{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T01:15:32Z","timestamp":1792718132942,"version":"4.5.0"},"reference-count":55,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2020,3,6]],"date-time":"2020-03-06T00:00:00Z","timestamp":1583452800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Venous thromboembolism (VTE) is frequent among patients with cancer. Ambulatory cancer patients starting chemotherapy have a 5% to 10% risk of cancer associated thrombosis (CAT) within the first year after cancer diagnosis. This risk may vary according to patient characteristics, cancer location, cancer stage, or the type of chemotherapeutic regimen. Landmark studies evaluating thrombophrophylaxis with low molecular weight heparin (LMWH) for ambulatory cancer patients have shown a relative reduction in the rate of symptomatic VTE of about one half. However, the absolute risk reduction is modest among unselected patients given a rather low risk of events resulting in a number needed to treat (NNT) of 40 to 50. Moreover, this modest benefit is mitigated by a trend towards an increased risk of bleeding, and the economic and patient burden due to daily injections of LMWH. For these reasons, routine thromboprophylaxis is not recommended by expert societies. Advances in VTE risk stratification among cancer patients, and growing evidence regarding efficacy and safety of direct oral anticoagulants (DOACs) for the treatment and prevention of CAT have led to reconsider the paradigms of this risk\u2013benefit assessment. This narrative review aims to summarize the recent evidence provided by randomized trials comparing DOACs to placebo in ambulatory cancer patients and its impact on expert recommendations and clinical practice.<\/jats:p>","DOI":"10.3390\/cancers12030612","type":"journal-article","created":{"date-parts":[[2020,3,6]],"date-time":"2020-03-06T09:26:41Z","timestamp":1583486801000},"page":"612","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Preventing Venous Thromboembolism in Ambulatory Patients with Cancer: A Narrative Review"],"prefix":"10.3390","volume":"12","author":[{"given":"Anne","family":"Rossel","sequence":"first","affiliation":[{"name":"Division of General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland"},{"name":"Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helia","family":"Robert-Ebadi","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland"},{"name":"Division of Angiology and Haemostasis, University Hospitals of Geneva, 1205 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2016-6759","authenticated-orcid":false,"given":"Christophe","family":"Marti","sequence":"additional","affiliation":[{"name":"Division of General Internal Medicine, University Hospitals of Geneva, 1205 Geneva, Switzerland"},{"name":"Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2020,3,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1001\/archinte.162.11.1245","article-title":"Relative impact of risk factors for deep vein thrombosis and pulmonary embolism: A population-based study","volume":"162","author":"Heit","year":"2002","journal-title":"Arch. Intern. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1001\/jama.293.6.715","article-title":"Malignancies, prothrombotic mutations, and the risk of venous thrombosis","volume":"293","author":"Blom","year":"2005","journal-title":"JAMA"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1001\/archinte.166.4.458","article-title":"Incidence of venous thromboembolism and its effect on survival among patients with common cancers","volume":"166","author":"Chew","year":"2006","journal-title":"Arch. Intern. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1404","DOI":"10.1016\/j.ejca.2012.10.021","article-title":"Incidence of venous thromboembolism in patients with cancer\u2013a cohort study using linked United Kingdom databases","volume":"49","author":"Walker","year":"2013","journal-title":"Eur. J. Cancer"},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Horsted, F., West, J., and Grainge, M.J. (2012). Risk of venous thromboembolism in patients with cancer: A systematic review and meta-analysis. PLoS Med., 9.","DOI":"10.1371\/journal.pmed.1001275"},{"key":"ref_6","unstructured":"Frere, C., Bournet, B., Gourgou, S., Fraisse, J., Canivet, C., Connors, J.M., Buscail, L., Farge, D., and Consortium, B. (2019). Incidence of Venous Thromboembolism in Patients with Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes. Gastroenterology."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1321","DOI":"10.1634\/theoncologist.2013-0226","article-title":"Venous thromboembolism risk in patients with cancer receiving chemotherapy: A real-world analysis","volume":"18","author":"Lyman","year":"2013","journal-title":"Oncologist"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"2339","DOI":"10.1002\/cncr.23062","article-title":"Frequency, risk factors, and trends for venous thromboembolism among hospitalized cancer patients","volume":"110","author":"Khorana","year":"2007","journal-title":"Cancer"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1200\/JCO.2014.59.7351","article-title":"Venous thromboembolism prophylaxis and treatment in patients with cancer: American society of clinical oncology clinical practice guideline update 2014","volume":"33","author":"Lyman","year":"2015","journal-title":"J. Clin. Oncol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1186\/1479-5876-9-179","article-title":"Chemotherapy-associated thromboembolic risk in cancer outpatients and effect of nadroparin thromboprophylaxis: Results of a retrospective analysis of the PROTECHT study","volume":"9","author":"Barni","year":"2011","journal-title":"J. Transl. Med."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"914","DOI":"10.1001\/jama.299.8.914","article-title":"Venous thromboembolism and mortality associated with recombinant erythropoietin and darbepoetin administration for the treatment of cancer-associated anemia","volume":"299","author":"Bennett","year":"2008","journal-title":"JAMA"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2280","DOI":"10.1200\/JCO.2009.27.2757","article-title":"Risk of arterial thromboembolic events with sunitinib and sorafenib: A systematic review and meta-analysis of clinical trials","volume":"28","author":"Choueiri","year":"2010","journal-title":"J. Clin. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1672","DOI":"10.1093\/annonc\/mdr592","article-title":"Risk of venous and arterial thromboembolic events associated with anti-EGFR agents: A meta-analysis of randomized clinical trials","volume":"23","author":"Petrelli","year":"2012","journal-title":"Ann. Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1016\/S1470-2045(09)70232-3","article-title":"Nadroparin for the prevention of thromboembolic events in ambulatory patients with metastatic or locally advanced solid cancer receiving chemotherapy: A randomised, placebo-controlled, double-blind study","volume":"10","author":"Agnelli","year":"2009","journal-title":"Lancet Oncol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1056\/NEJMoa1108898","article-title":"Semuloparin for thromboprophylaxis in patients receiving chemotherapy for cancer","volume":"366","author":"Agnelli","year":"2012","journal-title":"New Engl. J. Med."},{"key":"ref_16","first-page":"CD008500","article-title":"Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy","volume":"12","author":"Porreca","year":"2016","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3484","DOI":"10.1182\/blood-2002-01-0108","article-title":"Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis","volume":"100","author":"Prandoni","year":"2002","journal-title":"Blood"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"4902","DOI":"10.1182\/blood-2007-10-116327","article-title":"Development and validation of a predictive model for chemotherapy-associated thrombosis","volume":"111","author":"Khorana","year":"2008","journal-title":"Blood"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"615","DOI":"10.1056\/NEJMoa1711948","article-title":"Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism","volume":"378","author":"Raskob","year":"2018","journal-title":"New Engl. J. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2017","DOI":"10.1200\/JCO.2018.78.8034","article-title":"Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECT-D)","volume":"36","author":"Young","year":"2018","journal-title":"J. Clin. Oncol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Rossel, A., Robert-Ebadi, H., Combescure, C., Grosgurin, O., Stirnemann, J., Addeo, A., Garin, N., Agoritsas, T., Reny, J.L., and Marti, C. (2019). Anticoagulant therapy for acute venous thrombo-embolism in cancer patients: A systematic review and network meta-analysis. PLoS ONE, 14.","DOI":"10.1371\/journal.pone.0213940"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1056\/NEJMoa1814468","article-title":"Apixaban to Prevent Venous Thromboembolism in Patients with Cancer","volume":"380","author":"Carrier","year":"2019","journal-title":"New Engl. J. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"720","DOI":"10.1056\/NEJMoa1814630","article-title":"Rivaroxaban for Thromboprophylaxis in High-Risk Ambulatory Patients with Cancer","volume":"380","author":"Khorana","year":"2019","journal-title":"New Engl. J. Med."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1277","DOI":"10.3324\/haematol.2018.209114","article-title":"The Khorana score for prediction of venous thromboembolism in cancer patients: A systematic review and meta-analysis","volume":"104","author":"Mulder","year":"2019","journal-title":"Haematologica"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"5377","DOI":"10.1182\/blood-2010-02-270116","article-title":"Prediction of venous thromboembolism in cancer patients","volume":"116","author":"Ay","year":"2010","journal-title":"Blood"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1007\/s11739-012-0784-y","article-title":"A modified Khorana risk assessment score for venous thromboembolism in cancer patients receiving chemotherapy: The Protecht score","volume":"7","author":"Verso","year":"2012","journal-title":"Intern. Emerg. Med."},{"key":"ref_27","first-page":"2084","article-title":"Primary pharmacological prevention of thromboembolic events in ambulatory patients with advanced pancreatic cancer treated with chemotherapy?","volume":"138","author":"Pelzer","year":"2013","journal-title":"Dtsch. Med. Wochenschr."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"601","DOI":"10.1634\/theoncologist.2016-0246","article-title":"Preventing Venous Thromboembolism in Ambulatory Cancer Patients: The ONKOTEV Study","volume":"22","author":"Cella","year":"2017","journal-title":"Oncologist"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1222","DOI":"10.1634\/theoncologist.2016-0414","article-title":"A Predictive Score for Thrombosis Associated with Breast, Colorectal, Lung, or Ovarian Cancer: The Prospective COMPASS-Cancer-Associated Thrombosis Study","volume":"22","author":"Gerotziafas","year":"2017","journal-title":"Oncologist"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"2703","DOI":"10.1182\/blood-2008-02-142422","article-title":"High plasma levels of soluble P-selectin are predictive of venous thromboembolism in cancer patients: Results from the Vienna Cancer and Thrombosis Study (CATS)","volume":"112","author":"Ay","year":"2008","journal-title":"Blood"},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Sato, Y., Kamura, T., Shirata, N., Murata, T., Kudoh, A., Iwahori, S., Nakayama, S., Isomura, H., Nishiyama, Y., and Tsurumi, T. (2009). Degradation of phosphorylated p53 by viral protein-ECS E3 ligase complex. PLoS Pathog., 5.","DOI":"10.1371\/journal.ppat.1000530"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"e289","DOI":"10.1016\/S2352-3026(18)30063-2","article-title":"A clinical prediction model for cancer-associated venous thromboembolism: A development and validation study in two independent prospective cohorts","volume":"5","author":"Pabinger","year":"2018","journal-title":"Lancet Haematol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"2028","DOI":"10.1200\/JCO.2014.55.1481","article-title":"Efficacy of Prophylactic Low-Molecular Weight Heparin for Ambulatory Patients With Advanced Pancreatic Cancer: Outcomes From the CONKO-004 Trial","volume":"33","author":"Pelzer","year":"2015","journal-title":"J. Clin. Oncol."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Godinho, J., Casa-Nova, M., Moreira-Pinto, J., Simoes, P., Paralta Branco, F., Leal-Costa, L., Faria, A., Lopes, F., Teixeira, J.A., and Passos-Coelho, J.L. (2019). ONKOTEV Score as a Predictive Tool for Thromboembolic Events in Pancreatic Cancer-A Retrospective Analysis. Oncologist.","DOI":"10.1634\/theoncologist.2019-0510"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1494","DOI":"10.3324\/haematol.2017.169060","article-title":"Comparison of risk prediction scores for venous thromboembolism in cancer patients: A prospective cohort study","volume":"102","author":"Cesarman","year":"2017","journal-title":"Haematologica"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"729","DOI":"10.1111\/j.1538-7836.2007.02427.x","article-title":"The effect of low-molecular-weight heparin on cancer survival. A systematic review and meta-analysis of randomized trials","volume":"5","author":"Goss","year":"2007","journal-title":"J. Thromb. Haemost."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1944","DOI":"10.1200\/JCO.2004.10.002","article-title":"Low molecular weight heparin, therapy with dalteparin, and survival in advanced cancer: The fragmin advanced malignancy outcome study (FAMOUS)","volume":"22","author":"Kakkar","year":"2004","journal-title":"J. Clin. Oncol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"2071","DOI":"10.1200\/JCO.2010.31.9293","article-title":"Randomized trial of the effect of the low molecular weight heparin nadroparin on survival in patients with cancer","volume":"29","author":"Otten","year":"2011","journal-title":"J. Clin. Oncol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1177\/1076029611433769","article-title":"Low-molecular-weight heparin versus placebo for the prevention of venous thromboembolism in metastatic breast cancer or stage III\/IV lung cancer","volume":"18","author":"Haas","year":"2012","journal-title":"Clin. Appl. Thromb. Hemost."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1200\/JCO.2015.64.0268","article-title":"Randomized Phase III Trial of Standard Therapy Plus Low Molecular Weight Heparin in Patients With Lung Cancer: FRAGMATIC Trial","volume":"34","author":"Macbeth","year":"2016","journal-title":"J. Clin. Oncol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1283","DOI":"10.1016\/j.ejca.2011.10.017","article-title":"Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer","volume":"48","author":"Maraveyas","year":"2012","journal-title":"Eur. J. Cancer"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"89","DOI":"10.1016\/j.thromres.2017.01.009","article-title":"Dalteparin thromboprophylaxis in cancer patients at high risk for venous thromboembolism: A randomized trial","volume":"151","author":"Khorana","year":"2017","journal-title":"Thromb. Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1111\/bjh.12163","article-title":"Prediction and prevention of thromboembolic events with enoxaparin in cancer patients with elevated tissue factor-bearing microparticles: A randomized-controlled phase II trial (the Microtec study)","volume":"160","author":"Zwicker","year":"2013","journal-title":"Br. J. Haematol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"993","DOI":"10.1200\/JCO.1989.7.8.993","article-title":"A randomized trial of anticoagulation with warfarin and of alternating chemotherapy in extensive small-cell lung cancer by the Cancer and Leukemia Group B","volume":"7","author":"Chahinian","year":"1989","journal-title":"J. Clin. Oncol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1001\/jama.1981.03310330021017","article-title":"Effect of warfarin on survival in small cell carcinoma of the lung. Veterans Administration Study No. 75","volume":"245","author":"Zacharski","year":"1981","journal-title":"JAMA"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"3378","DOI":"10.1200\/JCO.1997.15.11.3378","article-title":"Randomized trial of chemotherapy and radiation therapy with or without warfarin for limited-stage small-cell lung cancer: A Cancer and Leukemia Group B study","volume":"15","author":"Maurer","year":"1997","journal-title":"J. Clin. Oncol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"886","DOI":"10.1016\/S0140-6736(94)90008-6","article-title":"Double-blind randomised trial of a very-low-dose warfarin for prevention of thromboembolism in stage IV breast cancer","volume":"343","author":"Levine","year":"1994","journal-title":"Lancet"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1182\/blood-2011-03-344333","article-title":"Aspirin or enoxaparin thromboprophylaxis for patients with newly diagnosed multiple myeloma treated with lenalidomide","volume":"119","author":"Larocca","year":"2012","journal-title":"Blood"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"986","DOI":"10.1200\/JCO.2010.31.6844","article-title":"Aspirin, warfarin, or enoxaparin thromboprophylaxis in patients with multiple myeloma treated with thalidomide: A phase III, open-label, randomized trial","volume":"29","author":"Palumbo","year":"2011","journal-title":"J. Clin. Oncol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"2130","DOI":"10.1200\/JCO.2005.03.134","article-title":"The effect of low molecular weight heparin on survival in patients with advanced malignancy","volume":"23","author":"Klerk","year":"2005","journal-title":"J. Clin. Oncol."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1959","DOI":"10.1111\/j.1538-7836.2010.03973.x","article-title":"PRODIGE: A randomized placebo-controlled trial of dalteparin low-molecular-weight heparin thromboprophylaxis in patients with newly diagnosed malignant glioma","volume":"8","author":"Perry","year":"2010","journal-title":"J. Thromb. Haemost."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1326","DOI":"10.1056\/NEJMoa1814051","article-title":"Full Study Report of Andexanet Alfa for Bleeding Associated with Factor Xa Inhibitors","volume":"380","author":"Connolly","year":"2019","journal-title":"New Engl. J. Med."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"2141","DOI":"10.1111\/jth.14613","article-title":"Direct oral anticoagulant for the prevention of thrombosis in ambulatory patients with cancer: A systematic review and meta-analysis","volume":"17","author":"Li","year":"2019","journal-title":"J. Thromb. Haemost."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Key, N.S., Khorana, A.A., Kuderer, N.M., Bohlke, K., Lee, A.Y.Y., Arcelus, J.I., Wong, S.L., Balaban, E.P., Flowers, C.R., and Francis, C.W. (2019). Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J. Clin. Oncol.","DOI":"10.1200\/JCO.19.01461"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"e566","DOI":"10.1016\/S1470-2045(19)30336-5","article-title":"2019 International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer","volume":"20","author":"Farge","year":"2019","journal-title":"Lancet Oncol."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/12\/3\/612\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T09:04:50Z","timestamp":1760173490000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/12\/3\/612"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,3,6]]},"references-count":55,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2020,3]]}},"alternative-id":["cancers12030612"],"URL":"https:\/\/doi.org\/10.3390\/cancers12030612","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,3,6]]}}}