Extended perioperative thromboprophylaxis in patients with cancer
A systematic review
Elie A. Akl
1
Department of Medicine, State University of New York at Buffalo, New York, USA
,
Irene Terrenato
2
Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
,
Maddalena Barba
2
Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
,
Francesca Sperati
2
Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
,
Paola Muti
2
Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
,
Holger J. Schünemann
2
Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy
3
CLARITY Research Group, Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Ontario, Canada
› InstitutsangabenFinancial support: This study was funded through institutional support. HJS is funded by a European Commission: The human factor, mobility and Marie Curie Actions. Scientist Reintegration Grant (IGR 42192).
We systematically reviewed the literature to compare the relative efficacy and safety of extended versus limited duration heparin for perioperative thromboprophylaxis in patients with cancer. We followed the Cochrane Collaboration systematic review methodology and searched MEDLINE, EMBASE, ISI the Web of Science, and CENTRAL. The outcomes of interest included mortality, symptomatic deep venous thrombosis (DVT), pulmonary embolism, and bleeding. We evaluated the quality of evidence by outcome using the GRADE approach. Of 3,986 identified citations, we included three randomized clinical trials using low-molecular-weight heparin (LMWH).The quality of evidence for mortality, DVT, and major bleeding was low. There was no significant difference between extended (4 weeks) and limited duration thromboprophylaxis in terms of death at three months (relative risk [RR]=0.49; 95% confidence interval [CI] 0.12–1.94), or major bleeding at four weeks (RR=2.94; 95% CI 0.12–71.85).An extended regimen was associated with a significantly lower risk of asymptomatic DVT (RR=0.21; 95% CI 0.05–0.94). No data was available for symptomatic DVT. In conclusion, there is limited and low-quality evidence that extended duration LMWH for perioperative thromboprophylaxis reduces DVT in patients with cancer undergoing major abdominal or pelvic surgery. More and better quality evidence is needed to justify extended regimens.
Keywords
Cancer -
heparins -
surgery -
prophylaxis -
thrombosis
2
Levitan N,
Dowlati A,
Remick SC.
et al. Rates of initial and recurrent thromboembolic disease among patients with malignancy versus those without malignancy. Risk analysis using Medicare claims data. Medicine 1999; 78: 285-291.
3
Hutten BA,
Prins MH,
Gent M.
et al. Incidence of recurrent thromboembolic and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol 2000; 18: 3078-3083.
4
Akl EA,
Terrenato I,
Barba M.
et al. Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer: a systematic review and a meta-analysis. Arch Intern Med 2008; 168: 1261-1269.
5
Guyatt GH,
Oxman AD,
Vist GE.
et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Br Med J 2008; 336: 924-926.
6
Bergqvist D,
Agnelli G,
Cohen AT.
et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. New Engl J Med 2002; 346: 975-980.
7
Rasmussen MS,
Jorgensen LN,
Wille-Jorgensen P.
et al. Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open-label study. J Thromb Haemost 2006; 04: 2384-2390.
8
Jorgensen LN,
Lausen I,
Rasmussen MS.
et al. Prolonged thromboprophylaxis with low molecular weight heparin (tinzaparin) following major general surgery primarily for cancer: An individual patient data meta-analysis. J Thromb Haemost 2003; 01 (Suppl. 01) P1870.
9
Jorgensen LN,
Lausen I,
Rasmussen MS.
et al. Prolonged thromboprophylaxis with low-molecular weight heparin following major general surgery: an individual patient data meta-analysis. Blood 2002; 100 Suppl. 1952.
10
Lausen I,
Jensen R,
Jorgensen LN.
et al. Incidence and prevention of deep venous thrombosis occurring late after general surgery: randomised controlled study of prolonged thromboprophylaxis. Eur J Surg 1998; 164: 657-663.
12
Akl EA,
Kamath G,
Kim SY.
et al. Oral anticoagulation for prolonging survival in patients with cancer. Cochrane Database Syst Rev 2007; 02: CD006466.
13
Akl EA,
van Doormaal FF,
Barba M.
et al. Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation. Cochrane Database System Rev 2007; 03: CD006652.
14
Geerts WH,
Bergqvist D,
Pineo GF.
et al. Prevention of Venous Thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). 2008: 381S-453.
15
Lyman GH,
Khorana AA,
Falanga A.
et al. American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 2007; 25: 5490-5505.
17
Bottaro FJ,
Elizondo MC,
Doti C.
et al. Efficacy of extended thrombo-prophylaxis in major abdominal surgery: What does the evidence show? - A meta-analysis. Thromb Haemost 2008; 99: 1104-1111.
19
Arcelus JI,
Monreal M,
Caprini JA.
et al. Clinical presentation and time-course of postoperative venous thromboembolism: Results from the RIETE Registry. Thromb Haemost 2008; 99: 546-551.
21
Seddighzadeh A,
Zurawska U,
Shetty R.
et al. Venous thromboembolism in patients undergoing surgery: low rates of prophylaxis and high rates of filter insertion. Thromb Haemost 2007; 98: 1220-1225.
