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6.6 Thrombosis and thromboembolic

events Thromboembolic events that develop during cancer and its treatment encompass both VTE and arterial thromboembolism (ATE) and are collectively referred to as cancer-associated thrombosis. Cancer-associated thrombosis is determined by the prothrombotic milieu induced by cancer, the prothrombotic properties of certain anticancer and adjunctive therapies, and patient-related risk factors, including demographics, genetic predisposition, and comorbidities.513

6.6.1 Venous thromboembolism

VTE, including deep vein thrombosis (DVT) and PE, is the second-leading cause of death in patients with malignancies.558 Cancer confers a five-fold higher risk of VTE and cancer-associated VTE represents 30% of all VTE cases.559,560 The risk of VTE varies in the course of cancer, with the highest risk occurring in the period following cancer diagnosis, during hospitalization and chemotherapy, and upon development of metastatic disease.561,562 Unprovoked VTE may be the first clinical sign of a malignancy, followed by a 5% incidence of cancer diagnosis during the subsequent 12 months.563

The risk factors for VTE in cancer are summarized in Figure 35.564,565 Patients with symptoms or signs suggestive of VTE, such as unilateral lower limb oedema or unexplained dyspnoea, should be screened with lower-extremity venous ultrasonography or contrast-enhanced CT for DVT and CT pulmonary angiography for PE, according to the 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism recommendations566

Risk factors for VTE in patients with cancer

Patient-related factors

Ageing Comorbiditiesa

Sex (female) Hereditary coagulation defectsb

Performance status Prior VTE history

Treatment-related factors

Cancer therapyc

Central venous catheters Hospitalization Major surgery

Cancer-related factors

Cancer type Genetic characteristics (JAK2 or K-ras mutations) Histology (adenocarcinoma) Initial period after diagnosis Primary site (pancreas, stomach, ovaries, brain, lung, myeloma) Stage (advanced, metastatic)

Figure 35 Risk factors for venous thromboembolism in patients with cancer. ATE, arterial thromboembolism; BMI, body mass index; CrCl, creatinine clearance; IMiD, immunomodulatory drugs; PI, proteasome inhibitors; VTE, venous thromboembolism. aAcute infection, chronic kidney disease (CrCl , 45 mL/min), pulmonary disease, obesity (BMI ≥30 kg/m2), ATE. bFactor V Leiden, prothrombin gene mutation. cChemotherapy (carboplatin, cyclophosphamide, anthracyclines, antimetabolites, irinotecan, taxanes, tasonermin), anti-angiogenic agents (bevacizumab, axitinib, lenvatinib, pazopanib, sorafenib, sunitinib), IMiD (thalidomide, lenalidomide), PI (carfilzomib), hormonal therapy, erythropoiesis-stimulating agents. Downloaded from academic.oup.com/eurheartj/article/43/41/4229/6673995 by guest on 07 October 2026