Venous thromboembolism risk stratification in medically-ill hospitalized cancer patients. A comprehensive cancer center experience

Abstract

Cancer and its treatment are recognized risk factors for VTE. Compliance rate with published VTE prophylaxis guidelines is low. Decision on when to offer prophylaxis for hospitalized cancer patients is difficult to make. This paper describes current clinical practice in offering VTE prophylaxis to hospitalized cancer patients. Prophylaxis rate and rate of VTE will be correlated with the risk level. We prospectively followed all consecutive adult cancer patients admitted to medical units over a 5-month period. Caprini risk assessment model, with some modifications, was utilized to determine risk of VTE. Six hundred and six patients (51% males, median age 52 years, range 18-91) were included. Reasons for admission included infections (25%), chemotherapy (22%) and palliative care (10%). In addition to cancer, the most frequently encountered risk factors for VTE were: Immobilization (35%), age > 60 years (31%) and body mass index > 30 in (20%). Patients were grouped according to their total risk score: low (9%), moderate (44%) and high risk (47%). VTE prophylaxis rate was 55.1% for the whole study group. Following discharge, patients were followed for 60 days. The incidence of VTE was 3.4% in the moderate and 4.2% in the high risk groups, while none in the low risk group developed VTE. Many additional risk factors for VTE are usually encountered in hospitalized cancer patients. Cancer alone may not be an enough reason for VTE prophylaxis. Risk assessment model able to stratify patients into different risk categories will simplify decision making and enhance VTE prophylaxis rate.

Risk of Venous Thromboembolism in Patients with Cancer: A Systematic Review and Meta-Analysis

“…Of these, 46 reports from 38 individual cohorts (studies) were included in the review [19],[20],[23]–[66] (Figure 1). There were six separate papers from a single cohort from California (one providing incidence rates of VTE for 15 separate cancer types [33], and five individual reports focussing on cancers of the lung, breast, bowel, brain, and leukaemia [24],[32],[34],[45],[56]).…”

“…Studies were classed as high risk when follow-up commenced following outpatient chemotherapy ( n  = 9), surgery ( n  = 8), inpatient hospitalisation (not specifically for surgery, n  = 2), or a receipt of a mixture of treatment types ( n  = 7), or because either all or the majority of patients had advanced or metastatic cancer at baseline ( n  = 5). Prophylaxis was administered to either some (>20%) or all of the participants in 11 studies; with this intervention taking the form of either anticoagulant prophylaxis (with or without mechanical methods) [23],[31],[47],[53],[55],[58],[59], mechanical prophylaxis only [25],[27], aspirin [42], or unspecified prophylaxis [28]. In a further six studies it was stated explicitly that no patients [20],[26],[37],[38],[43],[44] were receiving anticoagulant prophylaxis, and in two further studies [29],[66] there was a small number (<5%) receiving warfarin or heparin.…”

“…Where information on prophylaxis use in study participants was available, prophylaxis reflected existing guidelines, with anticoagulant prophylaxis given to medical inpatients [23],[53] and those undergoing surgical procedures for either brain [31],[58],[59], lung [28],[47], or prostate [55] tumours. In recent years, the trend towards shorter inpatient hospital stays and improved advice in terms of ambulation, in addition to prophylaxis, might have resulted in lower rates of VTE than in the past, especially among surgical patients.…”

Risk assessment models for cancer‐associated venous thromboembolism

“…The application of this risk model is limited by the small number of patients used to develop this risk model and the need for external validation of the tool. A recent prospective, observational study83 used the Caprini risk assessment model,84 applying it to cancer patients hospitalized because of infections, chemotherapy, or palliative care. This model assigns the same risk score to all patients with cancer, not distinguishing between any features such as the primary site, stage, or active treatment.…”

Assessment of the Risk of Venous Thromboembolism in Medical Inpatients using the Padua Prediction Score and Caprini Risk Assessment Model

“…Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major and potentially life-threatening complication among medical inpatients. It has been reported that 50%–75% of cases of VTE in hospitalized patients occur in those being treated for medical conditions, and that the incidence of fatal PE is higher in medical patients compared with surgical patients 1 – 4 ) . Evidence clearly demonstrates that prophylaxis significantly reduces the incidence of VTE 5 – 7 ) , and most guidelines recommend the use of prophylaxis for medical inpatients at an increased risk of developing VTE 8 , 9 ) .…”