Practice patterns for extended venous thromboembolism chemoprophylaxis among urologic oncologists after radical cystectomy.
INTRODUCTION
Extended outpatient chemoprophylaxis (ECP) following radical cystectomy (RC) for bladder cancer is proven to reduce rates of venous thromboembolism (VTE). While ECP is commonly performed with enoxaparin, its cost-effectiveness and adherence rate has been called into question. Data from orthopedic literature suggest that ECP with direct oral anticoagulants (DOACs) may be as effective in VTE prevention as enoxaparin in patients undergoing joint surgery. Our goal is to determine how urologic oncologists employ ECP following RC.


METHODS
Members of the Society of Urologic Oncology were surveyed on practice patterns for the use of ECP after RC. Specific questions were asked regarding the use of inpatient and outpatient VTE prophylaxis, as well as perceived barriers to DOACs and enoxaparin.


RESULTS
There were 121 of 878 (13.8%) respondents and the majority were in academic practices (83%). Most respondents had at least 5 years of experience and performed greater than 10 cystectomies annually. Almost all participants utilized inpatient (97%) and extended (80%) chemoprophylaxis for VTE prevention. Of those who elected for ECP, almost all (96%) used enoxaparin. Only 3 respondents (3%) prescribed oral agents such as rivaroxaban (2) or warfarin (1). Among those using enoxaparin, financial-specific barriers to treatment such as lack of insurance coverage (38%), inability to afford the medication (51%), and need for additional insurance authorization (44%) were reported. Poor patient adherence and refusal to perform injections were reported by 20% and 18% of respondents, respectively. Among the 23 physicians who did not use ECP, cost (39%) and delivery method (26%) were cited as barriers to treatment.


CONCLUSIONS
The majority of surveyed urologic oncologists are prescribing subcutaneous enoxaparin ECP following RC. Poor patient adherence due to self-injections and financial barriers were frequently reported and represent a possible opportunity for the use of oral anticoagulants in the post-operative setting. These data will be used in the development of a proposed clinical trial of a DOAC in the post-RC setting.
['Dall|Christopher P|CP|', 'Shaw|Nathan|N|', 'Egan|Jillian|J|', 'Carvalho|Filipe Lf|FL|', 'Galloway|Lan Anh S|LAS|', 'Krasnow|Ross|R|', 'Stamatakis|Lambros|L|']
D000359:Aftercare D000925:Anticoagulants D018890:Chemoprevention D015653:Cystectomy D017984:Enoxaparin D006801:Humans D011183:Postoperative Complications D010818:Practice Patterns, Physicians' D000071077:Surgical Oncology D001749:Urinary Bladder Neoplasms D014572:Urology D054556:Venous Thromboembolism
Cystectomy Bladder cancer Oral anticoagulant Prophylaxis Deep venous thrombosis Low-molecular weight heparin