Thromboprophylaxis practice patterns and beliefs among physicians treating patients with abdominopelvic cancers at a Canadian centre

Thromboprophylaxis practice patterns and beliefs among physicians treating patients with abdominopelvic cancers at a Canadian centre

Can J Surg 2020;63(6):E562-E568 | Full Text | PDF | Appendix

Kristen McAlpine, MD; Rodney H. Breau, MD, MSc; Marc Carrier, MD; Philippe D. Violette, MD; Christopher Knee, ND, MSc; Ilias Cagiannos, MD; Christopher Morash, MD; Luke T. Lavallée, MDCM, MSc

Abstract

Background: There is inadequate high-quality evidence on thromboprophylaxis for patients undergoing surgery for abdominopelvic cancer. We surveyed physicians who treat patients with abdominopelvic cancer to determine current thromboprophylaxis practice patterns and to determine where research is needed.

Methods: We created an online survey with questions on thromboprophylaxis topics, including type of thromboprophylaxis used, timing of initial thromboprophylaxis dose, use of thromboprophylaxis during chemotherapy, use of extended-duration thromboprophylaxis and areas for future research. The survey questions were reviewed by external content experts to ensure they were appropriate and relevant. Surgeons, thrombosis experts and medical oncologists who manage patients with abdominopelvic cancers at 1 large Canadian academic centre were invited to complete the survey between January and April 2019.

Results: Of the 57 physicians invited, 42 (74%) completed the survey, including 27 surgeons (response rate 79%), 9 thrombosis experts (response rate 75%) and 6 medical oncologists (response rate 55%). Most surgeons (22 [82%]) reported using mechanical thromboprophylaxis, whereas only 1 thrombosis expert (11%) recommended mechanical thromboprophylaxis. There was substantial variability in the timing of the initial dose of thromboprophylaxis, with 9/10 urologists (90%) and all 7 general surgeons giving the first dose intraoperatively, and three-quarters of thoracic surgeons (3/4 [75%]), gynecologists (3/4 [75%]) and thrombosis experts (7/9 [78%]) starting thromboprophylaxis after surgery. All medical oncologists believed chemotherapy increases the risk of venous thromboembolism, but 4 (67%) reported that they do not routinely prescribe thromboprophylaxis owing to bleeding concerns. Most respondents (35/38 [92%]) felt there was a need for more research on thromboprophylaxis and indicated willingness to participate in future clinical trials.

Conclusion: Variability exists in contemporary thromboprophylaxis practice patterns among physicians treating patients with abdominopelvic cancer. Future research is needed to standardize care and improve outcomes for patients.

Résumé

Contexte : On manque de données de qualité élevée sur la thromboprophylaxie chez les patients traités en chirurgie pour un cancer abdomino-pelvien. Nous avons sondé des médecins traitant ces patients afin de déterminer les tendances actuelles relatives à cette pratique et pour cerner les besoins en recherche.

Méthodes : Nous avons créé un sondage en ligne sur la thromboprophylaxie, comprenant des questions sur le type utilisé, le moment d’administration de la dose initiale, le recours durant la chimiothérapie, l’utilisation prolongée et les domaines de recherche à explorer. Les questions ont été validées par des experts de contenu externes, qui ont veillé à ce qu’elles soient appropriées et pertinentes. Des chirurgiens, des experts en thrombose et des oncologues qui s’occupent de patients atteints de cancers abdomino-pelviens dans un grand centre hospitalier universitaire canadien ont été invités à remplir le sondage entrer janvier et avril 2019.

Résultats : Des 57 médecins sollicités, 42 (74 %) ont répondu au sondage, dont 27 chirurgiens (taux de réponse de 79 %), 9 experts en thrombose (taux de réponse de 75 %) et 6 oncologues (taux de réponse de 55 %). La majorité des chirurgiens (22 [82 %]) recouraient à la thromboprophylaxie mécanique, alors qu’un seul expert en thrombose (11 %) recommandait cette pratique. Le moment d’administration de la dose initiale variait considérablement : 9 urologues sur 10 (90 %) et chacun des 7 chirurgiens généralistes administraient la première dose durant l’opération, alors que les trois quarts des chirurgiens thoraciques (3/4 [75 %]), des gynécologues (3/4 [75 %]) et des experts en thrombose (7/9 [78 %]) commençaient la thromboprophylaxie après l’intervention. Tous les oncologues étaient d’avis que la chimiothérapie augmentait le risque de thromboembolie veineuse, mais 4 (67 %) ont indiqué qu’ils ne prescrivaient pas d’emblée de thromboprophylaxie en raison des risques de saignements. La plupart des répondants (35/38 [92 %]) considéraient qu’il faudrait étudier davantage la thromboprophylaxie et ont indiqué leur volonté de participer à d’éventuels essais cliniques.

Conclusion : À l’heure actuelle, les pratiques liées à la thromboprophylaxie varient chez les médecins traitant des patients atteints de cancers abdomino-pelviens. Il faudra mener d’autres études pour normaliser la prestation des soins et améliorer les résultats pour les patients.


Accepted Jan. 20, 2020

Affiliations: From the Division of Urology, University of Ottawa, Ottawa, Ont. (McAlpine, Breau, Knee, Cagiannos, Morash, Lavallée); the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ont. (Breau, Carrier, Knee, Cagiannos, Morash, Lavallée); the Department of Medicine, University of Ottawa and The Ottawa Hospital, Ottawa, Ont. (Carrier); and the Departments of Health Research Methods, Evidence, and Impact and of Surgery, McMaster University, Hamilton, Ont. (Violette).

Competing interests: Marc Carrier reports grant funding from Bristol- Myers Squibb, LEO Pharma and Pfizer, and consulting fees from Bayer, Bristol-Myers Squibb, LEO Pharma, Sanofi and Servier, outside the submitted work. Christopher Morash participated in an advisory board run by Sanofi, outside the submitted work. Luke Lavallée reports a quality-improvement grant from Sanofi and advisory board participation for AbbVie, Bayer, Sanofi and Ferring, outside the submitted work. No other competing interests were declared.

Contributors: K. McAlpine, R. Breau, C. Knee, C. Morash and L. Lavallée designed the study. K. McAlpine, C. Knee, I. Cagiannos, C. Morash and L. Lavallée acquired the data, which K. McAlpine, R. Breau, M. Carrier, P. Violette, C. Knee, C. Morash and L. Lavallée analyzed. K. McAlpine, R. Breau and L. Lavallée wrote the article, which all authors critically reviewed. All authors gave final approval of the article to be published.

DOI: 10.1503/cjs.015219

Correspondence to: L. Lavallée, Ottawa Hospital Research Institute, Division of Urology, The University of Ottawa, General Campus, 501 Smyth Rd, PO Box 222, Ottawa ON K1H 8L6, lulavallee@toh.ca