Microsoft word - nov-dec 2012.doc
VENOUS THROMBOEMBOLISM IN ADVANCED CANCER
The Australian & New Zealand Society of Pal iative Medicine held its biennial conference in Queenstown,
NZ recently. As usual many interesting issues were raised and papers presented by both local and
One excel ent presentation was given by Prof Miriam Johnson, Professor in Pal iative Medicine, Hul York
Medical School, UK. Her 1999 MD thesis was on “Venous thromboembolism (VTE) in advanced cancer”
so she has much experience both clinical y and through on-going research. She also gave an excel ent
talk on pal iative care for heart failure patients, another of her research interests, but more of that later
I wil summarise some of the important messages from her work.
1. We know people with cancer have a significantly increased risk of DVT and pulmonary embolus
- secretion of cancer-related procoagulants (increase with advanced disease)
2. The prevalence of both symptomatic & undiagnosed VTE in advanced cancer is thought to be as
3. VTE has a significant negative impact on survival & quality of life.
4. Management of patients with VTE & advanced cancer is chal enging because:
- increased risk of bleeding and recurrent VTE with anticoagulation (especial y with
- these risks increase as cancer progresses due to:
- compression of venous return by tumour masses
- worsening disseminated intravascular coagulation (DIC)
- the term ‘advanced cancer’ refers to patients with widely differing features including
tumour histology, performance status, metastatic disease burden, mobility & prognosis.
These variables affect an individual patient’s risk of VTE or bleeding.
5. Very important to involve patients in their own management plans as for some, the advantages of
anticoagulants wil outweigh the risks (or vice versa).
- in the cancer population, warfarin is associated with bleeding rates up to 21.2% and
secondary VTE rates up to 27% - about twice the rates seen with low molecular weight
heparin (LMWH) such as enoxaparin (‘Clexane’).
- maintaining a stable INR is difficult due to poor nutritional status, liver metastases, multiple
and variable medications, variable oral intake & drug absorption, and significant drug- drug
- frequent INR testing is burdensome & inconvenient for many patients with advanced
- thus warfarin should be avoided in advanced disease
(unless patient chooses to
7. LMWH (eg Clexane):
- is the anticoagulant of choice in patients with advanced cancer
- usual y requires only once daily subcut administration
- many patients find it preferable to warfarin (see above)
- majority of patients or carers can learn how to give it
8. Recurrent VTE despite LMWH:
- firstly this is seen as a poor prognostic sign
- focus on reducing symptom burden without causing new problems!
- recheck patient’s weight and adjust dose accordingly
- check anti-factor Xa levels & increase dose if subtherapeutic
- consider changing to unfractionated heparin (UFH) i.v or s.c.
Clearly any options need to be considered in the light of the patient’s condition/prognosis/wishes
9. VTE in patients with bleeding:
- try to stop bleeding if possible (? pal iative radiotherapy, haemostatic dressings etc)
- consider reduced dose of Clexane (even to a prophylactic dose)
- mild, nuisance bleeding should not prevent anticoagulation in a patient with symptomatic
- bd dosing may smooth out peaks in anticoagulant levels
- for more serious & potential y life-threatening bleeding then anticoagulation not
10. Renal failure
- avoid LMWH (or monitor anti-factor Xa)
- 12 hrly s.c. injections with APPT checked 4-6 hrs post dose (titrate dose to target range)
11. Duration of therapy
- beyond this ‘indefinite’ therapy is traditional y recommended in patients with metastatic
disease because risk of recurrent VTE is high
12. Thromboprophylaxis in the palliative care unit
- consider prophylactic Clexane for those admitted with potential y reversible pathology and
- do not offer thromboprophylaxis to those admitted for terminal care
- we are likely to be missing some patients who could benefit
- new or worse breathlessness/pleuritic chest pain
Research in this difficult area of pal iative medicine continues particularly through The Thrombosis
Research in Advanced Disease (TRAD) Al iance in the UK (www.tradal iance.org).
Grampians Region Pal iative Care Consortium
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