Pattern of frequent but nontargeted pharmacologic thromboprophylaxis for hospitalized patients with cancer at academic medical centers: a prospective, cross-sectional, multicenter study

Gynecological Cancer and Venous Thromboembolism: A Narrative Review to Increase Awareness and Improve Risk Assessment and Prevention

The prevention and appropriate management of venous thromboembolism in cancer patients is of paramount importance. However, the literature data report an underestimation of this major problem in patients with gynecological cancers, with an inconsistent venous thromboembolism risk assessment and prophylaxis in this patient setting. This narrative review provides a comprehensive overview of the available evidence regarding the management of venous thromboembolism in cancer patients, focusing on the specific context of gynecological tumors, exploring the literature discussing risk factors, risk assessment, and pharmacological prophylaxis. We found that the current understanding and management of venous thromboembolism in gynecological malignancy is largely based on studies on solid cancers in general. Hence, further, larger, and well-designed research in this area is needed.

Room for Improvement: The Impact of Guideline-Recommended Extended Thromboprophylaxis in Patients Undergoing Abdominal Surgery for Colorectal and Anal Cancer at a Tertiary Referral Center

BACKGROUND

Venous thromboembolism occurs in approximately 2% of patients undergoing abdominal and pelvic surgery for cancers of the colon, rectum, and anus and is considered preventable. The American Society of Colon and Rectal Surgeons recommends extended prophylaxis in high-risk patients, but there is low adherence to the guidelines.

OBJECTIVE

This study aims to analyze the impact of venous thromboembolism risk-guided prophylaxis in patients undergoing elective abdominal and pelvic surgeries for colorectal and anal cancers from 2016 to 2021.

DESIGN

This was a retrospective analysis.

SETTING

The study was conducted at a multisite tertiary referral academic health care system.

PATIENTS

Patients who underwent elective abdominal or pelvic surgery for colon, rectal, or anal cancer.

MAIN OUTCOME MEASURES

Receipt of Caprini-guided venous thromboembolism prophylaxis, 90-day postoperative rate of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and bleeding events.

RESULTS

A total of 3504 patients underwent elective operations, of whom 2224 (63%) received appropriate thromboprophylaxis in the inpatient setting. In the postdischarged cohort of 2769 patients, only 2% received appropriate thromboprophylaxis and no thromboembolic events were observed. In the group receiving inappropriate thromboprophylaxis, at 90 days postdischarge, the deep vein thrombosis, pulmonary embolism, and venous thromboembolism rates were 0.60%, 0.40%, and 0.88%, respectively. Postoperative bleeding was not different between the 2 groups.

LIMITATIONS

Limitations to our study include its retrospective nature, use of aggregated electronic medical records, and single health care system experience.

CONCLUSION

Most patients in our health care system undergoing abdominal or pelvic surgery for cancers of the colon, rectum, and anus were discharged without appropriate Caprini-guided venous thromboembolism prophylaxis. Risk-guided prophylaxis was associated with decreased rates of inhospital and postdischarge venous thromboembolism without increased bleeding complications. See Video Abstract .

MARGEN DE MEJORA EL IMPACTO DE LA TROMBOPROFILAXIS RECOMENDADA POR LAS DIRECTRICES EN PACIENTES SOMETIDOS A CIRUGA ABDOMINAL POR CNCER COLORRECTAL Y ANAL EN UN CENTRO DE REFERENCIA TERCIARIO

ANTECEDENTES:El tromboembolismo venoso ocurre en aproximadamente el 2% de los pacientes sometidos a cirugía abdominal y pélvica por cánceres de colon, recto y ano, y se considera prevenible. La Sociedad Estadounidense de Cirujanos de Colon y Recto recomienda una profilaxis prolongada en pacientes de alto riesgo, pero el cumplimiento de las directrices es bajo.OBJETIVO:Este estudio tiene como objetivo analizar el impacto de la profilaxis guiada por el riesgo de tromboembolismo venoso (TEV) en pacientes sometidos a cirugías abdominales y pélvicas electivas por cáncer colorrectal y anal entre 2016 y 2021.DISEÑO:Este fue un análisis retrospectivo.AJUSTE:El estudio se llevó a cabo en un sistema de salud académico de referencia terciaria de múltiples sitios.PACIENTES:Pacientes sometidos a cirugía abdominal o pélvica electiva por cáncer de colon, recto o ano.PRINCIPALES MEDIDAS DE RESULTADO:Recepción de profilaxis de tromboembolismo venoso guiada por Caprini, tasa postoperatoria de 90 días de trombosis venosa profunda, embolia pulmonar, tromboembolismo venoso y eventos de sangrado.RESULTADOS:Un total de 3.504 pacientes se sometieron a operaciones electivas, de los cuales 2.224 (63%) recibieron tromboprofilaxis adecuada en el ámbito hospitalario. En el cohorte de 2.769 pacientes después del alta, solo el 2% recibió tromboprofilaxis adecuada en la que no se observaron eventos tromboembólicos. En el grupo que recibió tromboprofilaxis inadecuada, a los 90 días después del alta, las tasas de trombosis venosa profunda, embolia pulmonar y tromboembolia venosa fueron del 0,60%, 0,40% y 0,88%, respectivamente. El sangrado posoperatorio no fue diferente entre los dos grupos.LIMITACIONES:Las limitaciones de nuestro estudio incluyen su naturaleza retrospectiva, el uso de registros médicos electrónicos agregados y la experiencia de un solo sistema de atención médica.CONCLUSIÓN:La mayoría de los pacientes en nuestro sistema de salud sometidos a cirugía abdominal o pélvica por cánceres de colon, recto y ano fueron dados de alta sin una profilaxis adecuada de TEV guiada por Caprini. La profilaxis guiada por el riesgo se asoció con menores tasas de tromboembolismo venoso hospitalario y dado de alta sin un aumento de las complicaciones de sangrado. (Traducción-Dr. Aurian Garcia Gonzalez ).

The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study

Background  Cancer is a well-known risk factor of preventable thromboembolic disease. This study aims to provide guidance on the prevention and management of cancer-associated thrombosis (CT) that tailors prophylactic and therapeutic options for medical and surgical oncology patients presenting to health care settings in Saudi Arabia. Methods  The present consensus was developed in concordance with the modified Delphi-based approach, which incorporates a face-to-face meeting between two voting rounds to gain experts' feedback on the proposed statements. All experts were either oncologists, hematologists, or hemato-oncologist with an active clinical and research profile in hemato-oncology. Results  The experts highlighted that the comparatively high incidence of inherited thrombophilia among the Saudi population may account for a higher CT burden in the Kingdom than in other parts of the world. However, due to the lack of literature that assesses CT in Saudi Arabia, primary venous thromboembolism prophylaxis should be tailored according to a valid risk assessment of cancer patients and should be implemented in routine practice. For hospitalized medical oncology patients, the experts agreed that prophylaxis with low-molecular-weight heparin (LMWH) should be offered, regardless of the presence of acute illness. For ambulatory medical oncology patients, LMWH or direct oral anticoagulants (DOACs) prophylaxis should be offered for high-risk patients. Concerning surgical patients, they agreed that all oncology patients undergoing surgery should be offered thromboprophylaxis. In terms of secondary prophylaxis, the experts recommended continuing a prophylactic dose of anticoagulant (LMWH or DOAC), for an appropriate period depending on the cancer type and stage. Finally, they also provided a set of statements on management of CT in Saudi Arabia. Conclusion  The present modified Delphi-based study combined the best available evidence and clinical experience with the current health care policies and settings in Saudi Arabia to build a consensus statement on the epidemiology, prevention, and management of CT.

An update on the global use of risk assessment models and thromboprophylaxis in hospitalized patients with medical illnesses from the World Thrombosis Day steering committee: Systematic review and meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) is a leading cause of cardiovascular morbidity and mortality. The majority of VTE events are hospital-associated. In 2008, the Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting (ENDORSE) multinational cross-sectional study reported that only approximately 40% of medical patients at risk of VTE received adequate thromboprophylaxis.

METHODS

In our systematic review and meta-analysis, we aimed at providing updated figures concerning the use of thromboprophylaxis globally. We focused on: (a) the frequency of patients with an indication to thromboprophylaxis according with individual models; (b) the use of adequate thromboprophylaxis; and (c) reported contraindications to thromboprophylaxis. Observational nonrandomized studies or surveys focusing on medically ill patients were considered eligible.

RESULTS

After screening, we included 27 studies from 20 countries for a total of 137 288 patients. Overall, 50.5% (95% confidence interval [CI]: 41.9-59.1, I2 99%) of patients had an indication to thromboprophylaxis: of these, 54.5% (95% CI: 46.2-62.6, I2 99%) received adequate thromboprophylaxis. The use of adequate thromboprophylaxis was 66.8% in Europe (95% CI: 50.7-81.1, I2 98%), 44.9% in Africa (95% CI: 31.8-58.4, I2 96%), 37.6% in Asia (95% CI: 25.7-50.3, I2 97%), 58.3% in South America (95% CI: 31.1-83.1, I2 99%), and 68.6% in North America (95% CI: 64.9-72.6, I2 96%). No major differences in adequate thromboprophylaxis use were found across risk assessment models. Bleeding, thrombocytopenia, and renal/hepatic failure were the most frequently reported contraindications to thromboprophylaxis.

CONCLUSIONS

The use of anticoagulants for VTE prevention has been proven effective and safe, but thromboprophylaxis prescriptions are still unsatisfactory among hospitalized medically ill patients around the globe with marked geographical differences.

Prediction and Prevention of Cancer-Associated Thromboembolism

Venous and arterial thromboembolism are prevalent, highly burdensome, and associated with risk of worse outcomes for patients with cancer. Risk for venous thromboembolism (VTE) varies widely across specific cancer subpopulations. The ability to predict risk of cancer-associated VTE is critical because an optimal thromboprophylaxis strategy is best achieved by targeting high-risk patients with cancer and avoiding prophylaxis in patients with cancer at low risk for VTE. A validated risk tool for solid tumors has been available for a decade. Newer tools have focused on specific populations, such as patients with multiple myeloma. Emerging studies continue to optimize risk prediction approaches in patients with cancer. Recent randomized trials have specifically addressed risk-adapted thromboprophylaxis using direct oral anticoagulants, and revised guidelines have included these new data to formulate recommendations for outpatient thromboprophylaxis. Implementation science approaches to enhance use of outpatient prophylaxis in the context of these guideline changes are under way. However, major knowledge gaps remain, including a lack of data for inpatient thromboprophylaxis in the cancer setting and a lack of formal tools for identifying risk of bleeding. This review describes optimal approaches to risk prediction and patient selection for primary pharmacologic thromboprophylaxis of cancer-associated VTE, addresses barriers to implementing these practices, and highlights strategies to overcome them. IMPLICATIONS FOR PRACTICE: Risk for venous thromboembolism (VTE) varies widely among patients with cancer. Individual risk can be determined using validated approaches. Inpatient and postsurgical thromboprophylaxis is more widely accepted. However, most patients with cancer develop VTE in the outpatient setting. Recent randomized trials have demonstrated benefit to risk-adapted outpatient thromboprophylaxis. High-risk patients may therefore be considered for outpatient thromboprophylaxis as recommended by recently updated guidelines. System-wide implementation approaches are necessary to improve compliance with prophylaxis.

Cancer associated thrombosis and mortality in patients with cancer stratified by khorana score risk levels

BACKGROUND

The Khorana score (KS) clinical algorithm is used to predict VTE risk in cancer patients. The study objective was to evaluate VTE and survival rates among patients newly diagnosed with cancer and stratified by KS in a real-world population.

METHODS

Data from the Optum® Clinformatics® DataMart database between 01/01/2012-09/30/2017 was used to identify adults with ≥ 1 hospitalization or ≥ 2 outpatient claims with a cancer diagnosis (index date). Only patients who were initiated on chemotherapy or radiation therapy were included. Patients were classified based on KS (KS = 0, 1, 2 or ≥ 3). Time-to-first VTE and survival were evaluated from the index date to the earliest among end of data availability or insurance coverage, death, or 12 months post-index using Kaplan-Meier (KM) analyses.

RESULTS

A total of 2,488 (KS = 0); 2,125 (KS = 1), 1,074 (KS = 2), and 507 (KS ≥ 3) cancer patients were included. The 12-month KM rates of VTE were 3.1%, 5.4%, 7.9%, and 14.9% (associated median time to VTE of 2.7, 3.0, 1.4, and 1.7 months) among KS = 0, 1, 2, and ≥ 3 cohorts, respectively. Corresponding adjusted hazard ratios (95% CIs) relative to the KS = 0 cohort were 1.72 (1.25-2.38), 2.46 (1.73-3.50), and 4.99 (3.40-7.31) for the KS = 1, 2, and ≥ 3 cohorts, respectively (all P < .001). Regardless of KS, patients with VTE had significantly lower survival rates than those without.

CONCLUSIONS

This real-world claims-based cohort study of newly diagnosed cancer patients showed significantly higher rates of VTE with increased KS, confirming its predictive ability. Moreover, VTE was associated with lower survival rates within each KS cohort.

Progress in the study of cancer-associated venous thromboembolism

OBJECTIVE

Venous thromboembolism is a major cause of morbidity, mortality, and increased medical costs in tumor patients. In the current review, we summarize the progress made in the study of cancer-associated venous thromboembolism.

METHODS

By searching cancer-associated venous thromboembolism-related literature on PubMed, the epidemiology, pathological mechanisms, risk factors, risk prediction models, and prevention and treatment of cancer-associated venous thromboembolism were reviewed.

RESULTS

The pathophysiological mechanisms of cancer-associated venous thromboembolism are multifactorial. Various blood cell counts (such as platelets and white blood cells) and biomarkers (such as D-dimer and sP-selectin) were considered predictors of thrombosis in cancer patients and were incorporated into the venous thromboembolism risk stratification models. Thromboprophylaxis is currently recommended for all hospitalized cancer patients. In addition, outpatient thromboprophylaxis can be used for selected high-risk patients. Low-molecular-weight heparin was the preferred treatment for cancer-associated venous thromboembolism, but some issues arose in the long-term treatment. In this case, direct oral anticoagulants were a treatment option for tumor patients. The efficacy of direct oral anticoagulant in treating cancer patients is not inferior to low-molecular-weight heparin, but is associated with a higher risk of bleeding. Therefore, there were concerns regarding their safety.

CONCLUSION

Since thrombocytopenia, thrombosis recurrence, and bleeding are common in tumor patients, the selection of anticoagulants in this circumstance is a considerable challenge for clinicians.

Inpatient prophylaxis in cancer patients: where is the evidence?

Venous thromboembolism (VTE) is a leading cause of preventable in-hospital mortality. Cancer is associated with an increased risk of VTE which is further compounded by acute hospitalization for medical illness. The absolute incidence of VTE of hospitalized cancer patients ranges between 2% and 17% but the rates vary considerably depending on the type of study, method of VTE surveillance and whether pharmacologic thromboprophylaxis is administered. Complicating the interpretation of thromboprophylaxis trials is the paucity of reported data on the relative benefit of thromboprophylaxis relative to an increased risk of hemorrhage inherent to cancer patients. Efforts over the last decade have improved the rates of adherence to in-hospital pharmacologic thromboprophylaxis regimens. Whether these efforts also improve outcomes continues to be debated. In this review, the prevalence of VTE and hemorrhage in hospitalized cancer patients is presented in the context of pharmacologic thromboprophylaxis data along with a discussion of emerging approaches towards VTE risk-adapted prescription of antithrombotics during hospitalization.

Call to Action to Prevent Venous Thromboembolism in Hospitalized Patients: A Policy Statement From the American Heart Association

Venous thromboembolism (VTE) is a major preventable disease that affects hospitalized inpatients. Risk stratification and prophylactic measures have good evidence supporting their use, but multiple reasons exist that prevent full adoption, compliance, and efficacy that may underlie the persistence of VTE over the past several decades. This policy statement provides a focused review of VTE, risk scoring systems, prophylaxis, and tracking methods. From this summary, 5 major areas of policy guidance are presented that the American Heart Association believes will lead to better implementation, tracking, and prevention of VTE events. They include performing VTE risk assessment and reporting the level of VTE risk in all hospitalized patients, integrating preventable VTE as a benchmark for hospital comparison and pay-for-performance programs, supporting appropriations to improve public awareness of VTE, tracking VTE nationwide with the use of standardized definitions, and developing a centralized data steward for data tracking on VTE risk assessment, prophylaxis, and rates.

Incidence of Venous Thromboembolism in Patients With Newly Diagnosed Pancreatic Cancer and Factors Associated With Outcomes

BACKGROUND & AIMS

Pancreatic ductal adenocarcinoma (PDAC) is associated with the highest incidence of venous thromboembolism (VTE) of any cancer type. However, little is known about risk factors for VTE or its outcomes in patients with PDAC.

METHODS

We collected data from a prospective, observational study performed at multiple centers in France from May 2014 through November 2018 (the Base Clinico-Biologique de l'Adénocarcinome Pancréatique [BACAP] study) linked to a database of patients with a new diagnosis of PDAC of any stage. Data were collected from 731 patients at baseline and during clinical follow-up or in the event of symptoms. The primary endpoint was the onset of VTE during follow-up. The secondary endpoints were progression-free survival (PFS) and overall survival (OS) times.

RESULTS

During a median follow-up of 19.3 months, 152 patients (20.79%) developed a VTE. The median time from PDAC diagnosis to the onset of VTE was 4.49 months. Cumulative incidence values of VTE were 8.07% (95% confidence interval [CI], 6.31-10.29) at 3 months and 19.21% (95% CI, 16.27-22.62) at 12 months. In multivariate analysis, PDAC primary tumor location (isthmus vs head: hazard ratio [HR], 2.06; 95% CI, 1.09-3.91; P = .027) and stage (locally advanced vs resectable or borderline: HR, 1.66; 95% CI, 1.10-2.51, P = .016; metastatic vs resectable or borderline: HR, 2.50; 95% CI, 1.64-3.79; P < .001) were independent risk factors for the onset of VTE. Patients who developed VTE during follow-up had shorter times of PFS (HR, 1.74; 95% CI, 1.19-2.54; P = .004) and OS (HR, 2.02; 95% CI, 1.57-2.60; P < .001).

CONCLUSION

In an analysis of data from the BACAP study, we found that frequent and early onsets of VTE after diagnoses of PDAC are associated with significant decreases in times of PFS and OS. Studies are needed to determine whether primary prophylaxis of VTE in patients with PDAC will improve morbidity and mortality related to VTE. (ClinicalTrials.gov, Number: clinicaltrials.gov as number NCT02818829).

Thromboprophylaxis for inpatients with advanced cancer in palliative care settings: A systematic review and narrative synthesis

BACKGROUND

Patients with advanced cancer have an elevated risk of venous thromboembolism. Increasingly, patients are admitted to palliative care settings for brief admissions, with greater numbers of discharges (vs deaths) reported internationally. There is limited guidance around the use of thromboprophylaxis or incidence of venous thromboembolism for these patients.

AIM

The aim of this study was to review the use of thromboprophylaxis as well as incidence of venous thromboembolism and bleeding in palliative care units or residential hospices for patients with advanced cancer.

DESIGN

A systematic review using Cochrane methods.

DATA SOURCES

Medline, Embase and the Cochrane Library were searched up to 28 September 2018 along with a grey literature search; the reference lists of selected papers were hand-searched. Inclusion criteria were original papers assessing thromboprophylaxis use in palliative care units or residential hospices for adult inpatients with cancer. Two reviewers independently selected and appraised papers using a tool designed for disparate data. Heterogeneity in study design made a meta-analysis not possible.

RESULTS

A total of 11 full-text papers (9 quantitative and 2 qualitative) and 11 abstracts were included. Thromboprophylaxis use ranged between 4% and 53%; venous thromboembolism rates between 0.5% and 20%; and bleeding incidence was between 0.01% and 9.8%. Risk assessment tools were used infrequently and adherence to international thromboprophylaxis guidelines ranged between 5% and 71%. Physician opinions differed around the use of thromboprophylaxis; patients were largely accepting of thromboprophylaxis if it was offered.

CONCLUSION

There is limited evidence around the optimal use of thromboprophylaxis for patients with advanced cancer admitted to palliative care settings. Although some patients may derive benefit, further research in this area is warranted.

Improvement of appropriate pharmacological prophylaxis in hospitalised cancer patients with a multiscreen e-alert system: a single-centre experience

PURPOSE

Thromboprophylaxis use among medical inpatients, including cancer patients, is suboptimal. We aimed to evaluate the impact of a novel multiscreen version (v2.0) of an e-alert system for VTE prevention in hospitalised cancer medical patients compared to the original software.

METHODS

Prospective study including 989 consecutive adult cancer patients with high-risk of VTE. Patients were followed-up 30 days post-discharge. Two periods were defined, according to the operative software.

RESULTS

E-alert v2.0 was associated with an increase in the use of LMWH prophylaxis (65.5% vs. 72.0%); risk difference (95% CI) 0.064 (0.0043-0.12). Only 16% of patients in whom LMWH prophylaxis was not prescribed lacked a contraindication. No significant differences in the rates of VTE (2.9% vs. 3.2%) and major bleeding (2.7% vs. 4.0%) were observed.

CONCLUSIONS

E-alert v2.0 further increased the use of appropriate thromboprophylaxis in hospitalised cancer patients, although was not associated with a reduction in VTE incidence.

Incidence and predictors of venous thromboembolism in medically ill hospitalized elderly cancer patients: a prospective observational study

PURPOSE

The aim of this study was to estimate the incidence and predictors of venous thromboembolism (VTE) in medically ill hospitalized elderly cancer patients in a single Korean tertiary hospital.

METHODS

Patients were examined for deep vein thrombosis (DVT) by duplex and color Doppler ultrasonography (DUS) of both legs between days 5 and 14 of their hospital stays. The primary endpoint was the incidence of VTE by day 14, which was determined via a composite of DVT detected by routine DUS and symptomatic VTE.

RESULTS

A total of 140 patients with 31 hematologic and 109 nonhematologic malignancies were analyzed. The median age was 73 years, and 45.7% of the patients were female. The median length of hospital stay was 12 days. The modified Padua prediction score (PPS) ≥ 4 was 92.9%. The incidence of VTE by day 14 was 7.1%, including six proximal and four distal DVT cases. Being female, having a length of hospital stay of ≥ 13 days, and having a modified Padua prediction score of ≥ 6 were risk factors of VTE in univariate analysis. The incidence of VTE was 2.3%, 7.3%, and 41.7% in patients with 0-1, 2, and 3 of these risk factors, respectively.

CONCLUSION

The incidence of VTE in medically ill hospitalized elderly cancer patients was lower in Korean patients than in Western patients. However, the risk of VTE in those with more than two risk factors (female, long length of hospitalization, and high PPS) increased considerably, and pharmacologic thromboprophylaxis is warranted in these cases.

Insights into venous thromboembolism prevention in hospitalized cancer patients: Lessons from a prospective study

Hospitalized cancer patients are at high risk of venous thromboembolism (VTE). Despite current recommendations in clinical guidelines, thromboprophylaxis with low molecular weight heparin (LMWH) is underused. We performed an observational prospective study to analyse factors influencing prophylaxis use, VTE events and mortality in cancer-hospitalized patients. 1072 consecutive adult cancer patients were included in an University Hospital from April 2014 to February 2017, and followed-up for 30 days after discharge. The rate of LMWH prophylaxis was 67.6% (95% confidence interval [CI] 64.7% to 70.4%), with a 2.8% rate of VTE events (95% CI 1.9% to 3.9%) and 3.5% rate of major bleeding events (95% CI 2.5% to 4.8%). 80% of VTE events occurred despite appropriate thromboprophylaxis. Overall, 30-day mortality rate was 13.2% (95% CI 11.2% to 15.3%). Active chemotherapy treatment, hospital stay ≥ 4 days, and metastatic disease were associated with a higher use of LMWH. On the contrary, patients with hematologic malignancies, anemia or thrombocytopenia were less prone to receive thromboprophylaxis. The main reasons for not prescribing LMWH prophylaxis were thrombocytopenia (23.9%) and active/recent bleeding (21.8%). The PRETEMED score, used for VTE risk stratification, correlated with 30-day mortality. There is room for improvement in thromboprophylaxis use among hospitalized-cancer patients, especially among those with hematologic malignancies. A relevant number of VTE events occurred despite prophylaxis with LMWH. Therefore, identification of risk factors for thromboprophylaxis failure is needed.

Bleeding and venous thromboembolic events in patients with active cancer hospitalized for an acute medical illness

BACKGROUND

Cancer patients hospitalized for an acute medical illness are considered to be at high risk of venous thromboembolism (VTE). Information on bleeding and symptomatic VTE in these patients remains scant. The objectives of this study were to evaluate the incidence of bleeding and VTE during hospitalization and after discharge in a prospective cohort of hospitalized medically-ill cancer patients.

METHODS

Consecutive patients with active cancer admitted for an acute medical illness. The primary outcome was the incidence of clinically relevant bleeding. Secondary outcomes included symptomatic and incidentally detected VTE. Outcomes were recorded during hospitalization up to three months after discharge.

RESULTS

The study population consisted of 330 patients with a mean age of 73.2 (±12.1) years. During a median hospitalization of eight days, six patients (1.8%) developed a clinically relevant bleeding. Pharmacological thromboprophylaxis was administered to four of these six patients (66.6%), and 108 of 324 (33.3%) patients without bleeding. Twelve (3.6%) were diagnosed with VTE, of whom two had received thromboprophylaxis. In ten patients, VTE was detected incidentally. After discharge, 11 patients experienced major bleeding and two developed symptomatic VTE during a median follow-up of 92 days (range 19-110). Two thirds of all major bleeding events were gastrointestinal, and 87% occurred in patients with gastrointestinal or genitourinary cancer.

CONCLUSIONS

In patients with active cancer admitted for an acute medical illness, the risk of bleeding and symptomatic VTE appeared to be low during hospitalization. After discharge, the risk of bleeding was higher and significantly outweighed that of VTE.

Advances in managing and preventing thromboembolic disease in cancer patients

PURPOSE OF REVIEW

To update on new data for low-molecular weight heparins (LMWHs) and the direct oral anticoagulants (DOACs) for the treatment and prevention of cancer-associated thrombosis (CAT), to discuss progress with the risk-adaptive management scores (RAMS) and update on increased dose primary thromboprophylaxis (IDPTP).

RECENT FINDINGS

In a pooled meta-analysis of 1132 cancer patients who received DOACs vs. vitamin K analogues (VKAs), recurrence of venous thromboembolism (VTE) was reduced from 6.0% on VKA schedules to 3.9% on DOACs. In a randomized trial of warfarin vs. once daily sc. tinzaparin (175 IU/kg), cumulative 6-month VTE incidence reduced from 10.5 to 7.2% [hazard ratio, 0.65 (95% confidence interval, 0.41-1.03); P = 0.07]. Despite early suggestions that DOACs may have a role in CAT, 3-6 months of LMWH remain the standard for initial treatment of CAT. A prospective comparison of RAMS found the Vienna CATS or the PROTECHT scores superior to the Khorana score but concluded that RAMS did not perform well enough to be used in the clinic. An efficacy scale of LMWHs in pancreatic cancer facilitates IDPTP. Practical implementation of IDPTP was needed to control the 40% VTE incidence of the HALO-109-202 study in metastatic pancreatic cancer.

SUMMARY

DOACs have some encouraging data, but LMWHs remain the standard for CAT treatment. RAMS generated to predict VTE occurrence or recurrence are still of unproven significance and IDPTP for advanced pancreatic cancer has tools and guidance for implementation.

A systematic review of mobility/immobility in thromboembolism risk assessment models for hospitalized patients

Hospitalized patients are at risk of venous thromboembolism (VTE) and prophylaxis is often suboptimal due to difficulty in identifying at-risk patients. Simple and validated risk-assessment models (RAMs) are available to assist clinicians in identifying patients who have a high risk for developing VTE. Despite the well-documented association of immobility with increased risk of thrombosis, immobility is not consistently defined in clinical studies. We conducted a systematic review of published VTE RAMs and used objective criteria to determine how the term immobility is defined in RAMs. We identified 17 RAMs with six being externally validated. The concept of immobility is vaguely described in different RAMs, impacting the validity of these models in clinical practice. The wide variability in defining mobility in RAMs precluded its accurate clinical application, further limiting generalization of published RAMs. Externally validated RAMs with clearly defined qualitative or quantitative terms of immobility are needed to assess VTE risk in real-time at the point-of-care.

Clinical practice guidelines for prophylaxis of venous thomboembolism in cancer patients

Symptomatic venous thromboembolism (VTE) occurs 4-7 times more frequently in cancer patients as compared to non-cancer patients. A significant number of risk factors, which can be subcategorised as patient-, cancer- or treatment-related, have been shown to influence the risk of VTE during malignancy and further incorporated in risk-assessment models. Safe and efficient thromboprophylaxis regimens allow substantial decreased in VTE rates, since VTE is most often a largely preventable disease, but thromboprophylaxis remains underused in cancer compared to non-cancer patients. If thromboprophylaxis is warranted in cancer patients undergoing surgery or hospitalised for acute medical illness or with a lower mobility in the absence of contraindications to anticoagulants, its benefit remains controversial in outpatients and may be limited to locally advanced or metastatic pancreatic or lung cancer treated with chemotherapy. The International Initiative on Thrombosis and Cancer-CME free mobile app (ios and android), based on the International Clinical Practice Guidelines (CPG), facilitates their implementation and dissemination of knowledge worldwide so as to improve VTE treatment and prophylaxis in cancer patients.

Venous thromboembolic events in lymphoma patients: Actual relationships between epidemiology, mechanisms, clinical profile and treatment

Venous thromboembolic events (VTE) are an underestimated health problem in patients with lymphoma. Many factors contribute to the pathogenesis of thromboembolism and the interplay between various mechanisms that provoke VTE is still poorly understood. The identification of parameters that are associated with an increased risk of VTE in lymphoma patients led to the creation of several risk-assessment models. The models that evaluate potential VTE risk in lymphoma patients in particular are quite limited, and have to be validated in larger study populations. Furthermore, the VTE prophylaxis in lymphoma patients is largely underused, despite the incidence of VTE. The lack of adequate guidelines for the prophylaxis and treatment of VTE in lymphoma patients, together with a cautious approach due to an increased risk of bleeding, demands great efforts to ensure the implementation of current knowledge in order to reduce the incidence and complications of VTE in lymphoma patients.

Identifying predictors for bleeding in hospitalized cancer patients: A cohort study

BACKGROUND

Bleeding and thrombosis are both major complications of hospitalization in cancer patients. Concern regarding bleeding risk may reduce compliance with thromboprophylaxis. We assessed incidence of major and clinically relevant non-major bleeding (MCRNMB) and identified risk factors associated with in-hospital bleeding risk in hospitalized cancer patients.

METHODS

We conducted a retrospective cohort study of consecutive adults admitted to general oncology floor at Cleveland Clinic from 11/2012-12/2014 (n=3525). Patients were excluded for bleeding on admission (n=108), age<18 (n=1), non-malignant disease (n=2) and incomplete data (n=56). Data collected included demographics, body mass index (BMI), cancer type, length of stay (LOS), use of anticoagulants and baseline laboratory values (+48h). Univariate risk factors were identified with logistic regression analysis. Multivariable risk factors were identified with stepwise logistic regression and confirmed with bootstrap analysis.

RESULTS

The study population comprised 3358 patients of whom 69 (2.1%) developed MCRNMB. Median age was 62 (range, 19-98) years and 56% male. Median length of stay was 5 (range, 0-152) days. The majority of bleeding events were either gastrointestinal (GI) (N=23, 33%) or retroperitoneal (N=10, 14%). In multivariable analysis, anemia as the reason for admission (7.78, 95% CI 4.0-15.1, P<0.001), GI cancer site (2.96, 95% CI 1.7-5.2 P<0.001), BMI≥40 (3.08, 95% CI 1.3-2.9, P=0.008) and thrombocytopenia (1.7, 95% CI 1.0-2.9, P=0.05) were predictive.

CONCLUSION

The incidence of MCRNMB in a population of hospitalized cancer patients was 2.1%. Risk factors at admission included type of cancer and morbid obesity. Improved prediction of bleeding risk can assist physicians in optimizing selection of thromboprophylaxis in this population that is also at increased risk of VTE.

Antithrombotic therapy for prophylaxis and treatment of venous thromboembolism in patients with cancer: review of the literature on current practice and emerging options

The treatment of cancer-associated venous thromboembolism (VTE) is difficult because cancer patients with VTE on anticoagulation are at an increased risk of bleeding compared with patients without VTE. This review summarises the evidence supporting the current standard of care and emerging treatment options. In difficult-to-treat subpopulations, where clinical data are often lacking, this review also provides the best clinical practice strategies based on the available data. The use of therapeutic doses of parenteral anticoagulants in patients with cancer-associated VTE for at least 3 to 6 months is supported by the current clinical data. After major cancer surgery, extended thromboprophylaxis for approximately 1 month following hospital discharge is also supported. In select populations of ambulatory cancer patients with solid tumours, or in patients with myeloma receiving immunomodulatory agents in combination with chemotherapy and/or corticosteroids, pharmacological prophylaxis could be considered. Although parenteral anticoagulants may not be tolerated by some patients, the data pertaining to the use of direct oral anticoagulants (DOACs) in cancer patients with VTE at this point can only be considered hypothesis generating. Clarity of the use of DOACs is awaiting the results of head-to-head trials between DOACs and parenteral anticoagulants. In addition, because of the lack of clinical trials, there are still unanswered questions on the optimal treatment regimens in subpopulations at increased risk of bleeding, including cancer patients with thrombocytopenia and those with brain metastases. For clinicians to balance the risk of recurrent thrombosis with the chance of bleeding, they need to assess the relevant clinical data. Current data support the use of parenteral anticoagulants in cancer patients with VTE, but many unanswered questions pertaining to the optimal regimens in special subpopulations and regarding the efficacy and safety of DOACs remain. To address this need, there are currently several clinical trials under way.

Predicting risk of venous thromboembolism in hospitalized cancer patients: Utility of a risk assessment tool

Inpatient venous thromboembolism (VTE) is a priority preventable illness; risk in cancer varies and prophylaxis is inconsistently used. A previously validated tool (Khorana Score, [KS]) identifies VTE risk in cancer outpatients with 5 easily available variables but has not been studied in the inpatient setting. We evaluated the validity of KS in predicting VTE risk in hospitalized cancer patients. We conducted a retrospective cohort study of consecutive oncology inpatients at the Cleveland Clinic from 11/2012 to 12/2014 (n = 3531). Patients were excluded for VTE on admission (n = 304), incomplete KS data (n = 439) or other reasons (n = 8). Data collected included demographics, cancer type, length of stay (LOS), anticoagulant use, and laboratory values. Multivariate risk factors were identified with stepwise logistic regression, confirmed with bootstrap analysis. Of 2780 patients included, 106 (3.8%) developed VTE during hospitalization. Median age was 62 (range, 19-98) years and 56% were male. Median LOS was 5 (range, 0-152) days. High risk KS (≥ 3) was significantly associated with VTE in uni- and multivariate analyses (OR 2.5, 95% [confidence interval] CI 1.3-4.9). Other significant variables included male gender (OR 1.67, 1.1-2.53), older age (OR 0.86, 0.75-0.99) and use of anticoagulants (OR 0.57, 0.39-0.85). Recursive partitioning analysis suggested optimal cut point for KS is 2 (OR 1.82, 1.23-2.69). This is the first report validating KS as a risk tool to predict VTE in hospitalized cancer patients. Using this tool could lead to more consistent and successful application of inpatient thromboprophylaxis.

Cancer and Venous Thromboembolic Disease: A Review

Venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in cancer patients. Patients with cancer are six times more likely to develop VTE than their noncancer counterparts, and VTE is the second leading cause of death in cancer patients. Despite the publication of major consensus guidelines setting out recommendations for thromboprophylaxis in cancer patients, there remains a gulf between these guidelines and clinical practice. In general, thromboprophylaxis is recommended for most patients hospitalized with active cancer. Furthermore, outpatient thromboprophylaxis may be used in carefully selected high-risk ambulatory patients. Certain areas of controversy still remain. Although low-molecular-weight heparin has been shown to be superior to vitamin K antagonists in cancer patients, the role of direct oral anticoagulants is still uncertain. Moreover, recurrent thromboembolism, bleeding, and thrombocytopenia are frequently seen in cancer patients. Optimal anticoagulation in such instances presents a major challenge to clinicians. Modern computed tomography techniques have resulted in an increase in the detection of "incidental" VTE. Despite a growing body of evidence promulgating standard anticoagulant treatment in such cases, these cases present further challenges for members of the multidisciplinary team. The Oncologist 2017;22:199-207Implications for Practice: This article discusses venous thromboembolism (VTE) in patients with malignancy. Practical guidance is offered on how to prevent, diagnose, and treat VTE in cancer patients. The management of "challenging" cases of VTE is also discussed.

Venous thromboembolism in patients with hematologic malignancy and thrombocytopenia

The optimal management of hematologic malignancy-associated venous thromboembolism (VTE) in patients with moderate-to-severe thrombocytopenia is unclear. This is a retrospective study of 128 adult patients with hematologic malignancies who were diagnosed with VTE. The outcome of patients with significant thrombocytopenia (≤50,000/µL) was compared with those without. Forty-seven patients (36.7%) had a platelet count ≤50,000/µL during a period of time of perceived need for new or continued anticoagulation. The median nadir platelet count in those with significant thrombocytopenia was 10,000/µL (range 2,000-45,000/µL) versus 165,000/µL (50,000-429,000/µL) in those without (P < 0.001). The median duration of significant thrombocytopenia in the first group was 10 days (1-35 days). Therapy during the period of significant thrombocytopenia included prophylactic-dose low-molecular-weight heparin (LMWH) (47%), therapeutic-dose LMWH or heparin (30%), warfarin (2%), inferior vena cava filter (2%), and observation (17%). Patients without thrombocytopenia were managed with the standard of care therapy. At a median follow-up of more than 2 years, the risk of clinically significant bleeding (11% vs 6%, P = 0.22) including major bleeding (6% vs 2%) and clot progression or recurrence (21% vs 22%, P = 1.00) were similar in patients with or without significant thrombocytopenia. In a multivariate analysis, the risk of recurrence/progression (hazard ratio, HR 0.59, 95% CI 0.21-1.66, P = 0.31) and hemorrhage rate (HR 0.29, 95% CI 0.05-1.56, P = 0.15) did not differ based on the presence of significant thrombocytopenia. Within the limits of this retrospective study, cautious use of prophylactic-dose LMWH may be safe in thrombocytopenic patients with hematologic malignancy-associated VTE. Am. J. Hematol. 91:E468-E472, 2016. © 2016 Wiley Periodicals, Inc.

Development and validation of multivariable predictive model for thromboembolic events in lymphoma patients

Lymphoma patients are at increased risk of thromboembolic events but thromboprophylaxis in these patients is largely underused. We sought to develop and validate a simple model, based on individual clinical and laboratory patient characteristics that would designate lymphoma patients at risk for thromboembolic event. The study population included 1,820 lymphoma patients who were treated in the Lymphoma Departments at the Clinics of Hematology, Clinical Center of Serbia and Clinical Center Kragujevac. The model was developed using data from a derivation cohort (n = 1,236), and further assessed in the validation cohort (n = 584). Sixty-five patients (5.3%) in the derivation cohort and 34 (5.8%) patients in the validation cohort developed thromboembolic events. The variables independently associated with risk for thromboembolism were: previous venous and/or arterial events, mediastinal involvement, BMI>30 kg/m(2) , reduced mobility, extranodal localization, development of neutropenia and hemoglobin level < 100g/L. Based on the risk model score, the population was divided into the following risk categories: low (score 0-1), intermediate (score 2-3), and high (score >3). For patients classified at risk (intermediate and high-risk scores), the model produced negative predictive value of 98.5%, positive predictive value of 25.1%, sensitivity of 75.4%, and specificity of 87.5%. A high-risk score had positive predictive value of 65.2%. The diagnostic performance measures retained similar values in the validation cohort. Developed prognostic Thrombosis Lymphoma - ThroLy score is more specific for lymphoma patients than any other available score targeting thrombosis in cancer patients. Am. J. Hematol. 91:1014-1019, 2016. © 2016 Wiley Periodicals, Inc.

High Rates of Thromboembolic Events in Patients with Germ Cell Cancer Undergoing Cisplatin-Based Polychemotherapy

BACKGROUND

We examined whether or not extended prophylaxis with low molecular weight heparin (LMWH) would significantly reduce thromboembolic event (TEE) rates in germ cell cancer patients undergoing cisplatin-based chemotherapy.

PATIENTS AND METHODS

LMWH prophylaxis was given from the first day of chemotherapy until 21 days after completing the last chemotherapy cycle to 45 out of 93 (48.4%) patients (extended), and to 48 out of 93 (51.6%) patients during their hospitalization only (limited) between January 2008 and December 2013. Patients were analyzed retrospectively for TEEs such as deep vein thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI) or peripheral arterial thrombosis.

RESULTS

A total of 22/93 (23.7%) patients experienced 30 TEE during chemotherapy: 12 out of 30 (40%) deep vein thrombosis, 4 out of 30 (13.3%) MI, 10 out of 30 (33.3%) PE and 4 out of 30 peripheral arterial thrombosis (13.3%). TEE rates in both groups did not differ significantly (extended: 26.7 vs. limited: 20.8%).

CONCLUSIONS

The introduction of extended LMWH prophylaxis did not significantly reduce TEE rates in our patient cohort.

Factors influencing the use of thromboprophylaxis in cancer outpatients in clinical practice: A prospective study

INTRODUCTION

Current clinical practice guidelines do not recommend routine pharmacological thromboprophylaxis in cancer outpatients receiving chemotherapy. However, a high proportion of cancer-associated venous thromboembolism (VTE) events occur in this setting. There are scarce data on the use of thromboprophylaxis in ambulatory cancer patients in real clinical practice.

MATERIAL AND METHODS

We conducted a single-center prospective study aimed to evaluate the use and factors influencing pharmacological prophylaxis in consecutive cancer patients receiving ambulatory chemotherapy. Patients were followed for 90 days after inclusion.

RESULTS

A total of 1108 patients were included. According to the Khorana score, 45.8% patients were classified as low-risk, 47.4% intermediate-risk and 6.8% as high-risk. Outpatient pharmacological prophylaxis was administered at any time during follow-up to 157 patients (14.2%) with a median duration of 42 days (range 1-90). Main factors influencing thromboprophylaxis were: previous history of VTE (odds ratio [OR], 19.11; 95% CI, 9.61-37.98), intercurrent hospitalization (OR, 5.40; 95% CI, 3.57-8.16), and gastrointestinal or gynecologic cancer (OR, 1.76; 95% CI, 1.11-2.80 and OR, 2.34; 95% CI, 1.05-5.26, respectively). During follow-up 58 (5.2%) VTE events were observed. Independent predictors of VTE were the site of malignancy (OR, 3.04; 95%CI, 1.20-7.71 and OR, 2.47; 95%CI, 1.21-5.01 for pancreas and lung cancer, respectively) and previous VTE (OR, 4.23; 95%CI, 1.26-14.27). Outpatient prophylaxis was associated with a lower risk of VTE during follow-up (OR, 0.30; 95%CI, 0.10-0.95).

CONCLUSIONS

Although the type of malignancy appears as the most relevant variable for decision-making, additional efforts are required to identify patients at particular high thrombosis risk.

Prevention and treatment of venous thromboembolism in patients with cancer

Robust evidence remains scarce in guiding best practice in the prevention and treatment of venous thromboembolism in patients living with cancer. Recommendations from major consensus guidelines are largely based on extrapolated data from trials performed mostly in noncancer patients, observational studies and registries, studies using surrogate outcomes, and underpowered randomized controlled trials. Nonetheless, a personalized approach based on individual risk assessment is uniformly recommended for inpatient and outpatient thromboprophylaxis and there is consensus that anticoagulant prophylaxis is warranted in selected patients with a high risk of thrombosis. Prediction tools for estimating the risk of thrombosis in the hospital setting have not been validated, but the use of prophylaxis in the ambulatory setting in those with a high Khorana score is under active investigation. Symptomatic and incidental thrombosis should be treated with anticoagulant therapy, but little is known about the optimal duration. Pharmacologic options for prophylaxis and treatment are still restricted to unfractionated heparin, low molecular weight heparin, and vitamin K antagonists because there is currently insufficient evidence to support the use of target-specific, non-vitamin K-antagonist oral anticoagulants. Although these agents offer practical advantages over traditional anticoagulants, potential drug interaction with chemotherapeutic agents, gastrointestinal problems, hepatic and renal impairment, and the lack of rapid reversal agents are important limitations that may reduce the efficacy and safety of these drugs in patients with active cancer. Clinicians and patients are encouraged to participate in clinical trials to advance the care of patients with cancer-associated thrombosis.

Venous thromboembolism in cancer patients

OBJECTIVE

Venous thromboembolism (VTE) is a common complication in cancer patients. This review summarizes some of the most current knowledge of the epidemiology, risk factors, risk models, prophylaxis, and treatment of VTE in cancer patients.

METHODS

A literature search was conducted using PubMed; the search terms were venous thromboembolism, anticoagulation, and cancer. The bibliographies of pertinent studies and review articles were reviewed for additional references.

RESULTS

Venous thromboembolism is the second leading cause of death in patients with cancer. Cancer patients with VTE have poorer outcomes compared with noncancer patients with VTE. Many risk factors have been identified for VTE in patients with cancer that are patient-related, cancer-related, or treatment-related. Several biomarkers have been identified as potentially predictive of VTE risk. Risk assessment models such as the Khorana Risk Score stratify cancer patients with low, intermediate, and high risk of developing VTE based on baseline clinical and laboratory variables. Currently, enoxaparin is the preferred anticoagulant for initial VTE treatment in cancer patients. Low molecular weight heparin (LMWH) is recommended for both initial and long-term management of cancer-related VTE. Because the optimal duration of anticoagulation in cancer patients with VTE is unknown, the decision to extend anticoagulation requires weighing the risk of recurrent thrombosis against the risk of major bleeding. Patients with recurrent VTE can be bridged with LMWH, transitioned to full-dose LMWH or treated with LMWH dose escalation. While there is insufficient data to determine whether anticoagulation should be held in the setting of thrombocytopenia, full-dose anticoagulation is typically considered unsafe when platelets are < 50 000/μL. Inferior vena cava filters are currently recommended only for patients with acute VTE and contraindications to anticoagulation. Although management of catheter-associated thrombosis has not been well studied in cancer patients, it is recommended that cancer patients with catheter-associated thrombosis be treated with therapeutic anticoagulation for ≥ 3 months. Venous thromboembolism prophylaxis with UFH, LMWH, or fondaparinux is recommended in all hospitalized nonsurgical cancer patients and cancer patients undergoing major cancer surgery. Primary thromboprophylaxis is only currently recommended in high-risk ambulatory cancer patients such as multiple myeloma patients receiving thalidomide- or lenalidomide- based therapy.

CONCLUSION

Cancer-associated thrombosis is a common problem. As we begin to better understand the risk factors and biomarkers for cancer-associated VTE, we can further refine and develop risk-assessment models to determine those patients who would most likely benefit from anticoagulation. While LMWH products are generally preferred in cancer-related VTE, more research will continue to evolve our understanding of treatment and thrombopprophylaxis in cancer-associated VTE.