Advancing thromboprophylaxis in ambulatory high-risk cancer patients: addressing challenges and new insights from the TARGET-TP trial

Venous thromboembolism (VTE) remains a significant concern in cancer patients, contributing to increased morbidity and mortality, as well as additional healthcare burdens. While advances in cancer treatment have expanded survival rates, they have also been associated with an elevated risk of VTE, complicating the clinical landscape. This article explores the challenges posed by cancer-associated thromboembolism (CAT) management, particularly the dilemma of administering anticoagulation therapy in cancer patients with a heightened bleeding risk. Numerous clinical trials have demonstrated the efficacy of thromboprophylaxis in reducing symptomatic VTE in ambulatory cancer patients receiving chemotherapy. However, the lack of a universally accepted risk-stratification model in clinical practice has hindered its routine adoption. Among the existing models, the Khorana score is commonly used but is not definitively superior to others. Moreover, concerns over the absence of substantial survival benefits, metastasis-free survival differences, and the potential for increased bleeding risk have deterred the routine use of thromboprophylaxis in this population. Recent insights from the TARGET-TP trial, which employed a biomarker-driven risk assessment model based on fibrinogen and D-dimer levels, challenge these concerns. The trial demonstrated improved 6-month mortality rates without an associated increase in bleeding risk in high-risk ambulatory cancer patients. However, the trial's limited inclusion of lung and GI cancer patients necessitates further investigation to establish broader applicability. This article underscores the need for refined risk assessment models, evaluates the implications of the TARGET-TP trial's findings, and discusses the evolving landscape of thromboprophylaxis in ambulatory high-risk cancer patients.