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EDITORIALS: John W Eikelboom, Jeffrey S Ginsberg, and Jack Hirsh Anticoagulation for venous thromboembolism BMJ 2007; 334: 645 [Full text]

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Venous thrombo-embolic treatment and prophylaxis in cancer is underutilised but has multiple benefits

Amit Patel, Sukhjinder Nijjer [Senior House Officer in Oncology], Ben Garfield [Senior House Officer in Haematology]   (3 April 2007)

Venous thrombo-embolic treatment and prophylaxis in cancer is underutilised but has multiple benefits 3 April 2007
Amit Patel, Academic Clinical Fellow & Specialist Registrar in Haematology Imperial College London & Hammersmith Hospitals NHS Trust, Charing Cross Hospital, London, W6 8RF, Sukhjinder Nijjer [Senior House Officer in Oncology], Ben Garfield [Senior House Officer in Haematology] Send response to journal: Re: Venous thrombo-embolic treatment and prophylaxis in cancer is underutilised but has multiple benefits	The benefits of long-term anti-coagulation, particularly with warfarin, have been questioned.[1] Patients with cancer, however, require special consideration. Cancer may present with venous thrombo-embolism (VTE), while VTE is at least seven times more frequent in patients with cancer compared to controls.[2] The presence of metastasis increases this risk by at least 50 fold,[2] and some chemotherapy is thrombogenic. Several trials have demonstrated additional survival benefit from prophylactic, short and long-term treatment for VTE with low molecular weight heparin (LMWH), independent of clinical thrombotic events. This mechanism of action is unclear. The FAMOUS trial[3] was the first large prospective randomised double-blinded placebo-controlled study, and although slightly underpowered found a 5% increase in absolute survival at one year with prophylactic LMWH. The 336 patient CLOT trial[4] showed that six month therapy for VTE with LWMH improved survival in the predetermined subgroup without metastasis, compared to a vitamin-K antagonist with a target INR of 2-2.5 (80% versus 64%). Recurrent thromboembolism was also reduced in the LMWH group (9% versus 17%) without a significant difference in bleeding. Four meta-analyses have indicated improved survival with a short course of LMWH to un-fractionated heparin for VTE treatment, followed by a vitamin-K antagonist in both groups; an odds ratio 0.57 has recently been reported.[5] While the indications for VTE prophylaxis in hospitalised cancer patients are clear, a snapshoot audit of our own practice indicates it is not always implemented. Of 41 oncology patients, including 24% with metastatic disease, only 33% received appropriate LMWH prophylaxis. 78% had additional risk factors, including previous VTE and immobility. Three patients were currently being treated for VTE. We propose strengthening of hospital protocols and education for all staff. It is difficult to justify other expensive and sophisticated therapies, including chemo- and immuno- therapy, when evidenced simple and cheap measures are inadequately implemented. References [1] Eikelboom JW, Ginsberg JS, Hirsh J. Anticoagulation for venous thromboembolism. BMJ 2006;334:645. [2] Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism. Arch Intern Med 2000;160:809-815. [3] Kakkar AK, Levine MN, Kadziola Z, et al. Low molecular weight heparin, therapy with dalteparin, and survival in advanced cancer: the Fragmin Advanced Malignancy Outcome Study (FAMOUS). J Clin Oncol 2004;22:1944-1948. [4] Lee A. Y.Y., Levine M. N., Baker R. I., Bowden C., Kakkar A. K., Prins M., Rickles F. R., Julian J. A., Haley S., Kovacs M. J., Gent M.,. Low-Molecular-Weight Heparin versus a Coumarin for the Prevention of Recurrent Venous Thromboembolism in Patients with Cancer. N Engl J Med 2003;349:146-153. [5] Gould MK, Dembitzer AD, Doyle RL, et al. Low-molecular-weight heparins compared with unfractionated heparin for treatment of acute deep vein thrombosis: a meta-analysis of randomized, controlled trials. Ann Intern Med 1999;130:800-809. Competing interests: None declared