PB0040 - Antithrombotic Management of Cryptogenic Stroke in Patients with Cancer: A Survey of Physician Practices

Sunday, June 23, 2024

13:45 – 14:45 ICT

Room: Exhibition Hall

Presenting Author(s)

Shreyash Dalmia, MD FRCPC

Clinical Fellow - Hematology
McMaster University
Hamilton, Ontario, Canada

Co-Author(s)

DB

Dominick Bossé

Assistant Professor
Department of Oncology, University of Ottawa
Ottawa, Ontario, Canada
Marc Carrier, MD

Professor
Department of Medicine, University of Ottawa at the The Ottawa Hospital
Ottawa, Ontario, Canada
BD

Brian Dewar

Clinical Research Coordinator
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada
Avi Leader, MD

Attending Physician
Memorial Sloan Kettering Cancer Center
MS

Michel Shamy

Scientist
Ottawa Hospital Research Institute
Ottawa, Ontario, Canada
GS

Grant Stotts

Director, Ottawa Stroke Program
University of Ottawa
Ottawa, Ontario, Canada
Tzu-Fei Wang, MD, MPH

Associate Professor
Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Canada
Ottawa, Ontario, Canada
Deborah Siegal, MD MSc FRCPC

Associate Professor
University of Ottawa and Ottawa Hospital Research Institute
Ottawa, Ontario, Canada

Background: Optimal treatments for acute ischemic stroke in patients with cancer are uncertain, given the predominance of alternative stroke mechanisms linked to hypercoagulability, and high risk of both bleeding and thrombosis.

Aims: The primary aim was to assess practices for treatment of cryptogenic ischemic stroke in patients with cancer. Additional differences based on respondent and cancer characteristics were explored.

Methods: This was an anonymous, online survey of physicians distributed through professional organizations as well as social media and administered using Qualtrics. The survey was approved by the Ottawa Health Science Network Research Ethics Board (20220415-01H). Physician preferences regarding acute reperfusion and antithrombotic therapy were assessed using clinical vignettes of patients with ischemic stroke and varying types and stages of cancer. We also examined choice of investigations, and the influence of cancer characteristics on decision-making using a 5-point importance scale.

Results: Out of 167 respondents, 114 completed the survey (completion rate of 68%). Most respondents were from Canada (56%) and practiced stroke neurology (42%). Fifty-six (49%) respondents were women (Table 1). Cancer site/histology was the most important factor for decision-making, followed by cancer prognosis, treatment status, and stage. The most frequently recommended tests were extended cardiac rhythm monitoring (23%), transthoracic echocardiography (19%), and bubble echocardiography (15%) (Table 2). Although there was variability in treatment choices, the most frequently selected were intravenous thrombolysis plus mechanical thrombectomy for acute reperfusion (57%), and dual antiplatelet therapy for antithrombotic treatment (44%). Preferences were similar across cancer types (e.g., colorectal, breast, prostate, lymphoma). Fewer respondents chose combination reperfusion therapy (52% versus 67%) or dual antiplatelet therapy (40% versus 51%) for patients with cancer versus those without.

Conclusion(s): Physician preferences for investigation and management of cryptogenic ischemic stroke in patients with cancer are heterogeneous, reflecting clinical equipoise. Randomized trials are needed to evaluate the benefits and harms of treatments.