Variable support for ASCO recommendations for the prevention and treatment of cancer-associated venous thromboembolism

Summary

Objectives: To determine the attitude of physicians towards the ASCO evidence-based clinical practice guidelines for venous thromboembolism (VTE) prophylaxis and treatment in patients with cancer.

Methods: The ASCO guideline was published in Jan. 2015. Two specialists in in the field assembled a list of arguments for and against each of the ASCO recommendations. ASCO recommendations and pro & con arguments were presented to physicians attending 3 educational seminars on hemostasis in cancer patients. After the presentation each attendee was asked to fill out a questionnaire on how much he agreed with the recommendations and the pro & con arguments.

Results: A total of 89 physicians attended the three meetings. 56 questionnaires were returned. The ASCO recommendation with the highest degree of support was that patients undergoing major cancer surgery should receive prophylaxis for 7–10 days and for four weeks after major abdominal or pelvic surgery with high-risk features (84 % Pro). The recommendation with the lowest degree of support was that anticoagulation should not be used to extend survival of patients with cancer in the absence of other indications (56 % Pro = indifference). Arguments based on A) the scientific evidence underlying each recommendation, B) on clinical practicability and patients’ preferences/adherence, C) on the desire to avoid toxicity, malpractice litigation, and cost concerns, ranked equally.

Conclusion: The degree of support for ASCO guideline recommendations on prophylaxis and treatment of VTE in cancer is variable. For some key recommendations it is close to indifference. Scientific evidence for a recommendation is just one decision factor among others. Our study underscores the need to further promote educational activities on VTE prophylaxis and treatment in cancer patients particularly among all physicians caring for cancer patients.

Keywords

Cancer associated venous thromboembolism - VTE - ASCO guidelines

• References

• 1 Carrier M, Khorana AA, Moretto P. et al. Lack of evidence to support thromboprophylaxis in hospitalized medical patients with cancer. Am J Med 2014; 127: 82-86.
• 2 Wittkowsky AK. Barriers to the long-term use of low-molecular weight heparins for treatment of cancer-associated thrombosis. J Thromb Haemost 2006; 4: 2090-2091.
• 3 Delate T, Witt DM, Ritzwoller D. et al. Outpatient use of low molecular weight heparin monotherapy for first-line treatment of venous thromboembolism in advanced cancer. Oncologist 2012; 17: 419-427.
• 4 Imberti D, Agnelli G, Ageno W. et al. Clinical characteristics and management of cancer-associated acute venous thromboembolism: findings from the MASTER Registry. Haematologica 2008; 93: 273-278.
• 5 Spirk D, Ugi J, Korte W. et al. Long-term anticoagulation treatment for acute venous thromboembolism in patients with and without cancer. The SWIss Venous ThromboEmbolism Registry (SWIVTER) II. Thromb Haemost 2011; 105: 962-967.
• 6 Kahn SR, Springmann V, Schulman S. et al. Management and adherence to VTE treatment guidelines in a national prospective cohort study in the Canadian outpatient setting. The Recovery Study. Thromb Haemost 2012; 108: 493-498.
• 7 Mahé I, Rey J-B, Elalamy I. et al. Management of cancer associated thrombosis in France: a national survey in vascular disease and supportive care specialists. J Thromb Haemost 2015; 13 (Suppl. 02) 546 Abstr.# PO105-TUE.
• 8 Kalka C, Spirk D, Siebenrock KA. et al. Lack of extended venous thromboembolism prophylaxis in high-risk patients undergoing major orthopaedic or major cancer surgery. Electronic Assessment of VTE Prophylaxis in High-Risk Surgical Patients at Discharge from Swiss Hospitals (ESSENTIAL). Thromb Haemost 2009; 102: 56-61.
• 9 Sevestre MA, Belizna C, Durant C. et al. Carmen Investigators for the Groupe Francophone Throm-bose et Cancer (GFTC).. Compliance with recommendations of clinical practice in the management of venous thromboembolism in cancer: the CARMEN study. J Mal Vasc 2014; 39: 161-168.
• 10 Marchena PJ, Nieto JA, Guil M, García-Bragado F, Rabuñal R, Boccalon H, Trujillo-Santos J, Monreal M. RIETE Investigators.. Long-term therapy with low-molecular-weight heparin in cancer patients with venous thromboembolism. Thromb Haemost 2012; 107: 37-43.
• 11 Mahe I, Puget H, Chidiac J. et al. Adherence to international guidelines in treatment of thromboembolic events in cancer patients: A hospital-based cohort study in Paris, France. J Clin Oncol. 2015 33. (suppl.): Abstr. #e12647
• 12 Berger K, Fastenrath S, Ostermann H. Thromboembolic events in haematological/oncological patients: Adherence to treatment guidelines in clinical practice. GTH Annual Meeting 2015, Abstr. #PO5–6
• 13 Lyman GH, Bohlke K, Khorana AA. et al. American Society of Clinical Oncology Clinical Practice.. Venous thromboembolism prophylaxis and treatment in patients with cancer: american society of clinical oncology clinical practice guideline update 2014. J Clin Oncol 2015; 33: 654-656.
• 14 Kondryn HJ, Edmondson CL, Hill J. et al. Treatment non-adherence in teenage and young adult patients with cancer. Lancet Oncol 2011; 12: 100-108.
• 15 Patel JP, Auyeung V, Patel RK. et al. Women’s views on and adherence to low-molecular-weight heparin therapy during pregnancy and the puerperium. J Thromb Haemost 2012; 10: 2526-2534.
• 16 Noble S, Maraveyas A, Matzdorff A, Holm MV, Pisa G. Patients’ preferences for the treatment of cancer associated thrombosis. Haematologica. 2015 Aug 20. pii: haematol.2015.127126. [Epub ahead of print]
• 17 Nast A, Sporbeck B, Jacobs A. et al. Study of perceptions of the extent to which guideline recommendations are binding: a survey of commonly used terminology. Dtsch Arztebl Int 2013; 110: 663-668.
• 18 Caprini JA, Tapson VF, Hyers TM. et al. NABOR Steering Committee.. Treatment of venous thromboembolism: adherence to guidelines and impact of physician knowledge, attitudes, and beliefs. J Vasc Surg 2005; 42: 726-733.
• 19 Gitt AK, Juenger C, Smolka W. et al. Impact of a budget restrictive (Germany) versus an incentive-driven (UK) reimbursement system on LDL-goal achievement in statin treated patients for secundary prevention: results of DYSIS. European Heart Journal 2013; 34 (Abstract Suppl) 665 Abstr. #3689.