Advances in Clinical and Experimental Medicine

Title abbreviation: Adv Clin Exp Med
IF – 2.1 (5-Year IF – 2.0), JCI (2023) – 0.4
Scopus CiteScore – 3.7 (CiteScore Tracker – 4.3)
Q1 in SJR 2024, SJR score – 0.598
IC – 171.00; MNiSW – 70 pts
Initial editorial assessment and first decision within 24 h

ISSN 1899–5276 (print), ISSN 2451-2680 (online)
Periodicity – monthly

Download original text (EN)

Advances in Clinical and Experimental Medicine

2018, vol. 27, nr 2, February, p. 283–289

doi: 10.17219/acem/64593

Publication type: review

Language: English

Download citation:

  • BIBTEX (JabRef, Mendeley)
  • RIS (Papers, Reference Manager, RefWorks, Zotero)

Thromboprophylaxis in cancer patients in hospice

Ewa Zabrocka1,A,B,C,D, Marek Z. Wojtukiewicz1,A,E,F, Ewa Sierko1,A,C,E,F

1 Department of Oncology, Medical University of Bialystok, Poland

Abstract

Advanced cancer patients in hospice are at notably increased risk of venous thromboembolism (VTE) due to age, local and distal advancement of the malignancy and bed confinement, among other factors. Asymptomatic VTE prevalence among palliative care patients has been found to reach 50%, whereas the clinically overt form occurs in 10%. Hospice patients are frequently given medications increasing VTE risk, for instance megestrol which is a drug commonly used in cancer cachexia. Many of the available guidelines encourage the implementation of thromboprophylaxis (TPX) in cancer patients, e.g., in the perioperative period or over the course of chemotherapy. However, concerning patients remaining under hospice care where the priority goal is not life extension but assurance of the best possible quality of life (QoL), the main benefit from the TPX would be a decrease in the risk of symptom burden associated with VTE, i.e., pain, edema or dyspnea. Nevertheless, studies performed on a sufficiently large study group, which could unequivocally determine the influence of anticoagulation on VTE symptom burden in hospice patients, are still lacking. VTE prophylaxis is challenging for many reasons: its unknown effect on QoL, vague risk of its discontinuation, and risk of bleeding complications which is additionally increased in conditions prevalent in hospice population, i.e., malnutrition, renal or liver insufficiency. So far, most of the guidelines issued by oncological societies do not precisely refer to the problem of TPX in hospice patients. Therefore, the decisions on the implementation of anticoagulation should be taken individually, with previous assessment of VTE risk, comorbidities and possible hemorrhagic complications.

Key words

thromboprophylaxis, venous thromboembolism, hospice, palliative care

References (40)

  1. Pruemer J. Prevalence, causes, and impact of cancer-associated thrombosis. Am J Health Syst Pharm. 2005;62(22 Suppl 5):S4–S6.
  2. Cunningham MS, White B, O’Donnell J. Prevention and management of venous thromboembolism in people with cancer: A review of the evidence. Clin Oncol (R Coll Radiol). 2006;18:145–151.
  3. Ambrus JL, Ambrus CM, Mink IB, Pickren JW. Causes of death in cancer patients. J Med. 1975;6:61–64.
  4. Johnson MJ, Sproule MW, Paul J. The prevalence and associated variables of deep venous thrombosis in patients with advanced cancer. Clin Oncol (R Coll Radiol). 1999;11:105–110.
  5. Soto-Cárdenas MJ, Pelayo-García G, Rodríguez-Camacho A, Segura-Fernández E, Mogollo-Galván A, Giron-Gonzalez JA. Venous thromboembolism in patients with advanced cancer under palliative care: Additional risk factors, primary/secondary prophylaxis and complications observed under normal clinical practice. Palliat Med. 2008; 22:965–968.
  6. Falanga A, Panova-Noeva M, Russo L. Procoagulant mechanisms in tumour cells. Best Pract Res Clin Haematol. 2009;22:49–60.
  7. Davis MP. Hematology in palliative medicine. Am J Hosp Palliat Care. 2004;21:445–454.
  8. Gerotziafas GT, Mahé I, Elalamy I. New orally active anticoagulant agents for the prevention and treatment of venous thromboembolism in cancer patients. Ther Clin Risk Manag. 2014;10:423–436.
  9. Seaman S, Nelson A, Noble S. Cancer-associated thrombosis, low-molecular-weight heparin, and the patient experience: A qualitative study. Patient Prefer Adherence. 2014;8:453–461.
  10. Lyman GH, Khorana AA, Falanga A, et al. American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol. 2007;25:5490–5505.
  11. Weber C, Merminod T, Herrmann FR, Zulian GB. Prophylactic anti-coagulation in cancer palliative care: A prospective randomised study. Support Care Cancer. 2008;16:847–852.
  12. Johnson MJ, McMillan B, Fairhurst C, et al. Primary thromboprophylaxis in hospices: The association between risk of venous thromboembolism and development of symptoms. J Pain Symptom Manage. 2014;48:56–64.
  13. Definition of palliative care. World Health Organization Web site. www.who.int/cancer/palliative/definition/en. Accessed January 05, 2016.
  14. Teno JM, Plotzke M, Gozalo P, Mor V. A national study of live discharges from hospice. J Palliat Med. 2014;17:1121–1127.
  15. Johnson MJ, Sherry K. How do palliative physicians manage venous thromboembolism? Palliat Med. 1997;11:462–468.
  16. Noble SI, Nelson A, Finlay IG. Factors influencing hospice thromboprophylaxis policy: A qualitative study. Palliat Med. 2008;22:808–813.
  17. Noble SI, Finlay IG. Have palliative care teams’ attitudes toward venous thromboembolism changed? A survey of thromboprophylaxis practice across British specialist palliative care units in the years 2000 and 2005. J Pain Symptom Manage. 2006;32:38–43.
  18. Schildmann J, Hoetzel J, Baumann A, Mueller-Busch C, Vollmann J. Limitation of treatment at the end of life: An empirical-ethical analysis regarding the practices of physician members of the German Society for Palliative Medicine. J Med Ethics. 2011;37:327–332.
  19. Kierner KA, Gartner V, Schwarz M, Watzke HH. Use of thromboprophylaxis in palliative care patients: A survey among experts in palliative care, oncology, intensive care, and anticoagulation. Am J Hosp Palliat Care. 2008;25:127–131.
  20. Noble SI, Nelson A, Turner C, Finlay IG. Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: Qualitative study. BMJ. 2006; 332:577–580.
  21. Gartner V, Kierner KA, Namjesky A, et al. Thromboprophylaxis in patients receiving inpatient palliative care: A survey of present practice in Austria. Support Care Cancer. 2012;20:2183–2187.
  22. Noble SI, 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.
  23. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149:315–352.
  24. Martel N, Lee J, Wells PS. Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: A meta-analysis. Blood. 2005;106:2710–2715.
  25. Lee AY, Levine MN, Baker RI, et al. Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med. 2003;349:146–153.
  26. Akl EA, van Doormaal FF, Barba M, et al. Parenteral anticoagulation for prolonging survival in patients with cancer who have no other indication for anticoagulation. Cochrane Database Syst Rev. 2007;CD006652.
  27. Kakkar AK, Levine MN, Kadziola Z, et al. Low molecular weight heparin, therapy with dalteparin, and survival in advanced cancer: The fragmin advanced malignancy outcome study (FAMOUS). J Clin Oncol. 2004;22:1944–1948.
  28. Launay-Vacher V, Oudard S, Janus N, et al. Prevalence of renal insufficiency in cancer patients and implications for anticancer drug management: The renal insufficiency and anticancer medications (IRMA) study. Cancer. 2007;110:1376–1384.
  29. Zalpour A, Kroll MH, Afshar-Kharghan V, Yusuf SW, Escalante C. Role of factor Xa inhibitors in cancer-associated thrombosis: Any new data? Adv Hematol. 2011;2011:196135.
  30. Nagler M, Haslauer M, Wuillemin WA. Fondaparinux – data on efficacy and safety in special situations. Thromb Res. 2012;129:407–417.
  31. Pollack CV Jr, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373:511–520.
  32. Siegal DM, Curnutte JT, Connolly SJ, et al. Andexanet alfa for the reversal of factor Xa inhibitor activity. N Engl J Med. 2015;373:
  33. Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011;365:2167–2177.
  34. National Clinical Guideline Centre for Acute and Chronic Conditions. Venous thromboembolism in adults admitted to hospital: reducing the risk. London (UK): National Institute for Health and Care Excellence (NICE); 2015 Jun. 62 p. (Clinical guideline; no. 92). http://www.guideline.gov/content.aspx?id= 49437. Accessed January 05, 2016.
  35. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133:3815–453S.
  36. Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl), e195S–226S.
  37. Clinical practice guidelines in oncology: Cancer-associated venous thromboembolic disease, v.1.2015. National Comprehensive Cancer Network Web site. www.nccn.org/professionals/physician_gls/pdf/vte.pdf. Accessed January 05, 2016.
  38. Lyman GH, Bohlke K, Khorana AA, et al. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update 2014. J Clin Oncol. 2015;33:654–656.
  39. Mandalà M, Falanga A, Roila F. Management of venous thromboembolism (VTE) in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2011;22 (6 Suppl):vi85–92.
  40. Chambers JC. Prophylactic heparin in palliative care: ...to a challenging idea. BMJ. 2006;332:729.
© Wroclaw Medical University