Hypercoagulability

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Cancer is associated with hypercoagulability and an increased risk of venous thrombosis or pulmonary embolism. This susceptibility can be compounded by decreased mobility resulting from fatigue and diminished functional status, or by pain related to the operative procedure. Operations particularly of risk include operations of the abdomen, pelvis, hip, or leg. Surgery that is of long duration, which uses laparoscopy, or has a degree of postoperative immobilization adds additional risk. Cancer patients have twice the risk of postoperative venous thrombosis, and three times the risk of fatal pulmonary embolism, as noncancer patients undergoing the same procedure.51 Patients at a higher risk are those with a history of previous myeloproliferative disorders such as polycythemia vera and primary thrombocytosis, or a history of obesity, varicose veins, cardiac dysfunction, indwelling central venous catheters, inflammatory bowel disease, nephrotic syndrome, pregnancy, or estrogen use, or treatment with tamoxifen or chemotherapy. Treatment with tamoxifen induces hypercoagulability with an associated two- to threefold greater risk of venous thrombosis. This risk is increased even more in women undergoing treatment with both chemotherapy and tamoxifen.52,53 Chemotherapy has been shown to increase the risk of thromboembolism up to 7% in early-stage breast cancer patients.52,54

A history of hypercoagulable abnormalities should be ascertained, such as activated protein C resistance (factor V, Leiden); prothrombin variant 20210A; antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibody); deficiency or dysfunction of antithrombin, protein C, protein S, or heparin cofactor II; dysfibrinogenemia; decreased levels of plasminogen and plasminogen activators; heparin-induced thrombocytopenia; or hyperhomocystinemia.55

Cancer patients older than 40 years undergoing major surgery without prophylaxis have a risk of deep venous thrombosis of 10% to 20% and a risk of fatal pulmonary embolism of 0.2% to 5.0%.10 Although most clinical trials show pneumatic compression devices to be similar in effectiveness to prophylactic doses of subcutaneous heparin, their effectiveness is directly dependent on compliance with their use, and most clinicians recognize that, in practice, pneumatic compression devices are only on the patient a portion of the time they are nonambulatory and therefore they are not as effective.56 The sixth American College of Chest Physicians consensus conference in 2000 recommended the following: (1) oncology patients more than 40 years old undergoing major surgery, or nonmajor surgery in patients more than 60 years old, with no other risk factors, receive pneumatic compression devices or low molecular weight heparin; (2) oncology patients more than 40 years old undergoing major surgery and additional risk factors receive pneumatic compression devices and prophylactic low molecular weight heparin; and (3) low-dose coumadin for patients with central venous catheters. They did not recommend routine continuation of anticoagulation after discharge for surgical patients;

however, many clinical studies are under way regarding the efficacy of continued prolonged anticoagulation after discharge from a surgical procedure.

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