Pharmacology/ Pharmacy

    ¶ Surgery/Surgical oncology

    *Discussion section writing member

    NCCN Anita Engh, PhD Lydia Hammond, MBA

    Printed by Alok Khorana on 5/29/2019 12:30:00 PM. For personal use only. Not approved for distribution. Copyright © 2019 National Comprehensive Cancer Network, Inc., All Rights Reserved.

    https://www.nccn.org/professionals/physician_gls/default.aspx http://www.nccn.org/disclosures/panel_list.asp?ID=97

  • NCCN Guidelines Version 1.2019 Cancer-Associated Venous Thromboembolic Disease

    Version 1.2019, 02/28/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

    NCCN Guidelines Index Table of Contents

    Discussion

    Clinical Trials: NCCN believes that the best management for any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged. To find clinical trials online at NCCN Member Institutions, click here: nccn.org/clinical_trials/clinicians/aspx. NCCN Categories of Evidence and Consensus: All recommendations are category 2A unless otherwise indicated. See NCCN Categories of Evidence and Consensus.

    NCCN Cancer-Associated Venous Thromboembolic Disease Panel Members Summary of the Guidelines Updates

    Inpatient Venous Thromboembolism Prophylaxis (VTE-1) Acute Superficial Vein Thrombosis (SVT-1) Acute Deep Vein Thrombosis (DVT-1) Acute Pulmonary Embolism (PE-1) Heparin-Induced Thrombocytopenia (HIT-1) Splanchnic Vein Thrombosis (SPVT-1)

    VTE Risk Factors in Patients with Cancer (VTE-A) Contraindications to Prophylactic or Therapeutic Anticoagulation Treatment and Contraindications to Mechanical Prophylaxis (VTE-B)

    Management of Anticoagulation for VTE in Patients with Chemotherapy-Induced Thrombocytopenia (VTE-C) Inpatient/Outpatient Prophylactic Anticoagulation Treatment (VTE-D) Therapeutic Anticoagulation for Venous Thromboembolism (VTE-E) Reversal of Anticoagulation (VTE-F) Elements for Consideration in Decision Not to Treat (VTE-G) Therapeutic Anticoagulation Failure (VTE-H) Thrombolytic Agents (VTE-I) Contraindications to Thrombolysis and Indications for Thrombolysis (VTE-J)

    Perioperative Management of Anticoagulation and Antithrombotic Therapy (PMA-1) Bleeding Risk Assessment Table (PMA-A) Thromboembolic Risk Assessment for Arterial and Venous Thromboembolism Table (PMA-B) Perioperative Anticoagulation Management Guideline (PMA-C)

    The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not be reproduced in any form without the express written permission of NCCN. ©2019.

    Printed by Alok Khorana on 5/29/2019 12:30:00 PM. For personal use only. Not approved for distribution. Copyright © 2019 National Comprehensive Cancer Network, Inc., All Rights Reserved.

    https://www.nccn.org/professionals/physician_gls/default.aspx http://www.nccn.org/clinical_trials/clinicians.aspx http://www.nccn.org/clinical_trials/clinicians.aspx

  • NCCN Guidelines Version 1.2019 Cancer-Associated Venous Thromboembolic Disease

    Version 1.2019, 02/28/19 © 2019 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.

    NCCN Guidelines Index Table of Contents

    Discussion

    UPDATES

    Updates in Version 1.2019 of the NCCN Guidelines for Cancer-Associated Venous Thromboembolic Disease from Version 2.2018 include:

    VTE-1 • Footnote e was modified: "Most data come from surgical or stroke patients..." SVT-1 • Footnote b was modified: Symptomatic treatment includes warm compresses, non-steroidal anti-inflammatory medications (NSAIDs), and elevation. DVT-2 DVT: Treatment • Top pathway, bullet 3 was modified: Consider graduated compression stockings (GCS) if the patient tolerates therapeutic anticoagulation • Footnote f was modified by adding these statements: Appropriate candidates may include: patients who fail to respond to anticoagulation, those at risk of

    limb loss, and those with severe refractory proximal thrombosis. Candidates must have low bleeding risk. (Also on DVT-3) • Footnote was removed: Consider permanent filters only for rare patients with permanent contraindications to anticoagulation. (Also removed on PE-2) PE-2 PE: Treatment • Acute management using anticoagulation, stratified as Intermediate- or high-risk �Under bullet 2, sub-bullets 1 & 2 were combined and modified: Systemic or catheter-directed thrombolysis or embolectomy for massive hemodynamically

    unstable PE or submassive PE with moderate or severe RV enlargement or dysfunction in patients with low bleeding risk; Embolectomy (catheter or surgical)

    ◊ 2nd sub-bullet was added: Rescue thrombolysis/thrombectomy can be considered in patients with initially hemodynamically stable PE who deteriorate despite anticoagulation

    • Footnote g was modified: It is unclear if IVC filter placement is beneficial in the absence Consider IVC filter (retrievable filter preferred) in the presence of a proximal lower extremity, IVC, or pelvic DVT.

    • Footnote o was added: In randomized controlled trials, systemic or catheter-directed thrombolysis/thrombectomy has not been associated with a favorable risk versus benefit profile in patients with hemodynamically stable or submassive PE.

    • Footnote p (describing hemodyanmically unstable PE) was added: Acute PE with sustained hypotension (systolic blood pressure

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