1. VTE Prophylaxis in the Cancer Patient The Science and Medicine of
Cancer and Thrombosis Management
VTE Prophylaxis
in the Cancer Patient
Scope, Trials, Guidelines and Solutions
Samuel Z. Goldhaber, MD
Professor of Medicine
Harvard Medical School
Cardiovascular Division
Director, Venous Thromboembolism Research Group
Brigham and Women’s Hospital
Boston, MA

2. Learning Objectives Epidemiology/ Scope of the Problem
Prophylaxis Paradigm Shift
Surgeon General’s Call To Action
Medicare’s “Never Events”
Prophylaxis Modalities
Electronic, Computerized Alerts
Human, Physician-to-Physician Alerts
Guidelines: NCCN, ASCO, ACCP

3. Epidemiology: Scope of the Problem

4. ICOPER Cumulative Mortality5 10 15 20 25
17.5%
Mortality (%) 7 14 30 60 90
Days From Diagnosis
Lancet 1999;353:

6. At-Risk for VTE
The high death rate from PE (exceeding acute MI!) and the high frequency of undiagnosed PE causing “sudden cardiac death” emphasize the need for improved preventive efforts.
Failure to institute prophylaxis is a much bigger problem with Medical Service patients than Surgical Service patients.

7. At-Risk for VTE
Two quality improvement initiatives show that among at-risk-for-VTE Medical Service patients, Medical Oncology patients are the least likely group to receive VTE prophylaxis.
80% of omitted prophylaxis on Medical Services occurred in Medical Oncology patients.

8. Annual At-Risk for VTE: U.S. Hospitals
7.7 million Medical Service inpatients
3.4 million Surgical Service inpatients
Based upon ACCP guidelines for VTE prophylaxis
Anderson FA Jr, et al. Am J Hematol; 2007; 82:

9. Outpatient and Inpatient VTE Are Linked
74% of VTEs present in outpatients.
42% of outpatient VTE patients have had recent surgery or hospitalization.
Only 40% had received VTE prophylaxis.
Spencer FA, et al. Arch Intern Med 2007; 167:

10. ENDORSE : WORLDWIDE (Lancet 2008; 371: 387-394)
68,183 patients; 32 countries; 358 sites
First patient enrolled August 2, 2006;Last patient enrolled January 4, 2007

11. Surgical Medical ENDORSE: 68,183 Patients 52% at risk for VTE
(50% receive ACCP recommended prophylaxis)
Surgical
Medical
42% at risk for VTE
64% at risk for VTE
40% receive ACCP recommended prophylaxis
59% receive ACCP recommended prophylaxis

12. VTE Prophylaxis Paradigm Shift Cancer and Medical Conditions in the Crosshairs

13. Ten Years Ago…
Most Americans had not heard of DVT (deep vein thrombosis) or PE (pulmonary embolism)
Virtually no awareness
Media attention was limited to featuring a few celebrities who were stricken
No state or congressional resolutions
No patient advocacy
No Medicare input

14. VTE Awareness in 2009 Growing interest in VTE’s public health threat
Known as the most preventable illness in hospitalized patients
Publicity is increasing among health care professionals and the public
Patient advocacy is a reality
Congress and most States have adopted months for “Thrombosis Awareness”
Medicare has declared certain DVTs or PEs as “Never Events” and will not reimburse

15. Old Prophylaxis Paradigm
MD individualizes prophylaxis prescription and ultimately has complete “yes” or “no” authority to prescribe or withhold prophylaxis
Hospital, government auditors, patients, and families do not challenge the MD’s decision to withhold prophylaxis. Instead, they “defer to the physician’s medical judgment”

16. New Prophylaxis Paradigm
Hospital monitors VTE prophylaxis prescribing and insists upon guideline-based practice
Electronic reminders and automated electronic orders ultimately ensure appropriate prophylaxis for at-risk patients
Hospital’s financial and medicolegal penalty for failure to prophylax may be “passed on” to the responsible attending physician
Cancer patients represent high-risk, “must prophylax” subgroup

17. SURGEON GENERAL: CALL TO ACTION TO PREVENT DVT AND PE September 15, 2008

18. Medicare’s “Never Events”

19. Medicare’s “Never Events”
Medicare’s most recent strategy to reduce medical errors is to withhold payment to hospitals for treatment of serious preventable illnesses or complications termed “never events.” The initial 3 were:
Foreign object retained postop
Air embolism removing CVC
Blood transfusion incompatibility

20. Medicare’s “Never Events”
On October 1, 2008, Medicare added:
DVT or pulmonary embolism occurring after total knee or hip replacement.
Medicare will not pay the incremental cost to manage the complication. Nor will the patient be responsible.
The hospital will bear the additional financial burden.

21. Prophylaxis Modalities

22. VTE Prophylaxis in 19,958 Medical Patients/ 9 Studies (Meta-Analysis)
62% reduction in fatal PE
57% reduction in fatal or nonfatal PE
53% reduction in DVT
Dentali F, et al. Ann Intern Med 2007; 146:

23. VTE Prophylaxis in Medical Patients is Cost-Effective
$1,264 per patient for LMWH
$2,245 for No Prophylaxis
Deitelzweig et al. Thromb Haemostas 2008; 100:

24. Intermittent Pneumatic Compression Meta-Analysis in Postop Patients
2,270 patients in 15 randomized trials
IPC devices reduced DVT risk by 60% (Relative Risk 0.40, 95% CI , p< 0.001)
Urbankova J. Thromb Haemost 2005; 94:

25. Reversible Risk Factors
Nutrition: eat fruits, veggies, fish; less red meat (Circulation 2007;115: )
Quit cigarettes
Lose weight/ exercise
Prevent DM/ metabolic syndrome
Control hypertension
Lower cholesterol
Avoid air pollution
Arch Intern Med 2008; 168: )

26. Statins Prevent PE and DVT!

27. Total Venous Thromboembolism
JUPITER
Total Venous Thromboembolism
0.025
HR 0.57, 95%CI
P= 0.007
0.020
Placebo 60 / 8901
0.015
- 43 %
Cumulative Incidence
0.010
Rosuvastatin 34 / 8901
0.005
0.000 1 2 3 4
Number at Risk
Follow-up (years)
Rosuvastatin
8,901
8,648
8,447
6,575
3,927
1,986
1,376
1,003
548
161
Placebo
8,901
8,652
8,417
6,574
3,943
2,012
1,381
993
556
182
Glynn et al NEJM 2009

28. Venous Thromboembolism – Unprovoked vs Provoked
JUPITER
Venous Thromboembolism – Unprovoked vs Provoked
Unprovoked Venous Thromboembolism
Provoked Venous Thromboembolism
HR 0.61, 95% CI
P= 0.09
HR 0.52, 95% CI
P= 0.03
0.020
0.020
0.015
0.015
Cumulative Incidence
Cumulative Incidence
0.010
Placebo
0.010
Placebo
0.005
0.005
Rosuvastatin
Rosuvastatin
0.000
0.000 1 2 3 4 1 2 3 4
Follow-up (years)
Follow-up (years)
Clear clinical benefit in the absence of any bleeding hazard
(hemorrhagic events: rosuvastatin 258, placebo 275, P=0.45)
Glynn et al NEJM 2009

29. Electronic and “Human” Prophylaxis Alerts Implications for Cancer Patients

30. Randomization in ALERT Study
VTE risk score > 4
No prophylaxis
N = 2,506
INTERVENTION:
Single alert
N = 1,255
CONTROL
No computer alert
N = 1,251
Kucher N, et al. NEJM 2005;352:

32. Primary End Point Intervention Control %Freedom from DVT/ PE
Time (days) 30 60 90
%Freedom from DVT/ PE 92 94 96 98
100
Number at risk
Intervention
1255
977
900
853
Control
1251
976
893
839
Kucher N, et al. NEJM 2005;352:

33. Electronic Alerts Halve Rate of PE and Maintain Effectiveness
VTE Rate:
Pre-Alert 2005—3.3/1000
Post-Alert 2006—1.7/1000
Post-Alert 2007—1.7/1000
Thromb Haemost 2008; 100:

34. “Human” Physician Alert
As we planned a multicenter randomized trial applying the electronic alert strategy to a broad array of hospitals across the U.S., we learned that replication of our electronic alert was not feasible.
Therefore, we crafted a strategy that employed a “human” rather than electronic alerting system.
The physician alert consisted of a direct page from a hospital staff member to the Attending Physician.
The primary end point was reduction in symptomatic VTE within 90 days of randomization.

35. Physician Alert: Results
2493 patients (82% on Medical Services) from 25 study sites were randomized to the intervention (n=1238) versus the control group (n=1255).
Patients whose physicians were alerted were more than twice as likely to receive VTE prophylaxis (46.0% versus 20.6%, p<0.0001).
The symptomatic VTE rate was lower in the intervention group (2.7% versus 3.4%; hazard ratio, 0.79; 95% confidence interval, 0.50 to 1.25), but the difference did not achieve statistical significance.
Major bleeding at 30 days in the alert group was similar to the control group.
Risk score validated in e-alert

36. Physician Alert: Results
Piazza G. Circulation 2009;119:
100%
98%
96%
94%
92%
90%
Time after initial enrollment (days)
Freedom from Primary Endpoint
Wilcoxon P-value: 0.307; Long-Rank P-value: 0.309
Human Alert No Alert

37. Current Status of ASCO and NCCN Guidelines for VTE Prophylaxis in Cancer Patients

38. Hospitalized Patients with Cancer
ASCO Guidelines
Hospitalized Patients with Cancer
Role of VTE Prophylaxis
Evidence
Patients with cancer should be considered candidates for VTE prophylaxis with anticoagulants (UFH, LMWH, or fondaparinux) in the absence of bleeding or other contraindications to anticoagulation
Multiple RCTs of hospitalized medical patients with subgroups of patients with cancer. The 8th ACCP guidelines strongly recommend (1A) prophylaxis with either low-dose heparin or LMWH for bedridden patients with active cancer.

39. Role of VTE Prophylaxis
Ambulatory Patients with Cancer Without VTE Receiving Systemic Chemotherapy
Role of VTE Prophylaxis
Evidence
Routine prophylaxis with an antithrombotic agents is not recommended except as noted below
Routine prophylaxis in ambulatory patients receiving chemotherapy is not recommended due to conflicting trials, potential bleeding, the need for laboratory monitoring and dose adjustment, and the relatively low incidence of VTE.
LMWH or adjusted dose warfarin (INR ~ 1.5) is recommended in myeloma patients on thalidomide or lenalidomide plus chemotherapy or dexamethasone
This recommendation is based on nonrandomized trial data and extrapolation from studies of postoperative prophylaxis in orthopedic surgery and a trial of adjusted-dose warfarin in breast cancer

40. Patients with Cancer Undergoing Surgery
Role of VTE Prophylaxis
Evidence
All patients undergoing major surgical intervention for malignant disease should be considered for thromboprophylaxis with low- dose UFH, LMWH, or fondaparinux starting as early as possible for at least 7-10 days unless contraindicated.
RCTs of UFH and those comparing the effects of LMWH and UFH on DVT rates on patients with cancer indicate broadly similar prophylactic efficacies for these two agents
Mechanical methods may be added to anticoagulation in very high risk patients but should not be used alone unless anticoagulation in contraindicated.
A Cochrane review of 19 studies

41. Undergoing Surgery (continued)
Patients with Cancer
Undergoing Surgery (continued)
Role of VTE Prophylaxis
Evidence
LMWH for up to 4 weeks may be considered after major abdominal/pelvic surgery with residual malignant disease, obesity, and a previous history of VTE
Recent RCTs suggest that prolonging prophylaxis up to 4 weeks is more effective than short-course prophylaxis in reducing postoperative VTE.

42. Treatment of Patients with Established VTE to Prevent Recurrence
Role of VTE Prophylaxis
Evidence
LMWH is the preferred approach for the initial 5-10 days in cancer patient with established VTE.
LMWH for 3-6 months is more effective than vitamin K antagonists given for a similar duration for preventing recurrent VTE.
LMWH for at least 6 months is preferred for long-term anticoagulant therapy. Vitamin K antagonists with a targeted INR of 2-3 are acceptable when LMWH is not available. The CLOT study demonstrated a relative risk reduction of 49% with LMWH vs. a vitamin K antagonist. Dalteparin sodium approved by the FDA for extended treatment of symptomatic VTE to reduce the risk of recurrence of VTE in patients with cancer (FDA 2007)

43. Role of VTE Prophylaxis
Treatment of Patients with Established VTE to Prevent Recurrence (continued)
Role of VTE Prophylaxis
Evidence
Anticoagulation for an indefinite period should be considered for patients with active cancer (metastatic disease, continuing chemotherapy)
In the absence of clinical trials, benefits and risks of continuing LMWH beyond 6 months is a clinical judgment in the individual patient. Caution is urged in elderly patients and those with intracranial malignancy.
Inferior vena cava filters are reserved for those with contraindications to anticoagulation or PE despite adequate long-term LMWH.
Consensus recommendations due to lack of date in cancer-specific populations

44. Anticoagulants in the Absence of Established VTE to Improve Survival
Role of VTE Prophylaxis
Evidence
Anticoagulants are not currently recommended to improve survival in patients with cancer without VTE.
RCTs and meta-analysis of warfarin, UFH and LMWH have reported encouraging but variable results generally showing clinical benefit only in subgroup analyses.

45. Summary of the Guidelines Updates
Summary of Major Changes in the Version of the Venous Thromboembolic Disease Guidelines

46. Changes in 2009 NCCN Guidelines
Stage 1 Immediate:
“Stage 1 Immediate: Concomitant with diagnosis or while diagnosis and risk assessment (heparin phase)” changed to “Stage 1 Immediate: At diagnosis or during diagnostic evaluation”
Low –molecular-weight-heparin: New footnote “6” was added that states, “Although each of the low molecular weight heparins (LMWH), have been studies in randomized control trials in cancer patients, dalteparin’s efficacy in this population is supported by the highest quality evidence and it is the only LMWH approved by the FDA for this indication.”
Unfractionated heparin (IV): target aPTT range changed from “ x control) to “ x control…” (Also for VTE-H) in these patients.

47. Changes in 2009 NCCN Guidelines
Stage 3 Chronic:
“Third bullet: “Consider indefinite anticoagulation….” changed to “Recommend indefinite anticoagulation….”
Fourth bullet: “For catheter associated thrombosis, anticoagulate as long as catheter is in place and for at least 3 months after catheter removal”.

48. Changes in 2009 NCCN Guidelines
6Although each of the low molecular weight heparins (LMWH) have been studied in randomized controlled trials in cancer patients, dalteparin’s efficacy in this population is supported by the highest quality evidence and is the only LMWH approved by the FDA for this indication.
Lee AYY, Levine MN, Baker RI, Bowden C, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism on patients with cancer. New Eng J Med 2003;349(2):

49. (VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism
The NCCN panel recommends VTE thromboprophylaxis for all hospitalized patients with cancer who do not have contraindications to such therapy, and the panel also emphasized that an increased level of clinical suspicion of VTE should be maintained for cancer patients. Following hospital discharge, it is recommended that patients at high-risk of VTE (e.g. cancer surgery patients) continue to receive VTE prophylaxis for up to 4 weeks post-operation. Careful evaluation and follow-up of cancer patients in whom VTE is suspected and prompt treatment and follow-up for patients diagnosed with VTE is recommended after the cancer status of the patient is assessed and the risks and benefits of treatment are considered.

50. (VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism
Stage 1 Immediate: At diagnosis or during diagnostic evaluation:
Low-molecular-weight heparin (LMWH)
Dalteparin (200 units/kg subcutaneous daily)
Enoxaparin (1 mg/kg subcutaneous every 12 hours)
Tinzaparin (175 units/kg subcutaneous daily)
Fondaparinux (5 mg [<50 kg]; 7.5 mg [ kg]; 10 mg [> 100 kg] subcutaneous daily
Unfractionated heparin (IV) (80 units/kg load, then 18 units/kg per hour, target aPTT of x control or per hospital SOP)

51. (VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism
Additional VTE risk factors for surgical oncology patients with a previous episode of VTE include anesthesia times longer than 2 hours, advanced stage disease, bed rest, > 4 days and patients age 60 years or older. Extended prophylaxis out to 4 weeks post-surgery was associated with a greater than 50% reduction in venographic VTE

52. (VTE-D): Therapeutic Anticoagulation Treatment for VenousThromboembolism
Stage 2 Acute: Short term, during transition to chronic phase:
LMWH (category 1) is preferred as monotherapy without warfarin in patients with proximal DVT or PE and prevention of recurrent VTE in patients with advanced or metastatic cancer
If UFH or factor Xa antagonist, transition to LMWH or warfarin
Warfarin (2.5-5 mg every day initially, subsequent dosing based on INR value; target INR )

53. Therapeutic Anticoagulation Failure
INR
Switch to heparin (LMWH preferred) or fondaparinux
Increase warfarin dose and treat with parenteral agent until INR target achieved or consider switching to heparin (LMWH preferred) or fondaparinux
Patient on
warfarin
Check
Sub-therapeutic

54. Therapeutic Anticoagulation Failure
aPTT
Increase dose of heparin
or Switch to LMWH
or Switch to fondaparinux
and Consider placement
of IVC filter
and Consider HIT
Increase dose of heparin to reach therapeutic level
Patient on
heparin
Check
aPTT levels
Sub-therapeutic

55. Improving VTE Prophylaxis in Cancer
“Immunize” cancer patients with LMWH unless MD “opts out”—analogous to flu vaccine or pneumonia vaccine
Pay attention to the Continuum of Care and to VTE risk at the time of Discharge—Order discharge LMWH
Withhold payments to hospitals when DVT/ PE develops after total hip or knee replacement—Medicare began this practice in October 2008

56. Conclusions
VTE prophylaxis has enjoyed a paradigm shift. Gone are the days when the imperial physician reigned unchallenged on VTE prophylaxis decisions. Hospitals and Medicare are scrutinizing implementation of prophylaxis.
Hospital-acquired VTE is not supposed to happen any longer. Medicare is declaring some VTEs “Never Events” and will not reimburse hospitals for additional treatment.
Effective VTE prophylaxis in cancer patients usually requires anticoagulation with LMWH but when bleeding risk is too high, use mechanical measures.
DVT prophylaxis in cancer patients is under-utilized and requires increased vigilance and prophylaxis-focused intervention

57. Conclusions
DVT prophylaxis following cancer surgery for four weeks is recommended; longer periods may be necessary depending on risk assessment
DVT prophylaxis following established DVT in cancer for at least 6 months is recommended and for longer, indefinite periods with active cancer and/or chemotherapy.
Heart healthy lifestyle and statins reduce VTE risk
Electronic, computerized alerts can reduce symptomatic VTE by at least 40%.
When “human” alerts are used, symptomatic VTE is reduced by about 20%.
PE/ DVT patients with cancer warrant LMWH monotherapy.