Prevention of venous thromboembolism in the cancer surgery patient

April 1, 2008|Cleveland Clinic Journal of Medicine

Alex C. Spyropoulos, MD;Daniel J. Brotman, MD;Alpesh N. Amin, MD, MBA;Steven B. Deitelzweig, MD;Amir K. Jaffer, MD;Sylvia C. McKean, MD

Alex C. Spyropoulos, MD
Chair, Clinical Thrombosis Center, Lovelace Medical Center; Clinical Associate Professor of Medicine/Associate Professor of Pharmacy, University of New Mexico Health Sciences Center/College of Pharmacy, Albuquerque, NM

Daniel J. Brotman, MD
Director, Hospitalist Program; Associate Professor of Medicine, Johns Hopkins Hospital, Baltimore, MD

Alpesh N. Amin, MD, MBA
Professor and Chief, Division of General Internal Medicine; Executive Director, Hospitalist Program; Vice Chair for Clinical Affairs & Quality, Department of Medicine, University of California, Irvine, Irvine, CA

Steven B. Deitelzweig, MD
Vice President of Medical Affairs; Chairman, Department of Hospital Medicine, Ochsner Health System, New Orleans, LA

Amir K. Jaffer, MD
Associate Professor of Medicine; Chief, Division of Hospital Medicine, Department of Medicine, Leonard M. Miller School of Medicine, University of Miami, Miami, FL

Sylvia C. McKean, MD
Medical Director, BWH/Faulkner Hospitalist Service; Associate Professor of Medicine, Harvard Medical School and Brigham and Women’s Hospital, Boston, MA

Correspondence: Alex C. Spyropoulos, MD, Chair, Clinical Thrombosis Center, Lovelace Medical Center, 500 Walter Street NE, Suite 301, Albuquerque, NM 87108; alex.spyropoulos@lovelace.com

Dr. Spyropoulos reported that he has received consulting fees from Sanofi-Aventis, Eisai, and Boehringer Ingelheim.

Dr. Brotman reported that he has no financial relationships with commercial interests that are relevant to this article.

Dr. Amin reported that he has received research funding and honoraria for speaking from Sanofi-Aventis, Eisai, and GlaxoSmithKline.

Drs. Deitelzweig and McKean each reported that they have received honoraria for teaching/speaking from Sanofi-Aventis.

Dr. Jaffer reported that he has received consulting fees and honoraria for teaching/speaking from Sanofi-Aventis, consulting fees and research grant support from AstraZeneca, and consulting fees from Roche Diagnostics and Boehringer Ingelheim; he also serves on the governing board of the Society for Perioperative Assessment and Quality Improvement (SPAQI) and the board of directors of the Anticoagulation Forum.

Each author received an honorarium for participating in the roundtable that formed the basis of this supplement. The honoraria were paid by the Cleveland Clinic Center for Continuing Education from the educational grant from Sanofi-Aventis underwriting this supplement. Sanofi-Aventis had no input on the content of the roundtable or this supplement.

ABSTRACT

Cancer patients, especially those undergoing surgery for cancer, are at extremely high risk for developing venous thromboembolism (VTE), even with appropriate thromboprophylaxis. Anticoagulant prophylaxis in cancer surgery patients has reduced the incidence of VTE events by approximately one-half in placebo-controlled trials, and extended prophylaxis (for up to 1 month) has also significantly reduced out-of-hospital VTE events in clinical trials in this population. Clinical trials show no difference between low-molecular-weight heparin (LMWH) and unfractionated heparin in VTE prophylaxis efficacy or bleeding risk in this population, although the incidence of heparin-induced thrombocytopenia is lower with LMWH. The risk-benefit profile of low-dose anticoagulant prophylaxis appears to be favorable even in many cancer patients undergoing neurosurgery, for whom pharmacologic VTE prophylaxis has been controversial because of bleeding risks.

GUIDELINES FOR VTE PROPHYLAXIS IN THE CANCER SURGERY PATIENT

American College of Chest Physicians

The American College of Chest Physicians’ Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy makes a number of recommendations regarding VTE prevention in patients undergoing surgery for cancer, as outlined in Table 3.³⁴

National Comprehensive Cancer Network

The National Comprehensive Cancer Network (NCCN) recently published clinical practice guidelines on venous thromboembolic disease in cancer patients.³⁵ The defined at-risk population for these guidelines is the adult cancer inpatient with a diagnosis of (or clinical suspicion for) cancer. The guidelines recommend prophylactic anticoagulation (category 1 recommendation) with or without a sequential compression device as initial prophylaxis, unless the patient has a relative contraindication to anticoagulation, in which case mechanical prophylaxis (sequential compression device or graduated compression stockings) is recommended. (A category 1 recommendation indicates “uniform NCCN consensus, based on high-level evidence.”)

The NCCN guidelines include a specific recommended risk-factor assessment, which includes noting the patient’s age (VTE risk increases beginning at age 40 and then steeply again at age 75), any prior VTE, the presence of familial thrombophilia or active cancer, the use of medications associated with increased VTE risk (chemotherapy, exogenous estrogen compounds, and thalidomide or lenalidomide), and a number of other risk factors for VTE as outlined in the prior two articles in this supplement. The NCCN guidelines explicitly call for assessment of modifiable risk factors for VTE (ie, smoking or other tobacco use, obesity, and a low level of activity or lack of exercise) and call for active patient education on these factors.

American Society of Clinical Oncology

The American Society of Clinical Oncology (ASCO) recently released guidelines on VTE prevention and treatment in patients with cancer;¹ their key recommendations for prevention are summarized in Table 4. Notable differences from the recommendations of the Seventh ACCP Conference are the ASCO guidelines’ inclusion of fondaparinux among recommended prophylactic options for this population and more explicit recommendations on the prophylactic use of LMWH. Also, for treatment of cancer patients with established VTE, ASCO specifies that LMWH is the preferred anticoagulant for both initial and continuing treatment.

Our recommended algorithm

Figure 1. Algorithm for VTE prophylaxis in the patient undergoing major surgery for cancer.

Drawing from the above formal society guidelines and the published literature, we recommend the algorithm in Figure 1 as a practical approach to VTE prevention in patients undergoing major surgery for cancer.

LINGERING CHALLENGE OF UNDERUTILIZATION

Despite this consensus on ways to reduce thromboembolic risk in this population and the clear evidence of the benefit of VTE prophylaxis in patients with cancer, data from several registries confirm a persistently low utilization of prophylaxis in patients with cancer.^36–38 The global Fundamental Research in Oncology and Thrombosis (FRONTLINE) study surveyed 3,891 clinicians who treat cancer patients regarding their practices with respect to VTE in those patients.36 The survey found that only 52% of respondents routinely used thromboprophylaxis for their surgical patients with cancer. More striking, however, was the finding that most respondents routinely considered thrombo-prophylaxis in only 5% of their medical oncology patients. These data are echoed by findings of other retrospective medical record reviews in patients undergoing major abdominal or abdominothoracic surgery (in many cases for cancer), with VTE prophylaxis rates ranging from 38% to 75%.^37,38

SUMMARY

Patients undergoing surgery for cancer have an increased risk of VTE and fatal PE, even when thromboprophylaxis is used. Nevertheless, prophylaxis with either LMWH or UFH does reduce venographic VTE event rates in these patients. If UFH is chosen for prophylaxis, a three-times-daily regimen should be used in this population. In specific surgical cancer populations, especially those undergoing abdominal surgery, out-of-hospital prophylaxis with once-daily LMWH is warranted. Current registries reveal that compliance with established guidelines for VTE prophylaxis in this population is low.

References

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