Advertisement

No Evidence Not to Prescribe Thromboprophylaxis in Hospitalized Medical Patients with Cancer

      To the Editor:
      We read with great interest the literature review by Carrier et al
      • Carrier M.
      • Khorana A.A.
      • Moretto P.
      • Le Gal G.
      • Karp R.
      • Zwicker J.I.
      Lack of evidence to support thromboprophylaxis in hospitalized medical patients with cancer.
      indicating the lack of evidence to support thromboprophylaxis in hospitalized medical patients with cancer. However, this paper will change little if any of our clinical practice. The authors acknowledge that only 3 placebo-controlled studies, including 307 cancer patients, were analyzed. Moreover, the site and the stage of the cancers were not indicated, whereas patients with cancer are at high risk for deep vein thrombosis and pulmonary embolism, a common cause of death, depending on both tumor site and disease stage. Of note, several current guidelines strongly recommend routine thrombophylaxis.
      • Cohen A.T.
      • Gurwith M.M.
      • Dobromirski M.
      Thromboprophylaxis in non-surgical cancer patients.
      Indeed, pathogenesis of thromboembolic complications involves venous stasis due to immobilization and venous compression, endothelial damage related to chemotherapy and venous catheters, and blood hypercoagulability such as thrombocytosis and hyperfibrinogenemia.
      • Falanga A.
      • Marchetti M.
      • Vignoli A.
      Coagulation and cancer: biological and clinical aspects.
      Risk factors for venous thromboembolism in cancer patients are well known, including patient-related factors (age >65 years, comorbid conditions, prior history of venous thromboembolism, heritable thrombophilia), cancer-related factors (pancreatic, gastrointestinal, lung primary site; initial 3-6 months after diagnosis; current metastatic disease), and treatment-related factors (such as current hospitalization, active chemotherapy, active hormonal therapy, and thalidomide or lenalidomide therapy).
      • Cohen A.T.
      • Gurwith M.M.
      • Dobromirski M.
      Thromboprophylaxis in non-surgical cancer patients.
      Thromboprophylaxis is recommended, at least in these patients with acute illness at high risk for thromboembolic events. Conversely, thromboprophylactic treatment is clearly underutilized in nonsurgical cancer patients with acute medical illness cancer (<40% of patients).
      • Brown A.
      Preventing venous thromboembolism in hospitalized patients with cancer: improving compliance with clinical practice guidelines.
      In conclusion, we will continue to prescribe thromboprophylactic treatment in our hospitalized medical patients with cancer at high risk when there are no contraindications to such therapy, and we encourage our colleagues to improve compliance to current guidelines.

      References

        • Carrier M.
        • Khorana A.A.
        • Moretto P.
        • Le Gal G.
        • Karp R.
        • Zwicker J.I.
        Lack of evidence to support thromboprophylaxis in hospitalized medical patients with cancer.
        Am J Med. 2014; 127: 82-86
        • Cohen A.T.
        • Gurwith M.M.
        • Dobromirski M.
        Thromboprophylaxis in non-surgical cancer patients.
        Thromb Res. 2012; 129: S137-S145
        • Falanga A.
        • Marchetti M.
        • Vignoli A.
        Coagulation and cancer: biological and clinical aspects.
        J Thromb Haemost. 2013; 11: 223-233
        • Brown A.
        Preventing venous thromboembolism in hospitalized patients with cancer: improving compliance with clinical practice guidelines.
        Am J Health Syst Pharm. 2012; 69: 469-481

      Linked Article

      • Lack of Evidence to Support Thromboprophylaxis in Hospitalized Medical Patients with Cancer
        The American Journal of MedicineVol. 127Issue 1
        • Preview
          The administration of anticoagulant thromboprophylaxis for all patients with cancer who are hospitalized for acute medical illness is considered standard practice and strongly recommended in clinical guidelines. These recommendations are extrapolated from randomized controlled prophylaxis trials not specifically conducted in cancer cohorts. Because hospitalized patients with cancer constitute a unique population with increased risk of venous thromboembolic events and major hemorrhage, validation of the efficacy and safety of primary thromboprophylaxis in this population is critical.
        • Full-Text
        • PDF
      • The Reply
        The American Journal of MedicineVol. 127Issue 7
        • Preview
          We thank Bachmeyer and Budman1 for their comments on the evidence regarding the use of thromboprophylaxis in hospitalized patients with cancer. As discussed in our article, we do not recommend avoiding the use of thromboprophylaxis among patients with cancer who are hospitalized with medical illness.2 We aimed to highlight that the strong recommendations from clinical practice guidelines supporting the use of thromboprophylaxis in this population are based on limited evidence and largely derived from data on patients without cancer.
        • Full-Text
        • PDF