Abstract
Purpose
Data on long-term venous thromboembolism prophylaxis in cancer outpatients remain scarce. In the absence of clear and consistent treatment guidelines, our objectives were to describe and better understand clinical practice and to identify factors influencing the use of thromboprophylaxis.
Methods
CAT AXIS was a multicentred cross-sectional study based on the completion of physician-profile questionnaires and the assessment of 10 e-mailed credible clinical scenarios of lung, colon and breast cancers by each of participants using the case vignette-validated method.
Results
A total of 224 physicians participated allowing the completion and the analysis of 2085 reviewed case vignettes corresponding to 765, 703 and 617 fictive clinical scenarios on lung, colon and breast cancers, respectively. The overall rate of thromboprophylaxis was 680/2085 (32.6%) among participants with a comparable proportion for the three types of cancer. Low-molecular-weight heparin (LMWH) was the most frequently used, by 92.7, 93.8 and 83.9% of participants for lung, colon and breast cancers, respectively; thromboprophylaxis duration of ≥ 3 months was used by 74.4% of participants. Multivariate analyses revealed that the Eastern Cooperative Oncology Group index, metastatic malignancy, chemotherapy and history of thrombosis were significantly associated with the therapeutic decision unlike Khorana score and anaemia.
Conclusion
In the absence of clear guidance, the use of thromboprophylaxis remains low and rather empiric even though the selection of LMWH by the majority of participants and treatment duration seems appropriate based on available data to date. Specific guidelines with corresponding awareness are required.
Similar content being viewed by others
References
Levitan N, Dowlati A, Remick SC, Tahsildar HI, Sivinski LD, Beyth R, Rimm AA (1999) Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine (Baltimore) 78(5):285–291. https://doi.org/10.1097/00005792-199909000-00001
Noble S, Pasi J (2010) Epidemiology and pathophysiology of cancer-associated thrombosis. Br J Cancer 102(Suppl 1):S2–S9. https://doi.org/10.1038/sj.bjc.6605599
Lee AY (2003) Epidemiology and management of venous thromboembolism in patients with cancer. Thromb Res 110(4):167–172. https://doi.org/10.1016/S0049-3848(03)00347-5
Chew HK, Wun T, Harvey D, Zhou H, White RH (2006) Incidence of venous thromboembolism and its effect on survival among patients with common cancers. Arch Intern Med 166(4):458–464. https://doi.org/10.1001/archinte.166.4.458
Khorana AA, Francis CW, Culakova E, Kuderer NM, Lyman GH (2007) Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. J Thromb Haemost 5(3):632–634. https://doi.org/10.1111/j.1538-7836.2007.02374.x
Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, Nelson ME, Wells PS, Gould MK, Dentali F, Crowther M, Kahn SR, American College of Chest P (2012) Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(2):e419S–e494S. https://doi.org/10.1378/chest.11-2301
Lyman GH, Khorana AA, Kuderer NM, Lee AY, Arcelus JI, Balaban EP, Clarke JM, Flowers CR, Francis CW, Gates LE, Kakkar AK, Key NS, Levine MN, Liebman HA, Tempero MA, Wong SL, Prestrud AA, Falanga A (2013) Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 31(17):2189–2204. https://doi.org/10.1200/JCO.2013.49.1118
Farge D, Debourdeau P, Beckers M, Baglin C, Bauersachs RM, Brenner B, Brilhante D, Falanga A, Gerotzafias GT, Haim N, Kakkar AK, Khorana AA, Lecumberri R, Mandala M, Marty M, Monreal M, Mousa SA, Noble S, Pabinger I, Prandoni P, Prins MH, Qari MH, Streiff MB, Syrigos K, Bounameaux H, Buller HR (2013) International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. J Thromb Haemost 11(1):56–70. https://doi.org/10.1111/jth.12070
Khorana AA (2007) The NCCN Clinical Practice Guidelines on Venous Thromboembolic Disease: strategies for improving VTE prophylaxis in hospitalized cancer patients. Oncologist 12(11):1361–1370. https://doi.org/10.1634/theoncologist.12-11-1361
Meyer G, Marjanovic Z, Valcke J, Lorcerie B, Gruel Y, Solal-Celigny P, Le Maignan C, Extra JM, Cottu P, Farge D (2002) Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med 162(15):1729–1735. https://doi.org/10.1001/archinte.162.15.1729
Lee AY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M (2003) Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 349(2):146–153. https://doi.org/10.1056/NEJMoa025313
Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R, Wong T, Cook R, Solymoss S, Poon MC, Raskob G (2006) Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 119(12):1062–1072. https://doi.org/10.1016/j.amjmed.2006.02.022
Deitcher SR, Kessler CM, Merli G, Rigas JR, Lyons RM, Fareed J, Investigators O (2006) Secondary prevention of venous thromboembolic events in patients with active cancer: enoxaparin alone versus initial enoxaparin followed by warfarin for a 180-day period. Clin Appl Thromb Hemost 12(4):389–396. https://doi.org/10.1177/1076029606293692
Frere C, Doucet L, Farge D (2016) Prophylaxis of venous thromboembolism in cancer patients. Expert Rev Hematol 9(6):535–539. https://doi.org/10.1586/17474086.2016.1172959
Lyman GH, Khorana AA, Kuderer NM, Lee AY, Arcelus JI, Balaban EP, Clarke JM, Flowers CR, Francis CW, Gates LE, Kakkar AK, Key NS, Levine MN, Liebman HA, Tempero MA, Wong SL, Prestrud AA, Falanga A, American Society of Clinical Oncology Clinical P (2013) Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 31(17):2189–2204. https://doi.org/10.1200/JCO.2013.49.1118
Mandala M, Falanga A, Roila F, Group EGW (2011) Management of venous thromboembolism (VTE) in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 22(Suppl 6):vi85–vi92. https://doi.org/10.1093/annonc/mdr392
Lyman GH, Bohlke K, Falanga A, American Society of Clinical O (2015) Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Oncol Pract 11(3):e442–e444. https://doi.org/10.1200/JOP.2015.004473
Khorana AA (2013) Venous thromboembolism prevention in cancer outpatients. J Natl Compr Cancer Netw 11(11):1431–1438. https://doi.org/10.6004/jnccn.2013.0164
Barni S, Labianca R, Agnelli G, Bonizzoni E, Verso M, Mandala M, Brighenti M, Petrelli F, Bianchini C, Perrone T, Gasparini G (2011) Chemotherapy-associated thromboembolic risk in cancer outpatients and effect of nadroparin thromboprophylaxis: results of a retrospective analysis of the PROTECHT study. J Transl Med 9(1):179. https://doi.org/10.1186/1479-5876-9-179
Agnelli G, George DJ, Kakkar AK, Fisher W, Lassen MR, Mismetti P, Mouret P, Chaudhari U, Lawson F, Turpie AG, Investigators S-O (2012) Semuloparin for thromboprophylaxis in patients receiving chemotherapy for cancer. N Engl J Med 366(7):601–609. https://doi.org/10.1056/NEJMoa1108898
Peabody JW, Luck J, Glassman P, Jain S, Hansen J, Spell M, Lee M (2004) Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med 141(10):771–780. https://doi.org/10.7326/0003-4819-141-10-200411160-00008
Bachmann LM, Muhleisen A, Bock A, ter Riet G, Held U, Kessels AG (2008) Vignette studies of medical choice and judgement to study caregivers’ medical decision behaviour: systematic review. BMC Med Res Methodol 8(1):50. https://doi.org/10.1186/1471-2288-8-50
Khorana AA, Otten HM, Zwicker JI, Connolly GC, Bancel DF, Pabinger I, Subcommittee on H, Malignancy of the S, Standardization Committee of the International Society on T, Hemostasis (2014) Prevention of venous thromboembolism in cancer outpatients: guidance from the SSC of the ISTH. J Thromb Haemost 12(11):1928–1931. https://doi.org/10.1111/jth.12725
Farge D, Bounameaux H, Brenner B, Cajfinger F, Debourdeau P, Khorana AA, Pabinger I, Solymoss S, Douketis J, Kakkar A (2016) International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 17(10):e452–ee66. https://doi.org/10.1016/S1470-2045(16)30369-2
Scotté F, Mayeur D, Rey JB, Elalamy I, Lamblin A, Pernod G, Mahé I (2015) Influence of academic and regulatory environment on the management of cancer-associated thrombosis (CAT) in France: a survey among vascular disease and supportive care specialists. The European Cancer Congress 51:S239. https://doi.org/10.1016/S0959-8049(16)30692-X
Panizo E, Alfonso A, Garcia-Mouriz A, Lopez-Picazo JM, Gil-Bazo I, Hermida J, Paramo JA, Lecumberri R (2015) Factors influencing the use of thromboprophylaxis in cancer outpatients in clinical practice: a prospective study. Thromb Res 136(6):1145–1148. https://doi.org/10.1016/j.thromres.2015.10.015
Rhee C, Kadri SS, Danner RL, Suffredini AF, Massaro AF, Kitch BT, Lee G, Klompas M (2016) Diagnosing sepsis is subjective and highly variable: a survey of intensivists using case vignettes. Crit Care 20(1):89. https://doi.org/10.1186/s13054-016-1266-9
Saposnik G, Redelmeier D, Ruff CC, Tobler PN (2016) Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak 16(1):138. https://doi.org/10.1186/s12911-016-0377-1
Funding
The CAT AXIS study was funded by a LEO Pharma unrestricted grant.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Scotté, F., Elalamy, I., Mayeur, D. et al. Physicians’ decision about long-term thromboprophylaxis in cancer outpatients: CAT AXIS, a case vignette study on clinical practice in France. Support Care Cancer 26, 2049–2056 (2018). https://doi.org/10.1007/s00520-017-4034-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00520-017-4034-8