Management of Cancer-Associated Venous Thromboembolism in Patients with Concomitant Thrombocytopenia: A Survey of Canadian Practitioners
Bibliographic record
Abstract
INTRODUCTION: Both venous thromboembolism (VTE) and thrombocytopenia are common in cancer patients. The management of cancer-associated thrombosis (CAT) in the context of thrombocytopenia remains an important area of clinical equipoise; a paucity of evidence to support management strategies implies that guidelines and consensus statements rely on expert opinion. We aimed to characterize the practices of Canadian practitioners in the treatment of CAT in thrombocytopenic patients. METHODS: In May to July 2014, we conducted an electronic survey of Canadian practitioners likely to participate in the management of CAT. The survey was comprised mainly of open- ended questions. An estimated 300 members of the Canadian Hematology Society and Thrombosis Canada were invited to complete the survey. RESULTS: Respondents: 31 practitioners participated in the survey. 17 (55%) were board- certified hematologists, 10 (32%) were internists, and 3 (10%) were general practitioners. 14 (45%) had been in practice for < 5 years, and 15 (48%) had been practicing for >15 years. The majority of respondents, 27 (87%), worked in tertiary-care centers or university-affiliated institutions. 17 (55%) had self-reported expertise in thrombosis. Regarding frequency of encounters, 10 (32%) of participants reported seeing > 20 patients with CAT and thrombocytopenia per year, while 8 (26%) reported seeing <5 such patients per year. Management strategies: The median (IQR) platelet count above which respondents reported administering VTE prophylaxis, to patients in whom this would otherwise be indicated, was 25 (20, 30) . The median (IQR) platelet count above which respondents would administer full-dose anticoagulation for treatment of established CAT was 50 (40, 50); for reduced-dose anticoagulation, this threshold was 30 (20, 50). For patients with CAT and thrombocytopenia, 21 (68%) reported the use of sub-therapeutic doses of anticoagulation as a management strategy. A majority of respondents, 20 (65%), reported that there were cases in which they elect to withhold all anticoagulation due to thrombocytopenia in patients with acute CAT, in the absence of bleeding. 20 (65%) respondents reported using platelet transfusions to achieve a higher platelet count target than would otherwise be indicated in order to facilitate anticoagulation in patients with CAT and concomitant thrombocytopenia; the median platelet count target in such cases was 35 (30, 50). 14 of 20 respondents reporting the use of platelet transfusions for this purpose employed this transfusion strategy to facilitate full-dose anticoagulation, while a minority (n=6) administered reduced dose anticoagulation in this setting. Those who were newer to practice (< 5 year in practice) and those who reported treating higher volumes of patients with CAT and thrombocytopenia (>10 patients per year) were more likely to employ prophylactic platelet transfusions to facilitate the administration of anticoagulation (86% vs. 47%, p= 0.03, for newer to practice; 87% vs. 44%, p= 0.03, for those treating >10 patients per year) The use of three case studies, for which participants were asked to outline a management strategy, revealed considerable variability in practice (Figure 1). CONCLUSIONS: While most respondents' practices were somewhat consistent with published consensus statements and recommendations, strategies for anticoagulation of CAT in thrombocytopenic patients were highly variable among Canadian practitioners. High quality studies are required to establish an evidence-based approach to this uncommon clinical entity. Figure 1. Initial management approach of respondents for 3 cases of CAT with thrombocytopenia. LE-DVT= lower extremity deep vein thrombosis; PE= pulmonary embolism; UE-DVT= upper-extremity deep vein thrombosis; IVC= inferior vena cava. Figure 1. Initial management approach of respondents for 3 cases of CAT with thrombocytopenia. LE-DVT= lower extremity deep vein thrombosis; PE= pulmonary embolism; UE-DVT= upper-extremity deep vein thrombosis; IVC= inferior vena cava. Disclosures Kuo: Novartis Canada: Honoraria; Alexion: Honoraria.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.005 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.001 | 0.003 |
| Science and technology studies | 0.002 | 0.000 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.000 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".