Prioritizing quality of life over thrombotic risk: Thromboprophylaxis in multiple myeloma - an interview study

IntroductionMultiple myeloma (MM) is associated with an increased venous thromboembolism (VTE) risk despite the existence of current thromboprophylaxis guidelines. Although most patients have an indication for low-molecular-weight heparin (LMWH) based on additional risk factors for VTE, aspirin is still widely prescribed as thromboprophylaxis in newly diagnosed patients with MM. It is unclear why current guidelines are not implemented in daily practice. This qualitative interview study aims to identify which factors influence the choice of thromboprophylaxis in MM.MethodsFifteen Dutch physicians experienced in treating patients with MM were interviewed about the factors influencing their choice of thromboprophylaxis. We conducted semi-structured individual interviews. Participant inclusion was discontinued after reaching data saturation. We performed a thematic analysis using an inductive approach. The findings are reported according to the Consolidated Criteria for Reporting Qualitative Research.ResultsThree main themes influencing MM thromboprophylaxis were identified. The first theme, "Perception of Patient Experience", indicated that physicians perceive LMWH as a significant burden for patients. The second theme, "Thrombotic Risk Appraisal", describes how the VTE risk is often underestimated in clinical practice. The third theme, "Medical System-Level Constraints and Enablers", highlights how automatic aspirin prescription and the need for clearer guideline recommendations on direct oral anticoagulants (DOACs) influence decision-making.ConclusionThe preference for aspirin thromboprophylaxis may be explained by physicians prioritizing patient quality of life, underestimation of VTE risk, and the influence of current guidelines and hospital systems. From a physician's perspective, DOACs could offer a good solution as they represent a potential patient-friendly alternative. However, robust comparative evidence regarding their efficacy and safety is lacking. This study underscores the urgent need for large observational studies or randomized controlled trials evaluating DOACs in MM to guide patient-appropriate thromboprophylaxis in clinical practice.