Blood thinners for the prevention of clots in patients with cancer undergoing surgery

Akl EA, Labedi N, Terrenato I, Barba M, Sperati F, Sempos EV, Muti P, Cook D, Schünemann H

Published Online:

November 9, 2011

Patients with cancer undergoing surgical procedures are at an increased risk of blood clots. The blood thinner administered to prevent these clots can be either an unfractionated heparin or low molecular weight heparin. These two blood thinners may have different efficacies and safety profiles. In this systematic review, data from 16 trials found no difference between the two types of agents.

Abstract (click to read)

Background:

The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH).

Objectives:

To systematically review the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer.

Search strategy:

A comprehensive search for trials of anticoagulation in cancer patients including a February 2010 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and ISI Web of Science.

Selection criteria:

Randomized controlled trials (RCTs) that enrolled cancer patients undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, and thrombocytopenia.

Data collection and analysis:

Two review authors used a standardized form to independently extract in duplicate data on risk of bias, participants, interventions and outcomes of interest. Where possible, we conducted meta-analyses using the random-effects model.

Main results:

Of 8187 identified citations, we included 16 RCTs with 11,847 patients in the meta-analyses, all using preoperative prophylactic anticoagulation. The overall quality of evidence was moderate. The meta-analysis did not conclusively rule out either a beneficial or harmful effect of LMWH compared to UFH for the following outcomes: mortality (RR = 0.90; 95% CI 0.73 to 1.10), symptomatic DVT (RR = 0.73; 95% CI 0.23 to 2.28), PE (RR = 0.59; 95% CI 0.25 to1.41), minor bleeding (RR = 0.88; 95% CI 0.47 to 1.66) and major bleeding (RR = 0.84; 95% CI 0.52 to 1.36). LMWH was associated with lower incidence of wound hematoma (RR = 0.60; 95% CI 0.43, 0.84) while UFH was associated with higher incidence of intra-operative transfusion (RR = 1.16; 95% CI 0.69,1.62).

Authors' conclusions:

We found no difference between perioperative thromboprophylaxis with LMWH verus UFH in their effects on mortality and embolic outcomes in patients with cancer. Further trials are needed to more carefully evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population.

This record should be cited as:

Akl EA, Labedi N, Terrenato I, Barba M, Sperati F, Sempos EV, Muti P, Cook D, Schünemann H. Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD009447. DOI: 10.1002/14651858.CD009447

Assessed as up to date:

September 29, 2011

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Primary Review Group:

Gynaecological Cancer Group

Health topics:

Cancer > Generic cancer care > Thrombo-embolism prevention & treatment

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Independent high-quality evidence for health care decision making

Blood thinners for the prevention of clots in patients with cancer undergoing surgery

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