Who’s driving the bus?

I love trying to stay up to date with the medical literature, and there’s something fun about scanning the tables of contents of the journals that pass through my mailbox. But I also have to admit that the volume and pace of the information can be at times overwhelming. On the advice of a friend, I’ve started to tear out articles of interest, which at least shortens the size of the reading pile on my desk, if nothing else.

This morning, I realized that the only articles on my kitchen table from the previous day’s mail were from the journal Clinical Advances in Hematology & Oncology, a journal with which I’m admittedly not very familiar. So I thought I’d take one off the top of the stack to give me something to do while my car tried to warm up in the 11º morning weather.

This particular article was about a familiar topic — “appropriate thromboprophylaxis in hospitalized cancer patients” — and referenced familiar types of statistics, namely that only 54% of deserving patients received any venous thromboembolism prophylaxis, and even fewer (27%) received “appropriate” prophylaxis according to the 7th American College of Chest Physicians guidelines.

I took a look at the disclosures at the end of the article; financial and editorial support for the publication was provided by Sanofi Aventis, and all four of the authors are either employed or tied to the company. Sanofi, of course, makes enoxaparin (Lovenox), and hospitalized cancer patients represent an important and lucrative target population for the use of this drug.

I couldn’t help but think back to the recent American Society of Hematology plenary session, when an abstract was presented that touted the potential benefits of prophylactic anticoagulation (in this study, with nadroparin) for patients with cancer who were receiving chemotherapy and were primarily outpatients . The benefit in this study was modest, and potentially greatest in subsets of high-risk patients.

I reflected upon the significance of these two kinds of results presented in these two different settings. The ASH results, though interesting, probably aren’t ready for prime time in a practice-changing sort of way (much to the chagrin, I’m sure, of the makers of nadroparin). Most hematologists I’ve talked to think that the risks and costs involved in using prophylactic anticoagulation in all cancer patients receiving chemotherapy do not justify its use, given the modest benefits reported in this study.

On the other hand, we know that prophylaxing appropriate cancer inpatients for venous thromboembolism can save lives, and we know that as a profession, we’re doing a lousy job of this at present. It’s important that we’re able to recognize just how woeful a job we’re doing, and how many hundreds or thousands of clots we could conceivably prevent by using appropriate prophylaxis. It’s probably even more important that we identify and test interventions to improve our ability to deliver quality care.

I guess it’s not surprising that industry helped to finance the article I read this morning, given the financial benefits that stand to be realized from increasing anticoagulant use in the inpatient population. But rather than let industry entirely drive the quality bus, I would hope that as a profession we can push just as hard to fund and promote studies that report on care quality and improve this quality to directly benefit our patients. And I hope to see a well-designed quality improvement study whose intervention is ready for prime time in an ASH plenary session in the years ahead.