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Table 4.  

Rates of Venous Thromboembolic Disease According to Risk Score

Table 3.  

Predictive Model for Chemotherapy-Associated Venous Thromboembolic Disease

Table 2.  

Selected Biomarkers Predictive of Cancer-Associated Thrombosis

Table 1.  

Selected Clinical Risk Factors for Cancer-Associated Thrombosis


Risk Assessment and Prophylaxis for VTE in Cancer Patients

  • Authors: Alok A. Khorana, MD
  • CME Released: 7/5/2011
  • Valid for credit through: 7/5/2012, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, internists, oncologists, cardiologists, surgeons, and other physicians caring for patients with cancer who may be at risk for VTE.

The goal of this activity is to describe the identification of patients with cancer who may be at high risk for VTE and the role of thromboprophylaxis in these patients.

Upon completion of this activity, participants will be able to:

  1. Describe clinical risk factors for VTE in cancer, based on a review
  2. Describe biomarkers predictive of VTE and a recently validated risk model for VTE
  3. Describe the role of thromboprophylaxis in patients at high risk for VTE


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  • Alok A. Khorana, MD

    Associate Professor, Department of Medicine; Associate Professor, James P. Wilmot Cancer Center University of Rochester School of Medicine and Dentistry, Rochester, New York


    Disclosure: Alok A. Khorana, MD, has disclosed the following relevant financial relationships:
    Participated in funded/unfunded research for: Ortho Biotech Products, L.P.
    Served on the steering committee for: Leo Pharma, Inc.; sanofi-aventis
    Served as an advisory board member, speakers bureau member, expert witness, or consultant for: Boehringer Ingelheim Pharmaceuticals, Inc.; Daiichi Sankyo, Inc.; Eisai, Inc.; Ortho Biotech Products, L.P.; Roche, sanofi-aventis
    Supported by grants from the National Cancer Institute (K23 CA120587), the National Heart, Lung and Blood Institute (R01HL095109) and the V Foundation.


  • Kerrin M. Green, MA

    Assistant Managing Editor, Journal of the National Comprehensive Cancer Network


    Disclosure: Kerrin M. Green, MA, has disclosed no relevant financial relationships.

CME Author(s)

  • Charles P. Vega, MD

    Associate Professor; Residency Director, Department of Family Medicine, University of California, Irvine


    Disclosure: Charles P. Vega, MD, has disclosed no relevant financial relationships.

CME Reviewer(s)

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

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  • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Medscape, LLC and JNCCN - The Journal of the National Comprehensive Cancer Network. Medscape, LLC is accredited by the ACCME to provide continuing medical education for physicians.

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Risk Assessment and Prophylaxis for VTE in Cancer Patients

Authors: Alok A. Khorana, MDFaculty and Disclosures

CME Released: 7/5/2011

Valid for credit through: 7/5/2012, 11:59 PM EST


Abstract and Introduction


The frequency of venous thromboembolism (VTE) is rising in patients with cancer. VTE contributes to mortality and morbidity, but the risk for VTE can vary widely between individual patients. Clinical risk factors for VTE in cancer include primary site of cancer, use of systemic therapy, surgery, and hospitalization. Biomarkers predictive of VTE include platelet and leukocyte counts, hemoglobin, D-dimer, and tissue factor. A recently validated risk model incorporates 5 easily available variables and can be used clinically to identify patients at increased risk of VTE. In high-risk settings, including surgery and hospitalization, thromboprophylaxis with either unfractionated heparin or low-molecular-weight heparins has been shown to be safe and effective. Recent studies have also suggested a potential benefit for thromboprophylaxis in the ambulatory setting, although criteria for selecting patients for prophylaxis are not currently well defined. This article focuses on recent and ongoing studies of risk assessment and prophylaxis in patients with cancer. (JNCCN 2011;9:789–798)


Patients with cancer, particularly those undergoing active treatment, frequently experience thromboembolic events. These can include deep vein thrombosis (DVT), pulmonary embolism (PE), which together are categorized as venous thromboembolism (VTE), and arterial events, including stroke and myocardial infarction. The frequency of both VTE and arterial events has increased substantially in the past decade,[1] as have trends for venous thromboembolism among hospitalized cancer patients. However, despite the well-known prevalence of VTE in the cancer population, the risk varies widely among subgroups of patients and in individual patients over time.[2,3] Anticoagulants, including low-molecular-weight heparins (LMWHs) and warfarin, have been shown to be safe and effective in preventing VTE in high-risk settings. Understanding the risk for VTE in individual cancer patients or in specific settings therefore becomes especially important to applying targeted thromboprophylaxis.

Knowledge gained within the past decade has improved understanding of risk assessment and prophylaxis of cancer-associated VTE. This article focuses on clinical risk factors, biomarkers, and risk assessment tools that can help clinicians identify cancer patients at risk for VTE, and trials of prophylaxis in various settings, with a particular emphasis on recent developments. VTE is the primary focus of this article; when available, data relevant to arterial events are also discussed.