Venous Thromboembolism Risk and Prophylaxis Practices in Surgical Patients with Active Cancer: Findings from the Global ENDORSE Survey.
Authors: Kakkar Ajay K , Cohen Alexander T , Tapson Victor F , Bergmann Jean-Francois , Goldhaber Samuel Z. , Anderson Frederick A 
Published: October 2019

Abstract
Introduction : Cancer patients undergoing surgery have double the risk for VTE compared with non-cancer patients (Thromb Haemost2003;90:446–55). Current ACCP guidelines advocate the use of VTE prophylaxis in patients with active malignancy undergoing major surgical procedures. The recent ENDORSE survey reported that globally, 64% of patients admitted to surgical wards were at risk for VTE, and only 59% of these received ACCP-recommended prophylaxis (Lancet2008;371:387–94). In this subanalysis of ENDORSE, we evaluated the prevalence of VTE risk and prophylaxis practices in surgical patients with active malignancy.
Methods: The ENDORSE study evaluated data from 30,827 patients admitted to surgical wards in 358 hospitals across 32 countries (Lancet2008;371:387–94). The influence of active malignancy on VTE risk and prophylaxis use was assessed in patients who had undergone abdominal, urological or gynecological surgery. Patient data were grouped and analyzed according to whether the surgery was related to a cancer diagnosis (surgery for cancer) or performed in patients without a cancer diagnosis (no cancer). Risk for VTE and use of appropriate prophylaxis was evaluated according to the 2004 ACCP-guidelines (Chest2004;126:338S–400S). Bleeding risk factors considered sufficient to present a contraindication to anticoagulant use included intracranial hemorrhage, bleeding at hospital admission, presence of a known bleeding disorder and clinically relevant hepatic impairment.
Results: Of the 30,827 patients in surgical wards evaluated in ENDORSE, 18,461 had undergone major surgery as of the date of the survey, including 6172 patients who had abdominal, urological or gynecological operations and were considered at risk for VTE. All patients with a cancer diagnosis who underwent these types of surgery were considered at-risk for VTE, including 1767 patients whose surgical procedure was related to their diagnosis and 101 patients who underwent surgery unrelated to cancer. The proportion of patients receiving any ACCP-recommended prophylaxis ranged from 60% in patients undergoing surgery for urologic cancer to 86% in patients undergoing surgery for rectosigmoid cancer. Patients who had surgery related to their cancer had a higher rate of ACCP-recommended prophylaxis use, compared with patients who underwent surgery with no cancer diagnosis (Table). The proportion of patients considered to have bleeding risk sufficient to present a contraindication to anticoagulant use was 10.4% (surgery for cancer) and 10.9% (no cancer; Table). Fewer patients without a cancer diagnosis received anticoagulant prophylaxis, compared with those undergoing cancer-related surgery (Table).
Table: VTE prophylaxis practice according to the presence of active malignancy.
Surgery type At-risk receiving ACCP-recommendedprophylaxis n/N (%) Contrain-dications to anticoagulant use, n (%) Anticoagulant alone, n (%) Mechanical alone, n (%) Both, n (%) *4304 of 5097 patients without a cancer diagnosis were considered at risk for VTE Surgery for cancer (N=1767) 1295/1767 (73.3) 183 (10.4) 820 (46.4) 136 (7.7) 412 (23.3) No cancer (N=5097) 2495/4304* (58.0) 470 (10.9) 1455 (33.8) 426 (9.9) 762 (17.7)
Conclusion: The use of any type of ACCP-recommended VTE prophylaxis varied according to the type of cancer for which the surgery was performed. Although all cancer patients who undergo abdominal, urological or gynecological surgery are at risk for VTE, the results suggest that up to 30% of cancer patients where surgery is performed related to a cancer diagnosis do not receive ACCP-recommended prophylaxis. Less than 11% of patients who had surgery regardless of whether it was related to a cancer diagnosis had a bleeding risk sufficient to present a contraindication to anticoagulant use. These findings suggest that despite the existence of clear evidence-based guidelines, the use of VTE prophylaxis in cancer patients remains suboptimal.