|
1
|
Debourdeau P, Sevestre MA, Bertoletti L, Mayeur D, Girard P, Scotté F, Sanchez O, Mahé I. [Translation into French and republication of: "Treatment of cancer-associated venous thromboembolism in patients under palliative care"]. Rev Med Interne 2024; 45:437-443. [PMID: 38908989 DOI: 10.1016/j.revmed.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 06/24/2024]
Abstract
Many patients with cancer require palliative care at some stage and the vast majority of people followed in palliative care are cancer patients. Patients with cancer are at high risk of venous thromboembolism (VTE), and this is particularly true during the advanced palliative phase when mobility is limited or absent. Patients with cancer in palliative care are at higher bleeding risk compared to non-cancer patients. Decisions to treat VTE or withhold anticoagulation for these patients have proven to be difficult and depend largely on an individual clinician's judgment. For this reason, we have developed a consensus proposal for appropriate management of cancer-associated thromboembolism (CAT) in patients in palliative care, which is presented in this article. The proposal was informed by the recent scientific literature retrieved through a systematic literature review. In cancer patients in advanced palliative care, the benefit/risk ratio of anticoagulation seems unfavourable with a higher haemorrhagic risk than the benefit associated with prevention of CAT recurrence and, above all, in the absence of any benefit on quality of life. For this reason, we recommend that patients should be prescribed anticoagulants on a case-by-case basis. The choice of whether to treat, and with which type of treatment, should take into account anticipated life expectancy and patient preferences, as well as clinical factors such as the estimated bleeding risk, the type of VTE experienced and the time since the VTE event.
Collapse
Affiliation(s)
- P Debourdeau
- Équipe mobile territoriale soins palliatifs, hôpital Joseph-Imbert, Arles, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - M-A Sevestre
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire, EA Chimère 7516, CHU d'Amiens-Picardie, Amiens, France
| | - L Bertoletti
- F-CRIN INNOVTE network, Saint-Étienne, France; Équipe dysfonction vasculaire et hémostase, Inserm, UMR1059, CIC-1408, service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, université Jean-Monnet, Saint-Étienne, France
| | - D Mayeur
- Centre Georges-François-Leclerc, Dijon, France
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, institut mutualiste Montsouris, Paris, France
| | - F Scotté
- Département interdisciplinaire d'organisation des parcours patients (DIOPP), institut Gustave-Roussy, Villejuif, France
| | - O Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; Inserm UMRS 1140 Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Inserm UMRS 1140 Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France
| |
Collapse
|
|
2
|
Debourdeau P, Sevestre MA, Bertoletti L, Mayeur D, Girard P, Scotté F, Sanchez O, Mahé I. Treatment of cancer-associated venous thromboembolism in patients under palliative care. Arch Cardiovasc Dis 2024; 117:94-100. [PMID: 38072741 DOI: 10.1016/j.acvd.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Many patients with cancer require palliative care at some stage and the vast majority of people followed in palliative care are cancer patients. Patients with cancer are at high risk of venous thromboembolism (VTE), and this is particularly true during the advanced palliative phase when mobility is limited or absent. Patients with cancer in palliative cancer are at higher bleeding risk compared to non-cancer patients. Decisions to treat VTE or withhold anticoagulation for these patients have proven to be difficult and depend largely on an individual clinician's judgment. For this reason, we have developed a consensus proposal for appropriate management of cancer-associated thromboembolism (CAT) in patients in palliative care, which is presented in this article. The proposal was informed by the recent scientific literature retrieved through a systematic literature review. In cancer patients in advanced palliative care, the benefit-risk ratio of anticoagulation seems unfavourable with a higher haemorrhagic risk than the benefit associated with prevention of CAT recurrence and, above all, in the absence of any benefit on quality of life. For this reason, we recommend that patients should be prescribed anticoagulants on a case-by-case basis. The choice of whether to treat, and with which type of treatment, should take into account anticipated life expectancy and patient preferences, as well as clinical factors such as the estimated bleeding risk, the type of VTE experienced and the time since the VTE event.
Collapse
Affiliation(s)
- Philippe Debourdeau
- Équipe mobile territoriale soins palliatifs, hôpital Joseph-Imbert d'Arles, Arles, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Marie-Antoinette Sevestre
- Service de médecine vasculaire, EA Chimère 7516, CHU d'Amiens-Picardie, Amiens, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | | | - Philippe Girard
- Institut du thorax-Curie-Montsouris, institut mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Florian Scotté
- Département interdisciplinaire d'organisation des parcours patients (DIOPP), institut Gustave-Roussy, Villejuif, France
| | - Olivier Sanchez
- Université Paris Cité, Service de pneumologie et de soins intensifs, hôpital européen Georges Pompidou, AP-HP, INSERM UMRS 1140 Innovations thérapeutiques en hémostase, Paris, France; Université Paris Cité, INSERM UMRS 1140 Innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Service de médecine interne, hôpital Louis Mourier, AP-HP, Colombes, France; Université Paris Cité, INSERM UMRS 1140 Innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| |
Collapse
|
|
3
|
Allende-Pérez SR, Cesarman-Maus G, Peña-Nieves A, Arcos A, Baz-Gutiérrez P, Robles J, LeBlanc TW. Venous Thromboembolism in Patients with Cancer Receiving Specialist Palliative Care. Clin Appl Thromb Hemost 2022; 28:10760296221081121. [PMID: 35225029 PMCID: PMC8894932 DOI: 10.1177/10760296221081121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context The prevalence of venous thromboembolism (VTE) in patients with cancer is particularly high at disease progression and during relapse. Patients cared for in specialized palliative care units (SPCU) are rarely included in VTE studies. Objective: We sought to study the prevalence, clinical characteristics, and survival of individuals with VTE in an SPCU setting. Methods We retrospectively included 2707 consecutive individuals with active cancer managed at a SPCU. Data were summarized using descriptive statistics and frequency for categorical variables. Overall survival was estimated by Kaplan-Meier and comparisons by log-rank test. Thrombotic events were confirmed by imaging. Results We studied 1984(73.3%) women and 723 (26.7%) men. The overall prevalence of thrombosis was 22.2% with only 6.2% occurring after initiating SPCU care, and was higher in women (24.6% vs 15.8%), particularly with gynecological tumors (cervical: 30.5%, ovarian: 29.2%). Median survival was slightly longer for patients without VTE (80 days [IQR21-334] and 69 days [IQR 25-235]; p = 0.03). Conclusions Prevalence of VTE was high and varied by tumor origin. VTE may impact survival. Though median survival is short, some patients are followed over months, suggesting that in the absence of high bleeding risk, treatment for thrombosis in an attempt to decrease the morbidity of re-thrombosis should be considered. On the other hand, few patients developed symptomatic VTE during SPCU care, making generalized primary prophylaxis probably unwarranted. Customizing anticoagulation for the risk of hemorrhage and physical performance is essential.
Collapse
Affiliation(s)
| | | | | | - Amelia Arcos
- Palliative Care Service, Mexican Secretariat of the Navy, Mexico City, Mexico
| | | | - Joanna Robles
- 12277Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Department of Medicine, Hematologic malignancies and cellular therapy, Duke University School of Medicine Durham, Durham, North Carolina, USA
| |
Collapse
|
|
4
|
Noble S. Venous thromboembolism in palliative care patients: what do we know? Thromb Res 2020; 191 Suppl 1:S128-S132. [PMID: 32736771 DOI: 10.1016/s0049-3848(20)30410-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/20/2019] [Indexed: 12/21/2022]
Abstract
Despite a breadth of data on the management of cancer-associated thrombosis, all the studies informing clinical guidelines excluded patients receiving palliative care. Patients with advanced cancer have a higher rate of recurrent venous thromboembolism (VTE) and bleeding, making them one of the most challenging populations to treat. The dearth of population-specific research leaves clinicians with few options but to extrapolate data from clinical trials conducted on a healthier population. Recent observational studies have challenged the utility of doing this, suggesting the natural history of VTE in the advanced cancer patient may differ to our first beliefs and that a less aggressive approach to anticoagulation is warranted particularly near the end of life. This paper highlights what we know so far.
Collapse
Affiliation(s)
- Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, UK.
| |
Collapse
|
|
5
|
Kirkova J, Fainsinger RL. Thrombosis and Anticoagulation in Palliative Care: An Evolving Clinical Challenge. J Palliat Care 2019. [DOI: 10.1177/082585970402000206] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jordanka Kirkova
- Division of Palliative Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| | - Robin L. Fainsinger
- Division of Palliative Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
|
6
|
Chin-Yee N, Tanuseputro P, Carrier M, Noble S. Thromboembolic disease in palliative and end-of-life care: A narrative review. Thromb Res 2019; 175:84-89. [PMID: 30731388 DOI: 10.1016/j.thromres.2018.12.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Revised: 12/24/2018] [Accepted: 12/31/2018] [Indexed: 01/06/2023]
Abstract
Venous thromboembolism (VTE) is both common and a potential contributor to symptom burden in patients receiving palliative and end-of-life care. Many of the VTE treatment and prophylaxis recommendations are drawn from data of clinical trials assessing conventional VTE and cancer-associated thrombosis that excluded patients receiving specialist palliative or hospice care. In this group, the epidemiology of VTE and associated outcomes, as well as the risks and benefits of treatment in keeping with a palliative approach are of growing clinical and research interest. This narrative review summarizes current knowledge and challenges in the management of thromboembolic disease in palliative care, highlighting the complexity of decisions surrounding VTE treatment and prophylaxis.
Collapse
Affiliation(s)
- Nicolas Chin-Yee
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK.
| |
Collapse
|
|
7
|
Kirkova J, Oneschuk D, Hanson J. Deep vein thrombosis (DVT) in advanced cancer patients with lower extremity edema referred for assessment. Am J Hosp Palliat Care 2016; 22:145-9. [PMID: 15853094 DOI: 10.1177/104990910502200213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Lower extremity edema is a common complication in advanced cancer patients, and deep vein thrombosis (DVT) is one among many causes. Clinical signs and symptoms are known to be unreliable, and radiographic investigations are often required in diagnosing DVT. A retrospective chart review was conducted on 46 advanced cancer patients with lower extremity edema. Researchers analyzed 52 venous duplex scans to determine the radiographic incidence of DVT, the reliability of other clinical signs and symptoms in diagnosing DVT, apart from leg edema, and to assess other potential causes of lower extremity edema and their correlation to DVT. Twenty-three (44 percent) of 52 scans were positive for DVT. The most common presentation of edema in the patients with positive scans was bilateral asymmetric edema (11/23, 48 percent). There was limited documentation of other clinical signs and symptoms suggesting DVT. Other variables such as serum albumin (p = 0.46) and creatinine (p = 0.11) were not statistically different in patients who had positive and negative scans. Of other potential causes of lower extremity edema, such as previous surgery, radiotherapy, tumor, or lymph node compression, a number of patients had a coexisting DVT with bilateral asymmetric edema as the most common presentation. The results of this study suggest that advanced cancer patients with bilateral asymmetric lower extremity edema of potentially multifactorial origin have a high incidence of DVT.
Collapse
|
|
8
|
Riess H, Habbel P, Jühling A, Sinn M, Pelzer U. Primary prevention and treatment of venous thromboembolic events in patients with gastrointestinal cancers - Review. World J Gastrointest Oncol 2016; 8:258-270. [PMID: 26989461 PMCID: PMC4789611 DOI: 10.4251/wjgo.v8.i3.258] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/08/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
Venous thromboembolism event (VTE) is a common and morbid complication in cancer patients. Patients with gastrointestinal cancers often suffer from symptomatic or incidental splanchnic vein thrombosis, impaired liver function and/or thrombocytopenia. These characteristics require a thorough risk/benefit evaluation for individual patients. Considering the risk factors for the development of VTE and bleeding events in addition to recent study results may be helpful for correct initiation of primary pharmacological prevention and treatment of cancer-associated thrombosis (CAT), preferably with low molecular weight heparins (LMWH). Whereas thromboprophylaxis is most often recommended in hospitalized surgical and non-surgical patients with malignancy, there is less agreement as to its duration. With regard to ambulatory cancer patients, the lack of robust data results in low grade recommendations against routine use of anticoagulant drugs. Anticoagulation with LMWH for the first months is the evidence-based treatment for acute CAT, but duration of secondary prevention and the drug of choice are unclear. Based on published guidelines and literature, this review will focus on prevention and treatment strategies of VTE in patients with gastrointestinal cancers.
Collapse
|
|
9
|
Dwyer LL, Lau DT, Shega JW. Medications That Older Adults in Hospice Care in the United States Take, 2007. J Am Geriatr Soc 2015; 63:2282-9. [DOI: 10.1111/jgs.13795] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Lisa L. Dwyer
- National Center for Health Statistics; Centers for Disease Control and Prevention; Hyattsville Maryland
| | - Denys T. Lau
- National Center for Health Statistics; Centers for Disease Control and Prevention; Hyattsville Maryland
- College of Pharmacy; University of Illinois at Chicago; Chicago Illinois
- Milken Institute; School of Public Health; George Washington University; Washington District of Columbia
| | | |
Collapse
|
|
10
|
van Nordennen RTCM, Lavrijsen JCM, Vissers KCP, Koopmans RTCM. Decision Making About Change of Medication for Comorbid Disease at the End of Life: An Integrative Review. Drugs Aging 2014; 31:501-12. [DOI: 10.1007/s40266-014-0182-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
|
11
|
Smith JD, Baillie J, Baglin T, Griffiths GO, Casbard A, Cohen D, Fitzmaurice DA, Hood K, Rose P, Cohen AT, Johnson M, Maraveyas A, Bell J, Toone H, Nelson A, Noble SI. A feasibility study to inform the design of a randomized controlled trial to identify the most clinically and cost effective anticoagulation length with low molecular weight heparin in the treatment of cancer associated thrombosis (ALICAT): study protocol for a mixed-methods study. Trials 2014; 15:122. [PMID: 24726032 PMCID: PMC4003288 DOI: 10.1186/1745-6215-15-122] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/20/2014] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Venous thromboembolism is common in patients with cancer and requires anticoagulation with low molecular weight heparin. Current data informs anticoagulation as far as six months, yet guidelines recommend anticoagulation beyond six months in patients who have locally advanced or metastatic cancer. This recommendation, based on expert consensus, has not been evaluated in a clinical study. ALICAT (Anticoagulation Length in Cancer Associated Thrombosis) is a feasibility study to identify the most clinically and cost effective length of anticoagulation with low molecular weight heparin in the treatment of cancer associated thrombosis. METHODS/DESIGN ALICAT is a randomized multi-centre phase two mixed-methods study with three components: a randomized controlled trial, embedded qualitative study and a survey investigating pathways of care. The randomized controlled trial will compare ongoing low molecular weight heparin treatment for cancer-associated thrombosis versus cessation of low molecular weight heparin at six months treatment (current licensed practice) in patients with locally advanced or metastatic cancer. The embedded qualitative study will include focus groups with clinicians to investigate attitudes to recruiting to the study, identify the challenges of progressing to a full randomized controlled trial, and also semi-structured interviews with patients and relatives/carers to explore their attitudes towards participating in the study and potential barriers and concerns to participation. Finally, a UK wide survey exercise will be undertaken to develop a classification and enumeration system for the cancer associated thrombosis models and pathways of care. DISCUSSION There is a lack of evidence determining the length of anticoagulation for patients with cancer associated thrombosis and subsequently treatment length varies. The ALICAT study will consider the feasibility of recruiting patients to a phase three trial. TRIAL REGISTRATION Current Controlled Trials ISRCTN37913976.
Collapse
Affiliation(s)
- Joanna D Smith
- Wales Cancer Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Jessica Baillie
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Trevor Baglin
- Department of Hematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS, Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK
| | - Gareth O Griffiths
- Wales Cancer Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Angela Casbard
- Wales Cancer Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - David Cohen
- Faculty of Health, Sport and Science, University of South Wales, Pontypridd CF37 1DL, UK
| | - David A Fitzmaurice
- Primary Care Clinical Sciences, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Kerenza Hood
- South East Wales Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Peter Rose
- Department of Hematology, Warwick Hospital, Lakin Road, Warwick CV34 5BW, UK
| | - Alexander T Cohen
- Department of Surgery and Vascular Medicine, King’s College Hospital, Denmark Hill, London SE5 9RS, UK
| | - Miriam Johnson
- Hull York Medical School, The University of Hull, Castle Road, Hull HU16 5JQ, UK
| | - Anthony Maraveyas
- Hull York Medical School, The University of Hull, Castle Road, Hull HU16 5JQ, UK
| | - John Bell
- Wales Cancer Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Harold Toone
- Wales Cancer Trials Unit, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| | - Simon I Noble
- Marie Curie Palliative Care Research Centre, Cardiff University School of Medicine, Heath Park, Cardiff, Wales CF14 4YS, UK
| |
Collapse
|
|
12
|
Abstract
Clinically significant bleeding occurs in approximately 6%-10% of patients in the palliative-care setting. Bleeding can range from persistent and small in quantity (but enough to interfere with a patient's quality of life), to catastrophic bleeding that ultimately leads to the rapid demise of the patient. Uncontrolled bleeding can be very distressing for staff, patients and families. Advanced planning is necessary in all bleeding circumstances. This session will review the types of cancer associated with bleeding, as well as management options for these situations. Emphasis will be placed on aspects of communication with families.
Collapse
Affiliation(s)
- Eric Prommer
- UCLA School of Medicine, Division of Hematology /Oncology, VIP Palliative Care Program, Greater Los Angeles Healthcare, 11301 Wilshire 111-H, Los Angeles, CA, USA.
| |
Collapse
|
|
13
|
Pereira J. Control of bleeding in cancer. Cancer Treat Res 2009; 148:305-326. [PMID: 19377932 DOI: 10.1007/978-0-387-79962-9_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Jaime Pereira
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
| |
Collapse
|
|
14
|
Noble SIR, Shelley MD, Coles B, Williams SM, Wilcock A, Johnson MJ. Management of venous thromboembolism in patients with advanced cancer: a systematic review and meta-analysis. Lancet Oncol 2008; 9:577-84. [PMID: 18510989 DOI: 10.1016/s1470-2045(08)70149-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Venous thromboembolism is common in patients with cancer. However, no management guidelines exist for venous thromboembolism specific to patients with advanced progressive cancer. To help develop recommendations for practice, we have done a comprehensive review of anticoagulation treatment in patients with cancer, with particular focus on studies that included patients with advanced disease. Data from 19 publications, including randomised, prospective, and retrospective studies suggest that: long-term full-dose low-molecular-weight heparin (LMWH) is more effective than warfarin in the secondary prophylaxis of venous thromboembolism in patients with cancer of any stage, performance status, or prognosis; warfarin should not be used in patients with advancing progressive disease; and in patients at high risk of bleeding, full-dose LMWH for 7 days followed by a long-term decreased fixed dose long term can be considered. The optimum treatment duration is unclear, but because the prothrombotic tendency will persist in patients with advanced cancer, indefinite treatment is generally recommended. For patients with contraindications to anticoagulation, inferior-vena-caval filters can be considered, but their use needs careful patient selection. Ultimately, the decision to initiate, continue, and stop anticoagulation will need to be made on an individual basis, guided by the available evidence, the patient's circumstances, and their informed preferences.
Collapse
Affiliation(s)
- Simon I R Noble
- Department of Palliative Medicine, Cardiff University, Royal Gwent Hospital, Newport, UK.
| | | | | | | | | | | | | |
Collapse
|
|
15
|
Hill RR, Martinez KD, Delate T, Witt DM. A descriptive evaluation of warfarin use in patients receiving hospice or palliative care services. J Thromb Thrombolysis 2008; 27:334-9. [PMID: 18338110 DOI: 10.1007/s11239-008-0210-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2007] [Accepted: 02/27/2008] [Indexed: 01/22/2023]
Abstract
PURPOSE To describe and compare warfarin therapy use and outcomes between warfarin-receiving patients in hospice or palliative care (HPC) and not in HPC. METHODS This retrospective, matched analysis examined warfarin-receiving patients who did (study cohort) and did not receive (control cohort) HPC services between 2002 and 2005. The matched cohorts were compared on rates of international normalized ratio (INR) measurements, INR control, and warfarin-related adverse events. RESULTS Included were 101 and 484 study and matched control patients, respectively. Study patients had a higher mean rate of INR measurements per 30 days (2.2 +/- 1.7 vs. 1.7 +/- 1.4, P = 0.001) and were more likely to be above and below target INR range (P < 0.05) than control patients. Differences between the cohorts in incidences of warfarin-related adverse events were not statistically significant (P > 0.05). CONCLUSIONS Patients in HPC required more frequent INR monitoring but had similar risks for warfarin-related adverse events.
Collapse
Affiliation(s)
- Robin R Hill
- Department of Pharmacy, Kaiser Permanente, Aurora, CO 80014, USA.
| | | | | | | |
Collapse
|
|
16
|
Korte W. Cancer and thrombosis: an increasingly important association. Support Care Cancer 2008; 16:223-8. [PMID: 18197438 DOI: 10.1007/s00520-007-0376-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2007] [Accepted: 12/06/2007] [Indexed: 01/20/2023]
Affiliation(s)
- Wolfgang Korte
- Institut für Klinische Chemie und Hämatologie, Kantonsspital, St Gallen, Switzerland.
| |
Collapse
|
|
17
|
Noble S. The challenges of managing cancer related venous thromboembolism in the palliative care setting. Postgrad Med J 2007; 83:671-4. [PMID: 17989265 DOI: 10.1136/pgmj.2007.061622] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Cancer patients with venous thromboembolism (VTE) pose particular management challenges since they have an increased risk of bleeding and recurrent thrombosis compared to the non-cancer population. Also, as the disease progresses so do the hazards of anticoagulation, and patients in the palliative stages of their cancer could be viewed as a separate disease group with respect to diagnosis and management. As the focus from curative treatment moves towards symptom control, physicians face several challenges in providing the most appropriate care. Palliative care patients have rarely been included in research on VTE and the supporting evidence needs to be extrapolated cautiously. Quality of life aspects of VTE and their management may be a more appropriate outcome measure in this stage of disease than radiological end points. This paper looks at the challenges facing professionals in the management of VTE in the advanced cancer patient.
Collapse
Affiliation(s)
- S Noble
- Department of Palliative Medicine, Ward B6N, Royal Gwent Hospital, Cardiff Rd, Newport, NP20 2UB, UK.
| |
Collapse
|
|
18
|
Noble SIR, Hood K, Finlay IG. The use of long-term low-molecular weight heparin for the treatment of venous thromboembolism in palliative care patients with advanced cancer: a case series of sixty two patients. Palliat Med 2007; 21:473-6. [PMID: 17846086 DOI: 10.1177/0269216307080816] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The advantages of low-molecular weight heparin (LMWH) over warfarin, in the treatment of cancer associated venous thromboembolism (VTE) are well reported. However the studies supporting LMWH include few patients representative of the palliative care population. Although LMWH has advantages over warfarin it is still unclear, within the palliative care environment, how long anticoagulation should be continued, what dose of LMWH should be used and whether palliative care patients experience different complication rates such as bleeding, heparin-induced thrombocytopenia and osteoporosis. We report a case series of 62 patients with advanced malignancy and VTE treated with long-term LMWH according to either the CLOT (full dose) or Montreal (reduced dose) regime. Seventy-four percent of patients self-administered LMWH, whereas 24% had it given by a carer and 2% by the district nurse. LMWH was given for median duration of 97 days; the most common reason for discontinuation of therapy being admission to die or commencement of the care pathway (n = 50, 81%). A further 11% (n = 7) stopped after 6 months of treatment. Of these 3 (43%) developed clinical symptomatic recurrence of VTE. The overall minor bleeding rate was 8.1% (95% confidence interval 3.5-17.5%), and this was not associated with NSAID or steroid use. No major bleeding events were observed. No patients developed evidence of heparin-induced thrombocytopenia or osteoporosis.Long-term LMWH appears effective in treatment of VTE in the palliative care population with advanced cancer. A randomised control trial is required to identify the best dose required to ensure optimum efficacy and safety.
Collapse
Affiliation(s)
- S I R Noble
- Palliative Medicine, Cardiff University, Cardiff and Royal Gwent Hospital, Newport, UK.
| | | | | |
Collapse
|
|
19
|
Noble SIR, Finlay IG. Is long-term low-molecular-weight heparin acceptable to palliative care patients in the treatment of cancer related venous thromboembolism? A qualitative study. Palliat Med 2005; 19:197-201. [PMID: 15920933 DOI: 10.1191/0269216305pm1008oa] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Venous thromboembolism (VTE) is common in patients with terminal cancer. Current treatment practice with warfarin has a high incidence of complications, including bleeding, poor control and recurrent VTE. Long-term low-molecular-weight heparin (LMWH) therapy is safer and more efficacious in this patient group, but there are concerns that daily therapy may have a negative impact on quality of life. A qualitative study was carried out to determine whether LMWH was acceptable in palliative care patients, both in the community and in-patient units. Forty palliative care patients receiving LMWH for VTE were interviewed. Participants found LMWH to be an acceptable intervention, allowing them freedom from blood tests and optimism regarding their care. It was considered a preferable therapy to warfarin, which had a negative impact on participant's quality of life. The findings of this study support the use of LMWH, first line in the treatment of established VTE in the palliative care setting.
Collapse
Affiliation(s)
- Simon I R Noble
- Department of Palliative Medicine, Velindre Hospital, Whitchurch, Cardiff, UK.
| | | |
Collapse
|
|
20
|
Abstract
Bleeding occurs in up to 10% of patients with advanced cancer. It can present in many different ways. This article provides a qualitative review of treatment options available to manage visible bleeding. Local modalities, such as hemostatic agents and dressings, radiotherapy, endoscopic ligation and coagulation, and transcutaneous arterial embolization, are reviewed in the context of advanced cancer, as are systemic treatments such as vitamin K, vasopressin/desmopressin, octreotide/somatostatin, antifibrinolytic agents (tranexamic acid and aminocaproic acid), and blood products. Considerations at the end of life are described.
Collapse
Affiliation(s)
- Jose Pereira
- Department of Oncology, University of Calgary, Palliative Care Office, Room 710, South Tower, Foothills Medical Centre, 1403-29th Avenue NW, Calgary, Alberta, T2N 2T9, Canada.
| | | |
Collapse
|
|
21
|
Naysmith A. Clinical governance in specialist palliative care. Int J Palliat Nurs 2004; 10:329-32. [PMID: 15365485 DOI: 10.12968/ijpn.2004.10.7.14573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article is based on a talk presented at IJPN/Palliative Medicine conference held in London, June 2004. In it I hope to share my enthusiasm and provide a little advice on this sometimes less than popular topic.
Collapse
Affiliation(s)
- Anne Naysmith
- Pembridge Unit, Kensington and Chelsea PCT NHS Trust, St Charles Hospital, Exmoor Street, London W10 6DZ, UK
| |
Collapse
|
|
22
|
|