SUMMARY: The American Cancer Society estimates that in 2021, there will be an estimated 1.9 million new cancer cases diagnosed and 608,570 cancer deaths in the United States. Currently, more than 80% of all cancer care is delivered in outpatient oncology practice settings and tunneled Central Venous Catheters (Hickman), Peripherally Inserted Central Catheters (PICCs), and implantable PORTs are used to deliver systemic anticancer treatment via a central vein.
There are four types of Cental Venous Catheters (CVCs): Peripherally Inserted Central Catheters (PICCs), centrally inserted catheters (non-tunneled and tunneled), and implantable PORTS.
Nontunneled Central Venous Catheters (CVCs) are more commonly used, and inserted percutaneously into central veins (internal jugular, subclavian, or femoral vein), for short term use (usually less than 3 weeks, and account for the majority of central line-associated bloodstream infections.
Tunneled CVCs such as Hickman are implanted into internal jugular, subclavian, or femoral vein for long term use (weeks to months). They are associated with lower rate of infection than nontunneled CVCs and the dacron cuff inhibits migration of organisms into catheter tract when ingrown.
Implantable ports are inserted in the subclavian or internal jugular vein and tunneled beneath the skin, and the subcutaneous port is accessed with a noncoring needle. They are for long term use, and local catheter site care and dressing are not needed when not in use. They are associated with the lowest risk for central line-associated bloodstream infections.
Peripherally Inserted Central Catheter (PICC) is inserted percutaneously into basilic, brachial, or cephalic vein and enters the superior vena cava. They are usually for short to intermediate term use. PICC lines can usually be inserted at the bedside by a specially trained Registered Nurse. They can however be difficult to position in central vein and have the potential for occlusion.
The present study was conducted to compare the complication rates and costs of three central venous access devices, in order to establish acceptability, efficacy, and cost-effectiveness of the devices, for patients receiving systemic anticancer therapy.
This open-label, multicentre, randomized controlled trial (Cancer and Venous Access-CAVA) enrolled 1061 patients from 18 oncology centers in the UK. Eligible patients were over 18 years of age and had solid or hematological malignancy, and were receiving systemic anticancer therapy for 12 weeks or more. Enrolled patients assigned to use a central access device had four randomization options: Hickman versus PICC versus PORT (2:2:1), PICC versus Hickman (1:1), PORT versus Hickman (1:1), and PORT versus PICC (1:1). Randomization was done stratifying by centre, body mass index, type of cancer, device history, and treatment mode. The Primary outcome was complication rate (composite of infection, venous thrombosis, pulmonary embolus, inability to aspirate blood, mechanical failure, and other) assessed until device removal, withdrawal from study, or 1-year follow-up.
In the PORT versus Hickman comparison, PORTs were superior to Hickman with a complication rate of 29% versus 43% with Hickman catheters. PORTs were associated with lower rates of laboratory-confirmed bloodstream infection (6% versus 16%), exit site infection (4% versus 9%), were in place for a longer period (median 367 versus 165 days), were associated with a lower rate of complications per catheter week (0.02 versus 0.06), and a lower rate of removal due to complications (14% versus 32%), compared with Hickman catheters.
In the PORT versus PICC analysis, PORTs were again superior to PICCs, with a complication rate of 32% versus 47% respectively. PORTs were associated with lower rates of venous thrombosis (2% versus 11%; P=0.0024), mechanical failure (3% versus 11%), and were in place for a longer period of time (median 393 versus 119 days), and associated with a lower rate of complications per catheter week (0.05 versus 0.13), and a lower rate of removal due to complications (24% versus 38%).
In the PICC versus Hickman analysis, the complication rates observed with PICCs was 52% and was 49% with Hickman catheters. Non-inferiority of PICCs was not confirmed, potentially due to inadequate statistical power, even though the observed difference was less than 10%.
The authors based on this study concluded that for most patients receiving systemic anticancer therapy, PORTs are more effective and safer than both Hickman catheters and PICCs, and most patients receiving systemic anticancer therapy for solid tumors should therefore receive a PORT.
Central venous access devices for the delivery of systemic anticancer therapy (CAVA): a randomised controlled trial. Moss JG, Wu O, Bodenham AR, et al. Lancet 2021;398:403-415.
