title: Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment.
abstract: Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic. PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations. Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti-factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti-factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.
authors.affiliation: Alberta: Department of Oncology, Faculty of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary (Easaw, Shea-Budgell); Cancer Strategic Clinical Network, Alberta Health Services, Calgary (Shea-Budgell); Division of Hematology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (Wu); Guideline Utilization Resource Unit, CancerControl Alberta, Alberta Health Services, Calgary (Meek).
authors.forename: J C
authors.initials: JC
authors.lastname: Easaw
authors.affiliation: Alberta: Department of Oncology, Faculty of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary (Easaw, Shea-Budgell); Cancer Strategic Clinical Network, Alberta Health Services, Calgary (Shea-Budgell); Division of Hematology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (Wu); Guideline Utilization Resource Unit, CancerControl Alberta, Alberta Health Services, Calgary (Meek).
authors.forename: M A
authors.initials: MA
authors.lastname: Shea-Budgell
authors.affiliation: Alberta: Department of Oncology, Faculty of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary (Easaw, Shea-Budgell); Cancer Strategic Clinical Network, Alberta Health Services, Calgary (Shea-Budgell); Division of Hematology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (Wu); Guideline Utilization Resource Unit, CancerControl Alberta, Alberta Health Services, Calgary (Meek).
authors.forename: C M J
authors.initials: CM
authors.lastname: Wu
authors.affiliation: Manitoba: Department of Medicine, University of Manitoba, Cancer Care Manitoba, Winnipeg (Czaykowski).
authors.forename: P M
authors.initials: PM
authors.lastname: Czaykowski
authors.affiliation: Quebec: Hôpital Maisonneuve-Rosemont, Montreal (Kassis); Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal (Tagalakis); Department of Oncology, Faculty of Medicine, McGill University, Montreal (Kavan).
authors.forename: J
authors.initials: J
authors.lastname: Kassis
authors.affiliation: Ontario: Scientific Insights Consulting Group, Mississauga (Kuehl); Department of Medicine, St. Michael's Hospital Division of Nephrology, University of Toronto, Toronto (McFarlane); Department of Oncology, Western University, London (Welch).
authors.forename: B
authors.initials: B
authors.lastname: Kuehl
authors.affiliation: British Columbia: Department of Medical Oncology, BC Cancer Agency, Vancouver (Lim); BC Provincial Renal Agency and Faculty of Pharmaceutical Sciences, University of British Columbia and Royal Jubilee Hospital, Victoria (Martinusen).
authors.forename: H J
authors.initials: HJ
authors.lastname: Lim
authors.affiliation: Nova Scotia: Department of Medicine, Dalhousie University, Halifax (MacNeil); Department of Medicine, Dalhousie University and Capital District Health Authority, Halifax (Shivakumar).
authors.forename: M
authors.initials: M
authors.lastname: MacNeil
authors.affiliation: British Columbia: Department of Medical Oncology, BC Cancer Agency, Vancouver (Lim); BC Provincial Renal Agency and Faculty of Pharmaceutical Sciences, University of British Columbia and Royal Jubilee Hospital, Victoria (Martinusen).
authors.forename: D
authors.initials: D
authors.lastname: Martinusen
authors.affiliation: Ontario: Scientific Insights Consulting Group, Mississauga (Kuehl); Department of Medicine, St. Michael's Hospital Division of Nephrology, University of Toronto, Toronto (McFarlane); Department of Oncology, Western University, London (Welch).
authors.forename: P A
authors.initials: PA
authors.lastname: McFarlane
authors.affiliation: Alberta: Department of Oncology, Faculty of Medicine, University of Calgary, Tom Baker Cancer Centre, Calgary (Easaw, Shea-Budgell); Cancer Strategic Clinical Network, Alberta Health Services, Calgary (Shea-Budgell); Division of Hematology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton (Wu); Guideline Utilization Resource Unit, CancerControl Alberta, Alberta Health Services, Calgary (Meek).
authors.forename: E
authors.initials: E
authors.lastname: Meek
authors.affiliation: Saskatchewan: Department of Medicine, Division of Hematology, University of Saskatchewan, Saskatoon (Moodley).
authors.forename: O
authors.initials: O
authors.lastname: Moodley
authors.affiliation: Nova Scotia: Department of Medicine, Dalhousie University, Halifax (MacNeil); Department of Medicine, Dalhousie University and Capital District Health Authority, Halifax (Shivakumar).
authors.forename: S
authors.initials: S
authors.lastname: Shivakumar
authors.affiliation: Quebec: Hôpital Maisonneuve-Rosemont, Montreal (Kassis); Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal (Tagalakis); Department of Oncology, Faculty of Medicine, McGill University, Montreal (Kavan).
authors.forename: V
authors.initials: V
authors.lastname: Tagalakis
authors.affiliation: Ontario: Scientific Insights Consulting Group, Mississauga (Kuehl); Department of Medicine, St. Michael's Hospital Division of Nephrology, University of Toronto, Toronto (McFarlane); Department of Oncology, Western University, London (Welch).
authors.forename: S
authors.initials: S
authors.lastname: Welch
authors.affiliation: Quebec: Hôpital Maisonneuve-Rosemont, Montreal (Kassis); Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal (Tagalakis); Department of Oncology, Faculty of Medicine, McGill University, Montreal (Kavan).
authors.forename: P
authors.initials: P
authors.lastname: Kavan
keywords: Low molecular weight heparin; anticoagulation; clots; deep vein thrombosis; practice guideline; pulmonary embolism; venous thromboembolism