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Barriers and facilitators to preventing venous thromboembolism in oncology practice

  • Karlyn A. Martin
    Correspondence
    Corresponding author at: 645 N Michigan Ave, Suite 1020, Chicago, IL 60611, United States.
    Affiliations
    Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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  • Madison J. Lyleroehr
    Affiliations
    Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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  • Kenzie A. Cameron
    Affiliations
    Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States

    Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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      Venous thromboembolism (VTE) is a frequent complication of cancer and cancer-directed therapy that leads to increased morbidity and mortality [
      • Timp J.F.
      • Braekkan S.K.
      • Versteeg H.H.
      • et al.
      Epidemiology of cancer-associated venous thrombosis.
      ,
      • Khorana A.A.
      • Francis C.W.
      • Culakova E.
      • et al.
      Thromboembolism is a leading cause of death in cancer patients receiving outpatient chemotherapy.
      ]. Validated clinical scoring systems, such as the Khorana Score, assess risk of VTE in patients with cancer. Randomized controlled trials of primary prophylaxis in higher-risk patients by Khorana Score receiving chemotherapy demonstrated safety and efficacy [
      • Carrier M.
      • Abou-Nassar K.
      • Mallick R.
      • et al.
      Apixaban to prevent venous thromboembolism in patients with cancer.
      ,
      • Khorana A.A.
      • Soff G.A.
      • Kakkar A.K.
      • et al.
      Rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer.
      ]. Guidelines from the American Society of Oncology (ASCO), International Society on Thrombosis and Haemostasis (ISTH), National Comprehensive Cancer Network (NCCN), and International Initiative on Thrombosis and Cancer (ITAC) recommend assessing VTE risk for all ambulatory patients with cancer receiving chemotherapy. All recommend at least considering primary prophylaxis for intermediate to high risk patients, although the strength of recommendation varies: ITAC recommends primary prophylaxis; ASCO and ISTH recommend offering primary prophylaxis; and NCCN recommends considering primary prophylaxis for patients with intermediate to high risk of VTE by Khorana Score [
      • Key N.S.
      • Khorana A.A.
      • Kuderer N.M.
      • et al.
      Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update.
      ,
      • Wang T.-F.
      • Zwicker J.I.
      • Ay C.
      • et al.
      The use of direct oral anticoagulants for primary thromboprophylaxis in ambulatory cancer patients: guidance from the SSC of the ISTH.
      ,
      • Farge D.
      • Frere C.
      • Connors J.M.
      • et al.
      2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19.
      ,
      • Streiff M.B.
      • Holmstrom B.
      • Angelini D.
      • et al.
      Cancer-associated venous thromboembolic disease, version 2.2021, NCCN clinical practice guidelines in oncology.
      ]. However, oncologists rarely use VTE risk assessment nor provide primary prophylaxis [
      • Martin K.A.
      • Molsberry R.
      • Khan S.S.
      • Linder J.A.
      • Cameron K.A.
      • Benson A.
      Preventing venous thromboembolism in oncology practice: use of risk-assessment and anticoagulation prophylaxis.
      ,
      Association of Community Cancer Centers: Venous Thromboembolism
      Identifying cancer patients at risk.
      ,
      • Holmes C.E.
      • Ades S.
      • Gilchrist S.
      • et al.
      Successful model for guideline implementation to prevent cancer-associated thrombosis: venous thromboembolism prevention in the ambulatory cancer clinic.
      ]. The rationale for such underuse remains unknown; thus, we sought to identify clinician and patient barriers to and potential facilitators of using evidence-based recommendations for VTE prevention in clinical oncology practice.
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