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Primary VTE Prevention for Patients with Cancer
Based on results from randomized trials, current guidelines recommend primary prophylaxis against venous thromboembolism (VTE) for high-risk outpatients with cancer (J Clin Oncol 2023; 41:3063). However, few ambulatory patients with cancer receive VTE prophylaxis. Australian investigators identified 200 high-risk outpatients — defined as those with either elevated fibrinogen or D-dimer levels — who were being treated for gastrointestinal (GI) or lung cancer and randomized them to receive either low-molecular-weight heparin (LMWH) VTE prophylaxis or no prophylaxis. In addition, 128 low-risk patients (without elevation of fibrinogen or D-dimer) were followed in a low-risk observational arm.
In the randomized comparison between LMWH and no LMWH among high-risk patients, the LMWH group had significantly fewer thromboembolic events (8% vs. 23%; number needed to treat, 7) and significantly lower 6-month mortality (13% vs. 26%; NNT, 6). In the low-risk observational cohort, thromboembolism occurred in 8% of patients, and 6-month mortality was 7%. Bleeding was uncommon (<2%) and not different among groups.
Comment
This study adds to the evidence showing that high-risk outpatients with lung or GI cancer — when appropriately risk stratified — can benefit substantially from pharmacologic VTE prophylaxis. Risk stratification in this trial was done with D-dimer and fibrinogen levels, but other validated tools also are available (e.g., the Khorana Risk Score). Despite lack of blinding, this study should persuade physicians to provide VTE prophylaxis to high-risk outpatients with cancer; direct-acting oral anticoagulants are an acceptable alternative to LMWH. In an accompanying editorial, Dr. Khorana (who developed the aforementioned risk score) calls for systematic efforts to improve access to prophylaxis in suitable patients.
Citation(s)
Author:
Alexander M et al.
Title:
Risk-directed ambulatory thromboprophylaxis in lung and gastrointestinal cancers: The TARGET-TP randomized clinical trial.
Source:
JAMA Oncol
2023
Nov
; [e-pub].
(Abstract/FREE Full Text)
Author:
Khorana AA.
Title:
Primary thromboprophylaxis in people with cancer — Where next?
Source:
JAMA Oncol
2023
Nov
; [e-pub].
(Abstract/FREE Full Text)
Empfohlen von
Daniel D. Dressler, MD, MSc, MHM, FACP