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      We thank Bachmeyer and Budman
      • Bachmeyer C.
      • Budman D.R.
      No evidence not to prescribe thromboprophylaxis in hospitalized medical patients with cancer.
      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.
      • 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.
      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.
      • Lyman G.H.
      • Khorana A.A.
      • Falanga A.
      • et al.
      American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer.

      National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology Venous Thromboembolic Disease version 2.2011. National Comprehensive Cancer Network 2012. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive. Accessed January 10, 2012.

      Furthermore, a number of uncertainties regarding the efficacy and safety of thromboprophylaxis among hospitalized medically ill patients with cancer are worth reemphasizing.
      First, the current recommended thromboprophylactic doses may not be optimal for hospitalized patients with cancer, especially considering that higher doses of parenteral thromboprophylaxis in ambulatory patients with cancer have been shown to be efficacious.
      • Maraveyas A.
      • Waters J.
      • Roy R.
      • et al.
      Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer.
      • Reiss H.
      • Pelzer U.
      • Deutschinoff G.
      • et al.
      A prospective, randomized trial of chemotherapy with or without the low molecular weight heparin (LMWH) enoxaparin in patients (pts) with advanced pancreatic cancer (APC): results of the CONKO 004 trial.
      Second, it remains unclear whether all patients with cancer who are hospitalized with medical illness require pharmacologic parenteral thromboprophylaxis. Risk-adjusted models, such as the Padua scoring system, include additional risk factors (eg, elderly age [≥70 years], previous venous thromboembolism, reduced mobility for at least 3 days) for patients with cancer to be considered high risk for venous thromboembolism during their hospitalization.
      • Barbar S.
      • Noventa F.
      • Rossetto V.
      • et al.
      A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: The Padua Prediction Score.
      Finally, patients with cancer who are receiving anticoagulant therapy are at increased risk of bleeding compared with patients without cancer.
      • Prandoni P.
      • Lensing A.W.
      • Piccioli A.
      • et al.
      Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.
      The rates of major bleeding episodes among hospitalized medically ill patients with cancer receiving parenteral thromboprophylaxis have never been reported and represent an important knowledge gap.
      Therefore, it is currently impossible to accurately assess the risk–benefit ratio of thromboprophylaxis in patients with cancer who are hospitalized for medical reasons. Additional prospective studies and randomized controlled trials assessing the efficacy and safety of routine administration of parenteral thromboprophylaxis in hospitalized medically ill patients with cancer are desperately needed.

      References

        • Bachmeyer C.
        • Budman D.R.
        No evidence not to prescribe thromboprophylaxis in hospitalized medical patients with cancer.
        Am J Med. 2014; 127: e49
        • 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
        • Lyman G.H.
        • Khorana A.A.
        • Falanga A.
        • et al.
        American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer.
        J Clin Oncol. 2007; 25: 5490-5505
      1. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology Venous Thromboembolic Disease version 2.2011. National Comprehensive Cancer Network 2012. Available at: http://www.nccn.org/professionals/physician_gls/f_guidelines.asp#supportive. Accessed January 10, 2012.

        • Maraveyas A.
        • Waters J.
        • Roy R.
        • et al.
        Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer.
        Eur J Cancer. 2012; 48: 1283-1292
        • Reiss H.
        • Pelzer U.
        • Deutschinoff G.
        • et al.
        A prospective, randomized trial of chemotherapy with or without the low molecular weight heparin (LMWH) enoxaparin in patients (pts) with advanced pancreatic cancer (APC): results of the CONKO 004 trial.
        J Clin Oncol. 2009; (ASCO Annual Meeting Proceedings (Post-Meeting Edition) 27[18S])
        • Barbar S.
        • Noventa F.
        • Rossetto V.
        • et al.
        A risk assessment model for the identification of hospitalized medical patients at risk for venous thromboembolism: The Padua Prediction Score.
        J Thromb Haemost. 2010; 8: 2450-2457
        • Prandoni P.
        • Lensing A.W.
        • Piccioli A.
        • et al.
        Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis.
        Blood. 2002; 100: 3484-3488

      Linked Article

      • No Evidence Not to Prescribe Thromboprophylaxis in Hospitalized Medical Patients with Cancer
        The American Journal of MedicineVol. 127Issue 7
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          We read with great interest the literature review by Carrier et al1 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.
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