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 their quality of life, survival, and health care costs. This review summarizes key recommendations from the 2023 European Society for Medical Oncology guidelines on CAT prevention and treatment, illustrated by a real‑world case, and examines barriers to their 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 (eg, D‑dimer, thrombin generation, coagulome genes) and oncogenic mutations may refine risk stratification. The 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 6 months, with regular reassessment of risk thereafter. Treatment of CAT favors low‑molecular‑weight heparin or oral direct FXa inhibitors (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) as a safer long‑term treatment. Screening for antiphospholipid antibodies guides therapeutic strategies. Major challenges for optimization of the antithrombotic treatment include renal impairment, thrombocytopenia, and treatment adherence. Oral direct FXa inhibitors may improve quality of life. Effective CAT management requires individualized care, strong clinician-patient communication, and education. The guideline implementation remains suboptimal. Closing the gap demands national strategies promoting health‑provider training, patient empowerment, e‑health applications, equitable access, and dedicated CAT outpatient clinics for sustained, personalized care.