Real life application of the ESMO Guidelines for the prevention and treatment of cancer associated thrombosis: challenges and perspectives

Cancer-associated thrombosis (CAT) is the second leading cause of death in cancer patients, significantly affecting quality of life, survival, and healthcare costs. This review summarizes key recommendations from the 2023 ESMO guidelines on CAT prevention and treatment, illustrated by a real-world case, and examines barriers to implementation. CAT risk is multifactorial, shaped by tumor-related factors (type, stage, time since diagnosis), treatment exposures (anticancer agents, surgery, central venous catheters), and comorbidities, captured by the "4TS" rule. Emerging biomarkers (e.g., D-dimer, thrombin generation, coagulome genes) and oncogenic mutations may refine risk stratification. Guidelines recommend routine assessment using models such as the Khorana Score, COMPASS-CAT, or Vienna-CATS, with COMPASS-CAT demonstrating superior predictive accuracy for patients with breast, lung ovarian or colon cancer. For high-risk ambulatory patients, thromboprophylaxis is recommended for up to six months, with regular reassessment of risk thereafter. Treatment of CAT favors low-molecular-weight heparin or direct oral anti-Xa agents (apixaban, edoxaban, rivaroxaban), with incidental venous thromboembolism managed similarly to symptomatic events. The API-CAT study supports low-dose apixaban (2.5 mg twice a day[BID]) as a safer long-term treatment. Screening for antiphospholipid antibodies guides therapeutic strategy. Major challenges for optimization of the antithrombotic treatment include renal impairment, thrombocytopenia, and treatment adherence. Oral anti-Xa agents may improve quality of life. Effective CAT management requires individualized care, strong clinician-patient communication, and education. Implementation remains suboptimal. Closing the gap demands national strategies promoting health-provider training, patient empowerment, e-health applications, equitable access, and dedicated CAT out-patients clinics for sustained, personalized care.