Primary prophylaxis and treatment of venous thromboembolism in malignancy with focus on lung cancer: a review of current evidence

PURPOSE OF REVIEW: Cancer-associated thrombosis (CAT) is a significant cause of mortality in oncology, particularly in lung cancer. The clinical management requires a careful balance between preventing venous thromboembolism (VTE) and minimizing bleeding risks. The aim of this review is to provide the latest evidenced based-approach for primary and secondary prevention of CAT. RECENT FINDINGS: Results from randomized clinical trials, such as TARGET-TP, CASSINI, and AVERT demonstrated that low-molecular-weight heparin (LMWH) and direct oral anticoagulants (DOACs) reduce VTE incidence in high-risk ambulatory patients (Khorana score ≥2). Lung-cancer-specific data from FRAGMATIC showed that although VTE risk is halved, there is no overall survival benefit, and routine prophylaxis is not recommended for unselected patients, which aligns with current guidelines. For VTE treatment, randomized trials including CARAVAGGIO, SELECT-D, and ADAM VTE showed that DOACs are non-inferior to LMWH with similar major bleeding rates, although some DOACs increase non-major gastrointestinal or genitourinary bleeding. Invasive approaches such as mechanical thrombectomy and catheter-directed thrombolysis remain reserved for life-threatening presentations. SUMMARY: Pharmacotherapy for prevention of CAT in lung cancer must be individualized. DOACs have emerged as a practical and effective alternative to LMWH for both primary and secondary VTE prophylaxis after assessing risk-benefit.