U of Michigan: Outpatient surgery patients also at risk for dangerous blood clots | University of Michigan Health System

 
Outpatient surgery patients also at risk for dangerous blood clots | University of Michigan Health System

"...With the information, the researchers created and validated a risk-stratification tool that can be used to predict a patient’s risk for VTE. The tool identified a 20-fold variation in VTE risk from 0.04 percent to 1.12 percent among the outpatient surgery population.
“These data are in stark contrast to provider and patient expectations that outpatient surgery is a low-risk event,” Pannucci says. “It also underscores the importance of evaluating a patient’s individual risk factors as opposed to procedure-type alone.”.....

abstract: Postoperative venous thromboembolism predicts survival in cancer patients

Postoperative venous thromboembolism predicts survi... [Ann Surg. 2012]

OBJECTIVES:

To determine whether a postoperative venous thromboembolism (VTE) is associated with a worse prognosis and/or a more advanced cancer stage and to evaluate the association between a postoperative VTE and cancer-specific survival when known prognostic factors, such as age, stage, cancer type, and type of surgery, are controlled.

CONCLUSIONS:

Postoperative VTE in oncology patients with limited disease and a complete surgical resection is associated with an inferior cancer survival. A postoperative VTE remains a poor prognostic factor, even when controlling for age, stage, cancer type, and surgical procedure further supporting an independent link between hypercoagulability and cancer survival.

Cancer effect on periprocedural thromboembolism and bleeding in anticoagulated patients

Cancer effect on periprocedural thromboembolism and bleeding in anticoagulated patients:

Background:
Patients with active cancer are often on chronic anticoagulation and frequently require interruption of this treatment for invasive procedures. The impact of cancer on periprocedural thromboembolism (TE) and major bleeding is not known.

Patients and methods:
Two thousand one hundred and eighty-two consecutive patients referred for periprocedural anticoagulation (2484 procedures) using a standardized protocol were followed forward in time to estimate the 3-month incidence of TE, major bleeding and survival stratified by anticoagulation indication. For each indication, we tested active cancer and bridging heparin therapy as potential predictors of TE and major bleeding.

Results:
Compared with patients without cancer, active cancer patients (n = 493) had more venous thromboembolism (VTE) complications (1.2% versus 0.2%), major bleeding (3.4% versus 1.7%) and reduced survival (95% versus 99%). Among active cancer patients, only those chronically anticoagulated for VTE had higher rates of periprocedural VTE (2% versus 0.16%;) and major bleeding (3.7% versus 0.6%). Bridging with heparin increased the rate of major bleeding in cancer patients (5% versus 1%;) without impacting the VTE rate (0.7% versus 1.4%,).

Conclusions:
Cancer patients anticoagulated for VTE experience higher rates of periprocedural VTE and major bleeding. Periprocedural anticoagulation for these patients requires particular attention to reduce these complications.

abstract - EvidenceUpdates: Cochrane Review: Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy (including professional commentaries)

Abstract

BACKGROUND:  Venous thromboembolism (VTE) often complicates the clinical course of cancer disease. The risk is further increased by chemotherapy but the safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. OBJECTIVES:  To assess the efficacy and safety of primary thromboprophylaxis in ambulatory cancer patients receiving chemotherapy.  AUTHORS' CONCLUSIONS:   Primary thromboprophylaxis with LMWH significantly reduced the incidence of symptomatic VTE in ambulatory cancer patients treated with chemotherapy. However, the lack of power hampers definite conclusions on the effects on major safety outcomes, which mandates additional studies to determine the risk to benefit ratio of LMWH in this setting.

Comments from Clinical Raters
Oncology - Breast

open access: Risk of venous and arterial thromboembolic events associated with anti-EGFR agents: a meta-analysis of randomized clinical trials

summary: Risk of Venous and Arterial Thromboembolic Events Associated With Anti-EGFR Agents: A Meta-Analysis of Randomized Clinical Trials - OncologySTAT

 

SUMMARY

OncologySTAT Editorial Team

"Venous and arterial thromboembolism events (VTEs and ATEs) are common in patients with cancer and are a frequent cause of mortality in these patients. Antiangiogenic agents that target vascular endothelial growth factor receptor (VEGFR), such as sunitinib, sorafenib, and bevacizumab, are associated with increased risk of VTEs and ATEs. Other drugs target the epidermal growth factor receptor (EGFR), such as the monoclonal antibodies cetuximab and panitumumab, and the oral tyrosine kinase inhibitors (TKIs) erlotinib and gefitinib. This meta-analysis evaluated the risk of VTEs and ATEs associated with the anti-EGFR agents cetuximab, panitumumab, erlotinib, and gefitinib.
Medline and EMBASE were searched for randomized controlled phase II or III trials in which cetuximab, panitumumab, erlotinib, or gefitinib was used as treatment for patients with cancer....."

Ovarian Failure, VTE Risks Added to Avastin Label - in Product Alert, Prescriptions from MedPage Today

abstract: Cochrane Review - Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer.

BACKGROUND:

Compared to patients without cancer, patients with cancer who receive anticoagulant treatment for venous thromboembolism are more likely to develop recurrent venous thromboembolism (VTE).

AUTHORS' CONCLUSIONS:

LMWH (low molecular weight heparin)  is possibly superior to UFH (unfractionated heparin) in the initial treatment of VTE in patients with cancer. Additional trials focusing on patient important outcomes will further inform the questions addressed in this review.

Thirty-day mortality rate in women with cancer and venous thromboembolism. Findings from the RIETE Registry (abstract)

Note: different adverse events depending on cancer site

Access : Hospitalisation for venous thromboembolism in cancer patients and the general population: a population-based cohort study (abstract)

Conclusions:

Risk of VTE is higher among cancer patients than in the general population. Predictors of VTE include recency of cancer diagnosis, cancer site, stage and the type of cancer-directed treatment.

Summary- Clinical burden of venous thromboembolism

Conclusions:

Even among high-risk groups it is not possible to identify individuals who will go on to develop VTE, and, therefore, thromboprophylaxis is a recommended component of the management of high-risk patients. Ensuring patients receive safe, effective, easily administered antithrombotic therapy both in hospital and post-discharge, for a sufficient length of time, should be central to any strategy to reduce incident or recurrent VTE and minimise the risk of long-term complications.

When ‘never-events’ occur despite adherence to clinical guidelines: The case of venous thromboembolism in clear cell cancer of the ovary compared with other epithelial histologic subtypes

Note: 'never-events' is a term used in patient safety (eg. language - near misses, etc)


Conclusions.
"Women with CCC-O have a 2.5-times greater risk of disease related VTE than women with other histologies of epithelial ovarian cancer despite adherence to prophylactic guidelines. Given the high rate of VTE postoperatively as well as with disease recurrence, one should consider indefinite therapeutic anticoagulation in women with CCC-O. The case of CCC-O is one example of the impracticality of payment denial for ‘never-events,’ as VTE arises despite best efforts at prevention."

Venous Thromboembolism Risk and Prophylaxis in the Acute Care Hospital Setting (ENDORSE Survey): Findings in Surgical Patients

Note: study of data from 2004

"Use of prophylaxis varied according to major surgery type from 86.0% for orthopedic surgery to 53.8% in urologic/gynecologic...."  "Conclusions: The majority of surgical patients are at high-risk for VTE. Despite long-standing recognition of the high-risk for VTE in surgical patients, thromboprophylaxis remains underutilized."