Surgical Cancer Patients Research Articles

Abstract 528: Preventing perioperative cancer metastases formation by enhancing Natural Killer cell activity

Abstract Background: Surgical resection is the mainstay of therapy for patients with localized solid malignancies. Even with complete resection, many patients develop metastatic recurrence and ultimately die of their disease. The perioperative period is a uniquely susceptible time for the formation of metastases. A number of changes that occur following surgery promote the formation of metastases, including dissemination of tumour cells, a pro-mitotic and pro-angiogenic milieu and suppression of the immune system. Natural Killer (NK) cells are a key component of the innate immune response against cancer, in particular the elimination of micrometastases. NK cell suppression and dysfunction have been linked to the development of metastatic disease in animal models and in cancer patients. Objective: We hypothesized that surgical stress enhances the development of postoperative metastases by impairing NK clearance of tumor cells. Specifically, we aim to 1) define the mechanisms involved in NK cell suppression following surgery and 2) explore novel anti-cancer therapies to modulate postoperative NK cell suppression and inhibit metastases. Methods: A mouse model of surgical stress and tumor metastases was used to address these questions. In this model, NK cell functions were assessed using immunological functional assays following tumor challenge, surgical stress and novel perioperative anti-cancer therapy. Results and Conclusions: We observed enhanced lung metastases in tumor-bearing NK-deficient mice that received adoptively transferred NK cells from surgically stressed mice compared to NK cells from untreated mice. This establishes that NK cells play a crucial role in mediating the prometastatic effect of surgery. Accordingly, in vivo CFSE labeled MHC-I-deficient splenocyte and RMA-S tumor cell rejection and ex vivo chromium labeled YAC-1 and B16 tumor target cell killing by NK cells were significantly reduced in surgically stressed mice compared to untreated mice. A significant reduction in spleen NK cell surface expression of NKG2D and KLRG1 receptors were also observed in surgically stressed mice. These data suggest that surgical stress impairs global NK cell function. For the therapeutic arm of our project, we have demonstrated that using the perioperative administration of the non-specific NK cell activator poly I:C can reverse NK cell suppression following surgery and that this correlates with a reduction in the postoperative formation of metastases. We have also evaluated oncolytic vaccinia virus and observed a similar attenuation of metastases and recovery of NK cytotoxicity following perioperative administration. Significance of Research: Cancer therapies aimed at targeting the mechanisms responsible for the prometastatic effects of surgery will reduce recurrences and improve survival in surgical cancer patients when used in the perioperative period. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 528. doi:1538-7445.AM2012-528

A remifentanil/ketamine sedation in surgical cancer patients having severe Parkinson’s disease: Two case reports

Symptoms of Parkinson's disease are related to a progressive loss of substancia nigra's dopaminergic neurons in addition to persistent activation of N-methyl-D-aspartate receptors. In specific situations such as sedation for minor surgery, tremor and dyskinesia can be very disabling. We report the beneficial effect of the combination of remifentanil (target-controlled infusion mode) and ketamine (boluses IV) to control dyskinesia and tremor for two elderly patients with Parkinson's disease. The patients were scheduled for elective oncological plastic surgery under sedation, for which dyskinesia and tremor needed to be quickly abolished to permit surgery. Both procedures were completed with this drug combination resulting with no major side effects.

A comparison of two pre-operative frailty measures in older surgical cancer patients

Abstract Background Measuring frailty in older adults with cancer may identify patients with an increased risk of treatment complications. As it remains controversial how to identify frailty, the aim of this study was to compare a pre-operative multi-domain frailty measure based on a comprehensive geriatric assessment (CGA) to a modified version of the physical phenotype of frailty (PF) in a cohort of older adults with colorectal cancer, and to analyze the ability of the two classifications to predict post-operative complications and survival. Methods A prospective longitudinal study including 176 patients aged 70–94years electively operated for colorectal cancer in three Norwegian hospitals. A pre-operative CGA, self-reported quality of life, and measurements of grip strength and gait speed were performed. CGA-frailty was defined as fulfilling one or more of the following criteria: dependency in activities of daily living, severe comorbidity, cognitive dysfunction, depression, malnutrition, or >seven daily medications. PF was defined with three or more of the following criteria: unintentional weight loss, exhaustion, low physical activity, impaired grip strength, or slow gait speed. Outcome measures were post-operative complications and survival. Results The agreement between the classifications was poor. CGA-frailty was identified in 75 (43%) patients, while PF was identified in 22 (13%) patients. Only CGA-frailty predicted post-operative complications [P=0.001]. Both measures predicted survival. Conclusions A multi-domain frailty measure based on a CGA was more useful than frailty identified from a modified version of the PF criteria in predicting post-operative complications. For overall survival, both frailty measures were predictive.

Trend of analgesic consumption and pain scores in the post anesthetic care unit (A 9-year survey in surgical cancer patients)

Background and methodsAs part of a quality assurance program, we assessed the trend of our analgesic consumption using our anesthesia database which include anesthesia and postanesthetic care records for all patients. In recent years, emphasis was made on anesthesia personnel to decrease postoperative opioid analgesic at the expense of non-opioid analgesics in order to decrease opioid related side effects. The following items were recorded: intraoperative opioid consumption, total morphine consumption, non-opioid analgesic consumption pain and sedation scores in the postoperative care unit (PACU). ResultsThe database consisted of 57,967 patients for 9 consecutive years from 2002 to 2010, mean data exhaustivity was of 95%. Total morphine consumption per patient in the operative room and in the PACU decreased significantly from 11±4mg in year 2002 to 7±3mg in 2010, P<0.05. In the intraoperative period, remifentanil/sufentanil ratio increased significantly from 33/67 to 87/13% of patients (P<0.05) without affecting pain scores in the PACU. DiscussionThis multi-year trend shows a significant decrease in overall postoperative morphine consumption, in addition we showed that computerized database can easily follow the trend of analgesic consumption and can be used therefore as a powerful tool with easy access as part of a quality assurance program.

Perioperative nutrition in malnourished surgical cancer patients – A prospective, randomized, controlled clinical trial

Malnourished surgical patients are supposed to benefit from perioperative nutrition. It is unclear, however, whether enteral intervention really surpasses the parenteral one, and whether the modification of standard formula matters. The aim of the study was to evaluate the clinical value of the route and type of perioperative nutritional support. A group of 167 malnourished patients (91M, 76F, mean age 61.4 years) operated between June 2001 and December 2008 was randomly assigned during postoperative period to four groups according to nutritional intervention: enteral and parenteral, standard or immunomodulating. All patients received parenteral nutrition before surgery for 14 days, which provided homogenous groups for the postoperative evaluation. The trial was designed to test the hypothesis that enteral nutrition and/or immunonutrition can reduce the incidence of postoperative complications. The incidence of individual complications was comparable among all four groups (p>0.05). Infectious complications occurred in 23 of 84 patients with standard diets and in 20 of 83 patients receiving immunomodulatory formula (odds ratio 0.84; 95% CI 0.42 to 1.69). There were no significant differences in infectious complications' ratio in patients receiving enteral (24/84 patients) and parenteral formulas (19/83 patients). Neither immunomodulating formulas nor enteral feeding significantly affected the length of hospitalization, overall morbidity and mortality rates. Results demonstrated that postoperative nutritional intervention generates comparable results regardless of the route and formula used and that preoperative intervention is of the utmost importance. The study was registered in the Clinical Trials Database - number: NCT 00558155.

Analysis of the efficacy of surgical treatment for 80 elderly laryngeal cancer patients with type 2 diabetes

Objective To investigate the clinical curative effect of the surgical treatment elderly laryngeal cancer patients with type 2 diabetes. Methods 80 cases laryngeal cancer patients with type 2 diabetes, admitted to surgery 80 cases were randomly divided into observation group and control group. The control group was given perioperative oral glucose-lowering medications, the observation group in perioperative adopted continuously subcutaneous insulin pump infusion to control blood sugar. Compared two sets of patients intraoperative blood glucose level and postoperative blood sugar level,surgical tolerability, the incidence rate of laryngostomic fistula, the length of time and after 3 years,5 years of survival rate. Results The observation group intraoperative blood glucose level and postoperative blood sugar level, surgical tolerability, postoperative in 3 and 5 years survival rates were significantly better than control group( P ＜0.05) ,In the observation group the incidence rate of laryngostomic fistula,the length of time were significantly less than control group ( P ＜ 0.05 ). Conclusion Perioperative period by strengthening the control blood sugar treatment could be inside short time make a patient blood glucose levels drop to the desired level,decrease postoperatic complications,ensure therapeutic effect. Key words: Aged; Laryngeal Neoplasms; Type 2 diabetes,Surgical Procedures, Operaton

Colorectal Surgery Patients’ Pain Status, Activities, Satisfaction, and Beliefs about Pain and Pain Management

This study describes surgical colorectal cancer patients’ pain levels, recovery activities, beliefs and expectations about pain, and satisfaction with pain management. A convenience sample of 50 adult inpatients who underwent colorectal surgery for cancer participated. Patients were administered the modified American Pain Society Patient Outcome Questionnaire on postoperative day 2 and asked to report on their status in the preceding 24 hours. Patients reported low current (mean 1.70) and average (mean 2.96) pain scores but had higher scores and greater variation for worst pain (mean 5.48). Worst pain occurred mainly while turning in bed or mobilizing, and 25% of patients experienced their worst pain at rest. Overall, patients expected to have pain after surgery and were very satisfied with pain management. Patients with worst pain scores >7 reported interference with recovery activities, mainly general activity (mean 5.67) and walking ability (mean 5.15). These patients were likely to believe that “people can get addicted to pain medication easily” (mean 3.39 out of 5) and that “pain medication should be saved for cases where pain gets worse” (mean 3.20 out of 5). These beliefs could deter patients from seeking pain relief and may need to be identified and addressed along with expectations about pain in the preoperative nursing assessment.

Is replacement of albumin in major abdominal surgery useful?

Study Objective To evaluate retrospectively serum albumin concentrations as well as morbidity and mortalitiy of abdominal surgical patients who –if hypoalbuminemic– did not receive human albumin solutions versus those who did receive such solutions. Design Retrospective observational study. Setting Academic community hospital. Measurements The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital. Results 38 patients who received albumin replacement if they were hypoalbuminemic versus 38 patients who did not receive albumin replacement showed no significant difference in cumulative ( P < 0.52) or individual postoperative complications (infections P < 0.35, cardiovascular complications P < 1.0, organ failure P < 0.67, thromboembolic incidents P < 0.26), and mortality ( P < 0.47). Conclusions Postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.

Blood Type, Hormone Receptor Status, HER2/neu Status, and Survival in Breast Cancer: A Retrospective Study Exploring Relationships in a Phenotypically Well-Defined Cohort

Altered glycosylation has been associated with oncogenic potential. Relationships of blood types (where expression is due to glycosylation pattern) and HER2/neu (where expression arises due to altered glycosylation) and breast cancer-associated markers like estrogen receptor/progesterone receptor (ER/PR) were examined and related to outcomes in patients with breast cancer. A population-based retrospective study of 426 surgical breast cancer patients examined relationships between (1) patient characteristics, (2) breast tumor characteristics, and (3) outcomes of women diagnosed at the same medical center over a 10-year period relative to specific molecules defined by glycosylation patterns (eg. blood group, HER2/neu) and (4) ER/PR status. Following stratification by blood group, subjects exhibited significant differences in tumor size with persons in blood groups A and B having greater numbers of tumors ≤ 2 cm and those with blood types AB and O having tumors >2 cm. After adjusting for age, disease stage, and treatment with trastuzumab, tamoxifen, or aromatase inhibitors, no significant differences were observed in 5-year overall and disease-free survival based on blood type grouping. Blood group B was over-represented among the breast cancer cohort compared to the reference population, while blood group AB was under-represented. No significant differences were observed in overall and disease-free survival based on blood group. No correlation was noted between HER2/neu, ER or PR status, and blood group type. Among this cohort, HER2/neu positivity was less than 20% and correlated with a 5-year disease-free survival rate ≥ 75% and overall survival of >80% across all blood groups.

The immunomodulating enteral nutrition in malnourished surgical patients – A prospective, randomized, double-blind clinical trial

The immunomodulating nutrition was supposed to reduce the incidence of complications in surgical patients, but many authors have questioned its value recently. The aim of the study was to assess the impact of enteral immunonutrition in postoperative period. Between January 2003 and December 2009, 305 malnourished patients (123 F, 182 M, m. age 60.8) undergoing resection for pancreatic or gastric cancer, after preoperative 14 days of parenteral feeding, were randomized in double-blind manner to receive either postoperative immunomodulating enteral diet (IMEN) or standard oligopeptide diet (SEN). Outcome measures of the intend-to-treat analysis were: number and type of complications, length of hospitalization, mortality, and vital organ function. Median postoperative hospital stay was 17.1 days in SEN and 13.1 days in IMEN group (p = 0.006). Infectious complications were observed in 60 patients (39.2%) in SEN and 43 (28.3%) in IMEN group (p = 0.04). Differences were also observed in overall morbidity (47.1 vs 33.5%, p = 0.01) and mortality (5.9 vs 1.3%, p = 0.03), but the ratio of surgical complications, organ function, and treatment tolerance did not differ. The study proved that postoperative immunomodulating enteral nutrition should be the treatment of choice in malnourished surgical cancer patients. The Clinical Trials Database registry number: NCT00576940.

Empirical first-line treatment with tigecycline for febrile episodes following abdominal surgery in cancer patients

Cancer patients with complicated infections following abdominal surgery represent one of the worst clinical scenarios that is useful for testing the efficacy of empirical antimicrobial therapy. No study so far has evaluated the performance of tigecycline (TIG) when administered as empirical first-line treatment in a homogeneous population of surgical cancer patients with a febrile episode. An observational review of the data records of 24 sequential patients receiving TIG for a febrile episode following a major abdominal procedure in a single cancer institute was performed. Large bowel surgery represented 68% of all procedures, followed by gastric surgery (16%) and urinary–gynaecologic–biliary surgery (16%). Complications following surgery were observed in 68% of febrile episodes, with peritonitis and sepsis accounting for 59% and 24% of complications, respectively. Eight patients needed repeat surgery for source control. The mean duration of TIG treatment was 8 days. Causative pathogens were detected in 16 episodes (64%), and a total of 44 microorganisms were recovered (29% Escherichia coli, 9% Enterococcus faecalis and 9% coagulase-negative staphylococci). TIG was effective in 12 episodes (48%). The success rate was 67% when infectious episodes sustained by intrinsically resistant bacteria and fungi were excluded. Treatment failure was associated with the presence of complications and with microbiologically documented infection. TIG may be useful as a first-line treatment option in cancer patients requiring antibiotic treatment following surgery when complications are not present or suspected on clinical grounds and when local microbial epidemiology shows a low incidence of primary resistant bacteria.

Presurgery Psychological Factors Predict Pain, Nausea, and Fatigue One Week After Breast Cancer Surgery

Before scheduled surgery, breast cancer surgical patients frequently experience high levels of distress and expect a variety of postsurgery symptoms. Previous literature has supported the view that presurgery distress and response expectancies are predictive of postsurgery outcomes. However, the contributions of distress and response expectancies to postsurgical side effect outcomes have rarely been examined together within the same study. Furthermore, studies on the effects of response expectancies in the surgical setting have typically focused on the immediate postsurgical setting rather than the longer-term setting. The purpose of the present study was to test the contribution of presurgery distress and response expectancies to common postsurgery side effects (pain, nausea, and fatigue). Female patients (n=101) undergoing breast cancer surgery were recruited to a prospective study. Results indicated that presurgery distress uniquely contributed to patients' postsurgery pain severity (P<0.05) and fatigue (P<0.003) one week after surgery. Response expectancies uniquely contributed to pain severity (P<0.001), nausea (P<0.012), and fatigue (P<0.010) one week after surgery. Sobel tests indicated that response expectancies partially mediated the effects of distress on pain severity (P<0.03) and fatigue (P<0.03). Response expectancies also mediated the effects of age on pain severity, nausea, and fatigue. Results highlight the contribution of presurgery psychological factors to postsurgery side effects, the importance of including both emotional and cognitive factors within studies as predictors of postsurgery side effects, and suggest presurgical clinical targets for improving patients' postoperative experiences of side effects.

Prospective screening for Lynch syndrome (LS) in a cohort of colorectal cancer (CRC) surgical patients in a community hospital.

1535 Background: LS is the most common hereditary form of colon cancer yet it is under-diagnosed despite well-defined clinical criteria. Screening an incident U.S. population of patients with CRC placed the proportion of CRC due to LS at 2.8% (Hampel H et al, N Engl J Med 352: 1851, 2005 and J Clin Oncol 26: 5783, 2008). Immunohistochemistry (IHC) stains for the 4 mismatch repair (MMR) proteins have shown a high sensitivity for LS identification (Shia J, J Mol Diagnostics 10: 293, 2008). We hypothesized that if only CRC patients ≤ age 60 were screened for LS by IHC, only 25% of patients would undergo testing yet 75-80% of LS would be identified. Summarized here are the results of the first 24 months of the IHC screening program for LS in a community hospital. Methods: In January 2008 a pathology reflex protocol for MMR IHC staining was initiated on all CRC ≤ age 60. The protocol was reviewed and approved by the institution's clinical practice committees. Results: From 1/01/08 through 12/31/09, 302 surgica...

The Effect of Low Molecular Weight Heparin Thromboprophylaxis on Bleeding Complications After Gastric Cancer Surgery

Low molecular weight heparin (LMWH) has been widely used to prevent venous thromboembolism in cancer surgical patients. However, relatively few studies have examined the safety aspects related to the use of LMWH after abdominal cancer surgery. This study was designed to investigate the relationship between bleeding complications and LMWH thromboprophylaxis after gastric cancer surgery. From March to July in 2009, 179 consecutive patients who underwent gastric cancer surgery at our institution were administered LMWH (3200 U once daily from 2 to 6 h before surgery until discharge) perioperatively. A total of 182 patients consecutively treated before the introduction of LMWH prophylaxis were selected as controls. There were 234 men and 127 women (mean age, 60 +/- 12 years). No significant intergroup differences were observed with respect to clinicopathological features and operative procedures. No patient in the LMWH or control group developed symptomatic venous thromboembolism postoperatively. However, the LMWH group had a significantly higher surgical complication rate (27.4 versus 15.4%, P = 0.005). Among the surgical complications, postoperative bleeding and wound complications were significantly higher in the LMWH group, whereas other complications were similar in the two study groups. Multivariate analysis showed that LMWH administration was an independent risk factor (odds ratio, 2.83; 95% confidence interval, 1.28-6.23, P = 0.009) of postoperative bleeding. LMWH thromboprophylaxis was found to increase significantly the risk of bleeding complications after gastric cancer surgery. Optimal LMWH prophylaxis regimens, including the dosage and timing of treatment commencement, for gastric cancer surgery should be determined in further clinical trials.

Epidermal Inclusion Cyst after Breast Reconstruction with TRAM Flaps

Breast reconstruction with TRAM flaps has becomean increasingly common surgical procedure amongbreast cancer patients who undergo a mastectomy (1).TRAM flap reconstruction involves the transfer of lowerabdominal skin and subcutaneous fat to the chest defectat the mastectomy site (2). In this procedure, the epider-mal inclusion cyst can be developed at the surgical site ifthe de-epithelized portion of buried skin flaps retains theepithelial elements. This epidermal inclusion cyst,which can be mistaken for a recurrent cancer, may leadto a false positive finding on a mammogram.To our knowledge, reports on epidermal inclusioncysts after breast reconstruction surgery have not beenpreviously described in the literature. So, we report ourexperience of an epidermal inclusion cyst in a patientwho underwent a total mastectomy with breast recon-struction and TRAM flaps.Case ReportA 50-year-old woman was admitted to our hospital fora follow-up mammography. She underwent a left totalmastectomy and reconstruction with TRAM flaps fortreatment of the ductal carcinoma in situ, about 6-months prior. The mammography showed findings sug-gesting that the postoperative change and an oval-shaped, circumscribed partially indistinct marginal iso-dense mass at the 2 o’clock position of the left breast(Fig. 1A). The mass was believed to be benign, such asfat necrosis or benign granuloma, so the patient was rec-ommended to receive follow-up mammography 6-months later.The 6 month follow-up showed an increase in the sizeof the previously detected mass at the 2 o’clock positionfrom about 10 mm to 13 mm in diameter (Fig. 1B). Onultrasonography, the lesion was located in the peripher-al portion of reconstructed breast, adjacent to the inci-

Clinical results of loop ileostomy closures in rectal cancer surgical patients. Effect of chemotherapy in the waiting period

IntroductionThe introduction of sphincter preservation surgery in rectal cancer has led to an increase in the number of low resections protected with a loop ileostomy. This requires subsequent closure of the stoma, a surgical procedure which is not devoid of morbidity or mortality. The aims of the study were to analyse the clinical results of the passage reconstruction surgery and to find out the interval between both surgeries, as well as the role chemotherapy plays in this. Patients and methodThe prospective data of patients previously operated on for rectal cancer were used retrospectively with those whose ileostomy was closed between May 2004 and September 2008. Data associated to chemotherapy indication, interval between surgeries and complications were collected and analysed. ResultsA total of 54 consecutive patients with a mean age of 66 years were analysed. The mean interval between surgeries was 178 days, being significantly less in the patient group that did not receive chemotherapy (P=.008). The post-operative stay was 6.3 days (SD=4.1). Mortality due to respiratory failure was 1.8% and the morbidity was 22.2%, with 7.4% requiring further surgery. ConclusionsThe mortality and morbidity of ileostomy closures are not inconsiderable, although its advantages in the protection of the stoma justify its use. The ileostomy construction interval appears to be significantly affected by post-operative chemotherapy.

Mediators of a brief hypnosis intervention to control side effects in breast surgery patients: Response expectancies and emotional distress.

The present study was designed to test the hypotheses that response expectancies and emotional distress mediate the effects of an empirically validated presurgical hypnosis intervention on postsurgical side effects (i.e., pain, nausea, and fatigue). Women (n = 200) undergoing breast-conserving surgery (mean age = 48.50 years; 63% White, 15% Hispanic, 13% African American, and 9% other) were randomized to a hypnosis or to an attention control group. Prior to surgery, patients completed assessments of hypothesized mediators (response expectancies and emotional distress), and following surgery, patients completed assessments of outcome variables (pain, nausea, and fatigue). Structural equation modeling revealed the following: (a) Hypnotic effects on postsurgical pain were partially mediated by pain expectancy (p < .0001) but not by distress (p = .12); (b) hypnotic effects on postsurgical nausea were partially mediated by presurgical distress (p = .02) but not by nausea expectancy (p = .10); and (c) hypnotic effects on postsurgical fatigue were partially mediated by both fatigue expectancy (p = .0001) and presurgical distress (p = .02). The results demonstrate the mediational roles of response expectancies and emotional distress in clinical benefits associated with a hypnotic intervention for breast cancer surgical patients. More broadly, the results improve understanding of the underlying mechanisms responsible for hypnotic phenomena and suggest that future hypnotic interventions target patient expectancies and distress to improve postsurgical recovery.

Early postoperative feeding in resectional gastrointestinal surgical cancer patients

Malnutrition is present in the majority of patients presenting for surgical management of gastrointestinal malignancies, due to the effects of the tumour and preoperative anti-neoplastic treatments. The traditional practice of fasting patients until the resumption of bowel function threatens to further contribute to the malnutrition experienced by these patients. Furthermore, the rationale behind this traditional practice has been rendered obsolete through developments in anaesthetic agents and changes to postoperative analgesia practices. Conversely, there is a growing body of literature that consistently demonstrates that providing oral or tube feeding proximal to the anastomosis within 24 h postoperatively, is not only safe, but might be associated with significant benefits to the postoperative course. Early post operative feeding should therefore be adopted as a standard of care in oncology patients undergoing gastrointestinal resections.

Thromboprophylaxis with low-molecular-weight heparin in medical patients with cancer.

Venous thromboembolism (VTE) is a frequent complication of cancer and cancer treatment and is associated with multiple clinical consequences, including recurrent VTE, bleeding, and an increase in the risk of death. Although the risks associated with VTE have been well recognized in surgical cancer patients, there is also considerable and increasing risk in medical cancer patients. VTE risk factors in medical cancer patients include the type and stage of cancer, major comorbid illnesses, current hospitalization, active chemotherapy, hormone therapy, and antiangiogenic agents. Low-molecular-weight heparins (LMWHs) are recommended commonly for the prevention of VTE in hospitalized cancer patients and in higher risk ambulatory cancer patients because of their favorable risk-to-benefit profile. These agents have demonstrated effectiveness in both the primary and secondary prevention of VTE in medical cancer patients. Extended-duration anticoagulant therapy is often recommended to reduce the risk of VTE recurrence in patients with cancer. LMWHs are often used for long-term prophylaxis because of a reduced need for coagulation monitoring, few major bleeding episodes, and once-daily dosing. Despite clinical and practical benefits, a substantial proportion of medical cancer patients do not receive VTE prophylaxis. To improve the appropriate prevention and treatment of VTE in cancer patients, guidelines have been published recently by the American Society of Clinical Oncology and the National Comprehensive Cancer Network. Widespread dissemination and application of these guidelines are encouraged to improve the appropriate use of these agents and to improve clinical outcomes in medical cancer patients at risk for VTE and its complications.

Prevention of Venous Thromboembolism in the Cancer Surgical Patient

Venous thromboembolism is a common complication in patients with malignant disease. One of the environments in which patients can present with symptomatic thromboembolic disease is in the postoperative period. Operation in the patient with cancer increases the risk of thromboembolic complications some two to three fold. A variety of methods have been evaluated for the prevention of thromboembolic disease in cancer surgical patients. The most extensively investigated are the pharmacologic methods, including low-dose unfractionated heparin and low molecular weight heparin. These agents are recommended for the prevention of thromboembolic disease during hospital stay. For selected high-risk populations, extended thromboprophylaxis into the postdischarge period is also recommended.