Extended venous thromboprophylaxis post colorectal cancer surgery

Title: Extended venous thromboprophylaxis post colorectal cancer surgery; A survey of current practice

Aims: A pan-UK survey to determine current practice in every acute NHS hospital undertaking elective colorectal cancer surgery with regards extended VTE prophylaxis.

Background: Colorectal cancer is a risk factor for venous thromboembolism (VTE).  The incidence of VTE in colorectal cancer patients is 13.4 (95%CI 10.8 – 16.6) per thousand patients per year compared to the whole population incidence of 1.83 (95% CI 1.69 – 1.98) per thousand population per year12.  The development of a VTE is associated with a poor outcome and patients who develop postoperative VTE have an increased mortality.  In a retrospective cohort study of 44,656 patients undergoing elective surgery for a range of cancers there was a 6-fold increase in 30 day mortality in patients with VTE compared to those without3.  A prospective, observational study of 4466 consecutive patients undergoing chemotherapy for various cancers revealed that 9.2% of the 141 patients who died during the period of the study (median period 75 days) died as a result of arterial or venous thrombosis. This was the second highest cause of death after cancer, and the same rate as infection4.

In an autopsy based study, 20% of the colorectal cancer patients underwent autopsy had died from PE5.  Of these, 10% had local or regional disease and 50% had limited metastatic disease, thus 60% had disease that had potentially curative disease.

It has also been demonstrated that a large number patients who develop a VTE do so following their discharge from hospital.  One study found that 33.9% patients undergoing colonic resection who developed a VTE did so after discharge from hospital3.  This finding has led to international guidance that patients undergoing surgery for colorectal cancer receive extended prophylaxis (up to 4 weeks post major cancer surgery)67.   In the UK this guidance has been incorporated in the most recent NICE guidance regarding venous thromboprophylaxis.  The guidance recommends the use of both in hospital and extended course venous thromboprophylaxis in patients undergoing abdominal or pelvic surgery for cancer8. The national picture regarding the use of extended course venous thromboprophylaxis is not known.

Methods: This study is a pan-UK survey, to determine current practice in every acute NHS hospital undertaking elective colorectal cancer surgery with regards extended VTE prophylaxis. We used a novel method for data collection, using a freedom of information (FOI) request, submitted to each of the UK NHS hospital trusts to determine the local policies for VTE in colorectal surgery. Hospital sites will be compared with comparisons to NICE guidance to identify the current practices in the UK

Progress: This study protocol was presented as a novel method at the National Research Collaborative meeting in 2016. Data collection is currently nearing completion and results will be disseminated soon.

References

1. Blom JW, Vanderschoot JPM, OostindiËR MJ, Osanto S, Van Der Meer FJM, Rosendaal FR. Incidence of venous thrombosis in a large cohort of 66 329 cancer patients: results of a record linkage study. Journal of Thrombosis and Haemostasis 2006;4(3):529-35.

2. Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost 2000;83(5):657-60.

3. Merkow RP, Bilimoria KY, McCarter MD, Cohen ME, Barnett CC, Raval MV, et al. Post-discharge venous thromboembolism after cancer surgery: extending the case for extended prophylaxis. Annals of Surgery 2011;254(1):131-37.

4. Khorana A, Francis C, Culakova E, Kuderer N, Lyman G. Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy. Journal of Thrombosis and Haemostasis 2007;5(3):632-34.

5. SHEN VS, POLLAK EW. Fatal Pulmonary Embolism in Cancer Patients: Is Heparin Prophylaxis Justified. Southern Medical Journal 1980;73(7):841-43.

6. Farge D, Debourdeau P, Beckers M, Baglin C, Bauersachs RM, Brenner B, et al. International clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Journal of Thrombosis and Haemostasis 2013;11(1):56-70.

7. Lyman GH, Khorana AA, Kuderer NM, Lee AY, Arcelus JI, Balaban EP, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. Journal of Clinical Oncology 2013;31(17):2189-204.

8. NICE. Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital (CG92). London: National Institute for Health and Care Excellence, 2010.

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