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ESMO E-Learning: Management of Cancer Associated Thrombosis

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CME test

The CME test associated with this E-Learning Module has now expired.

Learning objectives

  • To provide in depth update on cancer associated thrombosis
  • To determine which patients are at high risk for cancer associated thrombosis and need thromboprophylaxis
  • To provide recommendations for the management of cancer associated thrombosis


Thrombosis in cancer patients is a common, costly and potentially fatal complication. Patients at highest risk are those with advanced disease receiving systemic chemotherapy and having other additional risk factors. This E-Learning module provides answers to questions such as why thrombosis occurs in patients with cancer, what is the influence on patient’s prognosis, what is the optimal management, should the patient be managed differently in case of an incidental finding, and could such events be prevented?

Among all cases of venous thromboembolism (VTE), about 20% occur in cancer patients. Furthermore, among all cancer patients, 20% will havesymptomatic VTE. 

Compared to patients without cancer, in patients with cancer there is a higher risk of first and recurrent VTE, higher risk of bleeding on anticoagulants, higher risk of dying, with VTE being the second leading cause of death in cancer patients. Overall, the incidence of cancer associated thrombosis is increasing. Of every seven patients with cancer who die while hospitalised, one will die of pulmonary embolism (PE), 30%-50% will develop post-thrombotic syndrome and 10% severe, while 5% will develop pulmonary hypertension ≤2 years after symptomatic PE.  

Unprovoked VTE may be the earliest sign of cancer. Up to 10% of patients will be diagnosed with cancer in the year after. More than 60% of occult cancers are diagnosed shortly after the diagnosis of unprovoked VTE. The incidence rate of cancer diagnosis returns to the rate in the general population after one year.

The pathogenesis of a pro-thrombotic state in cancer involves production of procoagulants by tumour cells, suppression of fibrinolytic activity and platelet activation.

In this E-Learning module the author provides a firm evidence of the close link between malignant transformation, tumour angiogenesis, metastasis and thrombosis.

Furthermore, upon providing evidence from randomised clinical trials and meta-analysis of data, this module provides very useful recommendations for clinical practice by emphasizing that a primary prophylaxis is not routinely indicated but could be discussed with patients at high risk; selected cancer patients benefit from extended prophylaxis up to 4 weeks after surgery; prophylaxis in hospitalised patients is a safety priority; low molecular weight heparins are the “best” choice available for patients with established VTE and PE for long-term secondary prophylaxis. 

Declaration of interest

The author has reported no conflicts of interest

Last update: 13 Mar 2018

This E-Learning module was published in 2018. The CME test expired in 2020.

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