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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.
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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
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Al‐Ansari AM, Abd‐El‐Gawad WM, AboSerea SM, Ali AA, Abdullah MM, Ali FA, ElShereafy EE, Bahnasy MA. Thromboprophylaxis for Inpatient with Advanced Cancer Receiving Palliative Care: A Retrospective study. Eur J Haematol 2022; 109:494-503. [DOI: 10.1111/ejh.13834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Wafaa Mostafa Abd‐El‐Gawad
- Geriatrics and Gerontology Department, Faculty of Medicine Ain Shams University, Al‐Abbaseya Cairo Egypt
| | | | - Ali Adli Ali
- Palliative Care Center, Al‐Sabah Medical Area Al‐Shuwaikh Kuwait
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3
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Deprescribing in Palliative Cancer Care. Life (Basel) 2022; 12:life12050613. [PMID: 35629281 PMCID: PMC9147815 DOI: 10.3390/life12050613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/23/2022] Open
Abstract
The aim of palliative care is to maintain as high a quality of life (QoL) as possible despite a life-threatening illness. Thus, the prescribed medications need to be evaluated and the benefit of each treatment must be weighed against potential side effects. Medications that contribute to symptom relief and maintained QoL should be prioritized. However, studies have shown that treatment with preventive drugs that may not benefit the patient in end-of-life is generally deprescribed very late in the disease trajectory of cancer patients. Yet, knowing how and when to deprescribe drugs can be difficult. In addition, some drugs, such as beta-blockers, proton pump inhibitors, anti-depressants and cortisone need to be scaled down slowly to avoid troublesome withdrawal symptoms. In contrast, other medicines, such as statins, antihypertensives and vitamins, can be discontinued directly. The aim of this review is to give some advice according to when and how to deprescribe medications in palliative cancer care according to current evidence and clinical praxis. The review includes antihypertensive drugs, statins, anti-coagulants, aspirin, anti-diabetics, proton pump inhibitors, histamin-2-blockers, bisphosphonates denosumab, urologicals, anti-depressants, cortisone, thyroxin and vitamins.
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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: 0.8] [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.
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Affiliation(s)
- Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, UK.
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Venous Thromboembolism in Cancer Patients on Simultaneous and Palliative Care. Cancers (Basel) 2020; 12:cancers12051167. [PMID: 32384641 PMCID: PMC7281278 DOI: 10.3390/cancers12051167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022] Open
Abstract
Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment. Cancer patients require a composite clinical, social and psychological management that can be effective only if care continuity from hospital to home is guaranteed and if such a care takes place early in the course of the disease, combining standard oncology care and palliative care. In these settings, venous thromboembolism (VTE) represents a difficult medical challenge, for the requirement of acute treatments and for the strong impact on anticancer therapies that might be delayed or, even, totally discontinued. Moreover, cancer patients not only display high rates of VTE occurrence/recurrence but are also more prone to bleeding and this forces clinicians to optimize treatment strategies, balancing between hemorrhages and thrombus formation. VTE prevention is, therefore, regarded as a double-edged sword. Indeed, while on one hand the appropriate use of antithrombotic agents can reduce VTE occurrence, on the other it significantly increases the bleeding risk, especially in the frail patients who present with multiple co-morbidities and poly-therapy that can interact with anticoagulant drugs. For these reasons, thromboprophylaxis should start while active cancer treatment is ongoing, according to a simultaneous care model in a patient-centered perspective.
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Thromboprophylaxis in the End-of-Life Cancer Care: The Update. Cancers (Basel) 2020; 12:cancers12030600. [PMID: 32150978 PMCID: PMC7139629 DOI: 10.3390/cancers12030600] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/01/2020] [Accepted: 03/02/2020] [Indexed: 01/20/2023] Open
Abstract
Cancer patients are at increased risk for venous thromboembolism (VTE), which further increases with advanced stages of malignancy, prolonged immobilization, or prior history of thrombosis. To reduce VTE-related mortality, many official guidelines encourage the use of thromboprophylaxis (TPX) in cancer patients in certain situations, e.g., during chemotherapy or in the perioperative period. TPX in the end-of-life care, however, remains controversial. Most recommendations on VTE prophylaxis in cancer patients are based on the outcomes of clinical trials that excluded patients under palliative or hospice care. This translates to the paucity of official guidelines on TPX dedicated to this group of patients. The problem should not be underestimated as VTE is known to be associated with symptoms adversely impacting the quality of life (QoL), i.e., limb or chest pain, dyspnea, hemoptysis. In end-of-life care, where the assurance of the best possible QoL should be the highest priority, VTE prophylaxis may eliminate the symptom burden related to thrombosis. However, large randomized studies determining the benefits and risks profiles of TPX in patients nearing the end of life are lacking. This review summarized available data on TPX in this population, analyzed potential tools for VTE risk prediction in the view of this group of patients, and summarized the most current recommendations on TPX pertaining to terminal care.
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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: 1.8] [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.
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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.
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Palomar-Muñoz C, Martín-Zamorano M, Mogollo A, Pascual-Pérez S, Rodríguez-Morales I, Girón-González JA. Assessment of the Palliative Prognostic Index in hospitalized oncologic patients treated by a palliative care team: impact of acute concomitant diseases. Oncotarget 2018; 9:18908-18915. [PMID: 29721171 PMCID: PMC5922365 DOI: 10.18632/oncotarget.24826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/27/2018] [Indexed: 12/29/2022] Open
Abstract
The differential prognostic accuracy of the Palliative Prognostic Index (PPI) in hospitalized oncologic patients treated by a palliative care team according to the presence or absence of acute concomitant diseases was analyzed. All patients (n = 322) hospitalized in a palliative unit of a university hospital were included in a 2-year prospective study. PPI was determined at the time of hospital admission and discharge. Patients were grouped into two categories according to the causes of hospitalization (presence and absence of acute concomitant diseases). Metastases, PPI punctuation, refractory symptoms, and the presence of acute concomitant diseases were analyzed as survival-related factors. The absence of acute concomitant diseases and a PPI calculated at admission >4 or >6 were related with survival at 3 and 6 weeks, respectively. After hospital discharge, the accuracy of PPI was lower, decreasing the positive predictive value from 84% (PPI calculated at the time of hospital admission) to 67% (PPI calculated at the time of discharge) for survival <6 weeks. In conclusion, the impact of acute concomitant diseases on survival should be considered in prediction models for patients receiving palliative care.
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Affiliation(s)
- Carmen Palomar-Muñoz
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - Marina Martín-Zamorano
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - Amparo Mogollo
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - Susana Pascual-Pérez
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - Inmaculada Rodríguez-Morales
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
| | - José-Antonio Girón-González
- Service of Internal Medicine, Palliative Care and Infectious Diseases, Hospital Universitario Puerta del Mar, Facultad de Medicina, Universidad de Cádiz, Instituto para la Investigación e Innovación en Ciencias Biomédicas de Cádiz (INiBICA), Cádiz, Spain
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9
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Palliative care in ovarian carcinoma patients-a personalized approach of a team work: a review. Arch Gynecol Obstet 2017; 296:691-700. [PMID: 28803353 DOI: 10.1007/s00404-017-4484-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/01/2017] [Indexed: 01/06/2023]
Abstract
Most ovarian cancer patients are diagnosed in an advanced stage; and after the initial treatment experience disease recurrence, which eventually becomes palliative. Many questions arise in this setting including how to address patients in the palliative setting, how to discuss end-of-life issues, and how to manage symptoms. In this review, we discuss the timing and setting of end-of-life discussion in the context of end-stage ovarian cancer. We review the approach to relieving disease burden by improving and decreasing symptoms. These symptoms include recurrent ascites, bowel obstruction, pain, pulmonary effusion, and deep vein thrombosis.
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Tardy B, Picard S, Guirimand F, Chapelle C, Danel Delerue M, Celarier T, Ciais JF, Vassal P, Salas S, Filbet M, Gomas JM, Guillot A, Gaultier JB, Merah A, Richard A, Laporte S, Bertoletti L. Bleeding risk of terminally ill patients hospitalized in palliative care units: the RHESO study. J Thromb Haemost 2017; 15:420-428. [PMID: 28035750 DOI: 10.1111/jth.13606] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Indexed: 12/25/2022]
Abstract
Essentials Bleeding incidence as hemorrhagic risk factors are unknown in palliative care inpatients. We conducted a multicenter observational study (22 Palliative Care Units, 1199 patients). At three months, the cumulative incidence of clinically relevant bleeding was 9.8%. Cancer, recent bleeding, thromboprophylaxis and antiplatelet therapy were independent risk factors. SUMMARY Background The value of primary thromboprophylaxis in patients admitted to palliative care units is debatable. Moreover, the risk of bleeding in these patients is unknown. Objectives Our primary aim was to assess the bleeding risk of patients in a real-world practice setting of hospital palliative care. Our secondary aim was to determine the incidence of symptomatic deep vein thrombosis and to identify risk factors for bleeding. Patients/Methods In this prospective, observational study in 22 French palliative care units, 1199 patients (median age, 71 years; male, 45.5%), admitted for the first time to a palliative care unit for advanced cancer or pulmonary, cardiac or neurologic disease were included. The primary outcome was adjudicated clinically relevant bleeding (i.e. a composite of major and clinically relevant non-major bleeding) at 3 months. The secondary outcome was symptomatic deep vein thrombosis. Results The most common reason for palliative care was cancer (90.7%). By 3 months, 1087 patients (91.3%) had died and 116 patients had presented at least one episode of clinically relevant bleeding (fatal in 23 patients). Taking into account the competing risk of death, the cumulative incidence of clinically relevant bleeding was 9.8% (95% confidence interval [CI], 8.3-11.6). Deep vein thrombosis occurred in six patients (cumulative incidence, 0.5%; 95% CI, 0.2-1.1). Cancer, recent bleeding, antithrombotic prophylaxis and antiplatelet therapy were independently associated with clinically relevant bleeding at 3 months. Conclusions Decisions regarding the use of thromboprophylaxis in palliative care patients should take into account the high risk of bleeding in these patients.
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Affiliation(s)
- B Tardy
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
- Service de Soins Intensifs Médicaux, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Picard
- Unité de Soins Palliatifs, Hôpital les Diaconesses, Paris, France
| | - F Guirimand
- Pôle Recherche SPES "soins palliatifs en société", Maison Médicale Jeanne Garnier, Paris, France
| | - C Chapelle
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
| | - M Danel Delerue
- Unité de Soins Palliatifs, Centre Hospitalier Saint Vincent de Paul, Lille, France
| | - T Celarier
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - J-F Ciais
- Unité de Soins Palliatifs, Centre Hospitalo-Universitaire de Nice, Nice, France
| | - P Vassal
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Salas
- Service d'Oncologie Médicale, Assistance Publique des Hôpitaux de Marseille, Marseille, France
- CRO2, Aix Marseille Université, Marseille, France
- INSERM U911, Marseille, France
| | - M Filbet
- Centre de Soins Palliatifs, Centre Hospitalier Lyon Sud, Hospices Civiles de Lyon, Pierre-Bénite, France
| | - J-M Gomas
- Unité de Soins Palliatifs, Hôpital Sainte Perine, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - A Guillot
- Service d'Oncologie Médicale, Institut de Cancérologie Lucien Neuwirth, Saint Priest en Jarez, France
| | - J-B Gaultier
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - A Merah
- Inserm, CIC 1408, FCRIN-INNOVTE, Saint-Etienne, France
| | - A Richard
- Fédération de Soins Palliatifs, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - S Laporte
- UMR1059 SAINBIOSE, Université Jean Monnet, PRES de Lyon, Saint-Etienne, France
- Unité de Recherche Clinique, Innovation et Pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
| | - L Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalo-Universitaire de Saint-Etienne, Saint-Etienne, France
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Morgan ER, Mason WP, Maurice C. A critical balance: managing coagulation in patients with glioma. Expert Rev Neurother 2016; 16:803-14. [PMID: 27101362 DOI: 10.1080/14737175.2016.1181542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cancer-associated thrombosis, including both arterial and venous thromboembolism (VTE), is a significant source of morbidity and mortality in patients with glioma. This risk is highest in the immediate postoperative period and is increased by chemotherapy, radiation, and corticosteroids. Systemic anticoagulation with low molecular weight heparin is the treatment of choice in both the therapeutic and prophylactic settings. However, these patients are also at risk of intracranial hemorrhage, a potentially catastrophic complication of anticoagulation, and this risk must be carefully balanced against the risk of VTE. In this review we outline the incidence, pathophysiology and management of thrombosis in patients with glioma, with a focus on clinical considerations including perioperative management, chemotherapy-induced thrombocytopenia, and end-of-life management.
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Affiliation(s)
- Erin R Morgan
- a Pencer Brain Tumor Centre , Princess Margaret Hospital Cancer Centre , Toronto , Canada.,b Department of Medical Oncology and Hematology , University of Toronto , Toronto , Canada
| | - Warren P Mason
- a Pencer Brain Tumor Centre , Princess Margaret Hospital Cancer Centre , Toronto , Canada.,b Department of Medical Oncology and Hematology , University of Toronto , Toronto , Canada
| | - Catherine Maurice
- a Pencer Brain Tumor Centre , Princess Margaret Hospital Cancer Centre , Toronto , Canada.,b Department of Medical Oncology and Hematology , University of Toronto , Toronto , Canada
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12
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In patients receiving end-of-life care, medications used to treat co-morbid diseases should be discontinued when appropriate. DRUGS & THERAPY PERSPECTIVES 2014. [DOI: 10.1007/s40267-014-0153-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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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: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Seaman S, Nelson A, Noble S. Cancer-associated thrombosis, low-molecular-weight heparin, and the patient experience: a qualitative study. Patient Prefer Adherence 2014; 8:453-61. [PMID: 24748774 PMCID: PMC3986276 DOI: 10.2147/ppa.s58595] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Venous thromboembolism is a common complication of cancer and its treatments. Treatment of cancer-associated thrombosis (CAT) differs from treatment of thrombosis in noncancer patients, requiring a daily injection of low-molecular-weight heparin (LMWH) for 6 months instead of an oral anticoagulant. Previous research suggested LMWH is an acceptable intervention in the treatment of CAT, yet clinical practice and therapeutic opportunities have changed in the decade since the study was conducted. Furthermore, in the previous study there was acknowledged selection bias in participant recruitment. There is increasing clinical use of the novel oral anticoagulants, although their efficacy and safety is yet to be demonstrated within the cancer population. The experience of patients receiving anticoagulation for CAT will inform future practice with respect to quality of life and adherence to anticoagulation therapy. AIM To explore the acceptability of long-term LMWH for the treatment of CAT in the contexts of living with cancer and quality of life. DESIGN Qualitative study of cancer patients who had been receiving LMWH for at least 3 months for CAT was undertaken. Audiotaped semistructured interviews were conducted and transcribed. Thematic analysis was undertaken until theoretical saturation. SETTING/PARTICIPANTS Fourteen patients attending a palliative care or CAT clinic were interviewed. Participants had been receiving LMWH for a median 6 months. RESULTS Participants reported distressing symptoms associated with symptomatic CAT, which they rated as worse than their cancer experiences. LMWH was considered an acceptable intervention despite challenges of long-term injections. Several adaptive techniques were reported to optimize ongoing injections. Participants would only favor a novel oral anticoagulant if it was equivalent to LMWH in efficacy and safety. CONCLUSION Although LMWH remains an acceptable intervention for the treatment of CAT, its long-term use is associated with bruising and deterioration of injection sites. These are considered an acceptable trade-off against their strongly negative experiences of symptomatic venous thromboembolism.
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Affiliation(s)
- Siwan Seaman
- Department of Palliative Medicine, Royal Gwent Hospital, Newport, Wales, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Unit, Cardiff University, Cardiff, Wales, UK
| | - Simon Noble
- Marie Curie Palliative Care Research Unit, Cardiff University, Cardiff, Wales, UK
- Correspondence: Simon Noble, Marie Curie Palliative Medicine Research Group, Sixth Floor, Neuadd Meirionnydd, Cardiff University, Heath Park Campus, CF14 4YS, Wales, UK, Tel +44 29 2068 7500, Fax +44 29 2068 7501, Email
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15
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Pautex S, Vayne-Bossert P, Jamme S, Herrmann F, Vilarino R, Weber C, Burkhardt K. Anatomopathological Causes of Death in Patients with Advanced Cancer: Association with the Use of Anticoagulation and Antibiotics at the End of Life. J Palliat Med 2013; 16:669-74. [DOI: 10.1089/jpm.2012.0369] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sophie Pautex
- Division of Primary Care, University of Geneva, Switzerland
- Division of Palliative Medicine, University of Geneva, Switzerland
| | | | - Sharon Jamme
- Division of Palliative Medicine, University of Geneva, Switzerland
| | | | - Raquel Vilarino
- Division of Clinical Pathology, University of Geneva, Switzerland
| | - Catherine Weber
- Division of Primary Care, University of Geneva, Switzerland
- Division of Medical Readaptation, University Hospital Geneva, University of Geneva, Switzerland
| | - Karim Burkhardt
- Division of Clinical Pathology, University of Geneva, Switzerland
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Sheard L, Prout H, Dowding D, Noble S, Watt I, Maraveyas A, Johnson M. Barriers to the diagnosis and treatment of venous thromboembolism in advanced cancer patients: a qualitative study. Palliat Med 2013; 27:339-48. [PMID: 23093572 DOI: 10.1177/0269216312461678] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Venous thromboembolism is common in patients with cancer and the risk increases with advanced disease. Evidence-based treatment is administration of low-molecular-weight heparin daily by subcutaneous injection. Clinical uncertainty exists as to whether treating venous thromboembolism in advanced disease is in the patient's best interests. AIM To explore the barriers faced by doctors when diagnosing and treating patients with cancer-associated thrombosis. DESIGN Qualitative, in-depth interview study using framework analysis. PARTICIPANTS Forty-five UK doctors across urban and rural settings, from three specialties, oncology, palliative medicine and general practice, with a mixture of senior and junior staff. RESULTS Organisational constraints served to act as barriers to the diagnosis and treatment of this patient group. Issues were identified around access to diagnostic testing. A cancer-associated thrombosis patient having to wait for a scan as an inpatient was sometimes deemed unnecessary. Patient ambulance transport (especially transportation of hospice patients) was often viewed as inflexible and bureaucratic. Low-molecular-weight heparin prescribing had sometimes led to tension between the acute, community and hospice sectors about whose prescribing responsibility this was, with different areas having divergent 'rules' and practices. Finally, the doctors interviewed discussed the role of nurses. CONCLUSIONS Multiple logistical barriers are hindering best patient care for people with cancer-associated thrombosis. There is scope for some of these barriers to be reduced to improve service delivery and ultimately patient care. The research team proposes practical recommendations, which could yield direct benefit for patients and the health services.
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Affiliation(s)
- Laura Sheard
- Department of Health Sciences, University of York, York, UK.
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Holmes HM, Bain KT, Zalpour A, Luo R, Bruera E, Goodwin JS. Predictors of anticoagulation in hospice patients with lung cancer. Cancer 2010; 116:4817-24. [PMID: 20572034 DOI: 10.1002/cncr.25284] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Guidelines recommend lifelong anticoagulation in patients with cancer and a history of thromboembolism, but the use of anticoagulation in hospice has not been described. A retrospective study of medication data was conducted to determine patterns of anticoagulant use and predictors of type of anticoagulant prescribed for hospice patients with lung cancer. METHODS Medication data were evaluated for 16,896 hospice patients with lung cancer in 2006 to determine patient and hospice characteristics that predicted anticoagulant prescription. Independent predictors of warfarin versus low molecular weight heparin (LMWH) prescription were identified using a logistic regression model. RESULTS One of every 11 patients was prescribed an anticoagulant, most commonly warfarin. Compared with patients prescribed LMWH, patients prescribed warfarin were older (71.6 vs 65.8 years, P<.001), were more likely white (81.2% vs 74.3%, P = .03), had a longer stay in hospice (median 21 days vs 17 days, P = .001), and were more likely to have ≥3 comorbid illnesses (37.5% vs 25.0%, P<.001). The strongest independent predictor of type of anticoagulant prescribed was geographic region, with hospices in the Northeast more likely to prescribe LMWH. CONCLUSIONS Anticoagulant use is prevalent in patients with lung cancer enrolled in hospice. This study highlights the need to understand the benefits and risks of anticoagulation at the end of life.
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Affiliation(s)
- Holly M Holmes
- Department of General Internal Medicine, Ambulatory Treatment, and Emergency Care, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Harenberg J, Bauersachs R, Diehm C, Lawall H, Burkhardt H, Gerlach H, Darius H, Völler H, Rabe E, Wehling M. [Anticoagulation in the elderly]. Internist (Berl) 2010; 51:1446-55. [PMID: 20802990 DOI: 10.1007/s00108-010-2702-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The recommendations for anticoagulation in over 80 years old patients are based on the thromboembolic/bleeding risk relation. They add to the published recommendations for the specific indications. Low-molecular-weight heparin (LMWH) is used to prevent thromboembolism postoperatively. Compression stockings and/or intermittent pneumatic compression are used if bleeding risk is very high. The dose is increased starting at day two if the thromboembolic risk is very high. Bleeding and thromboembolic risks are re-evaluted daily. The antithrombotic therapy is adjusted accordingly. Prophylaxis of thromboembolism in patients with acute illnesses and bedrest is performed according postoperative care. Two-thirds of therapeutic doses of low-molecular-weight heparin are used to treat acute venous thromboembolism. Reduced renal function (creatinine clearance <30 ml/ min for most LMWHs or <20 ml/min for tinzaparin) should result in a further reduction of dose. Intensity and duration of prophylaxis of recurrent events with vitamin K antagonist or LMWH in malignancy follow current or herein described recommendations. Patients with atrial fibrillation are treated with vitamin K antagonists adjusted to an INR of 2-3 for prophylaxis of embolism. Further details of anticoagulant therapy should be in agreement with the national or international recommendations.
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Affiliation(s)
- J Harenberg
- Klinische Pharmakologie Mannheim, Ruprecht-Karls-Universität Heidelberg, Maybachstraße 14, 68169, Mannheim.
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McLean S, Ryan K, O'Donnell JS. Primary thromboprophylaxis in the palliative care setting: a qualitative systematic review. Palliat Med 2010; 24:386-95. [PMID: 20360427 DOI: 10.1177/0269216310365735] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Symptomatic venous thromboembolism (VTE) occurs in 15% of patients with advanced malignancy. Primary thromboprophylaxis using low-molecular-weight heparin (LMWH) is supported by Level 1A evidence but is under-utilized in the palliative setting. A systematic search was performed of Medline, Cochrane Library, EMBASE, AMED, and Web of Science for papers published between 1960 and January 2010 using search terms: 'palliative', 'thromboprophylaxis', 'thromboembolism', 'heparin', and 'advanced cancer'. Forty-two citations were obtained, of which 34 were excluded as they dealt with treatment of VTE, novel anticoagulants, or LMWH as a cancer treatment. Eight original articles were reviewed independently by two authors. Data was extracted according to a predetermined questionnaire. Studies examined practice in specialist palliative care (SPC) units, and attitudes held by a total of 32 physicians and 198 patients. Patients find LMWH acceptable, particularly patients who experienced a sudden decline in performance status. Reluctance to prescribe LMWH is based on physicians' concerns regarding negative impact on quality of life, and lack of evidence specific to the palliative care setting. In conclusion, LMWH prophylaxis should be implemented in patients with a previously good performance status who have a transiently increased risk of VTE and no contraindications. Further research is required using outcome measures specific to palliative care.
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Affiliation(s)
- Sarah McLean
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
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Noble S, Johnson M. Finding the evidence for thromboprophylaxis in palliative care: first let us agree on the question. Palliat Med 2010; 24:359-61. [PMID: 20507865 DOI: 10.1177/0269216310366389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Simon Noble
- Cardiff University and Honorary Consultant, Royal Gwent Hospital, Newport, UK
| | - Miriam Johnson
- Hull York Medical School and Honorary Consultant St Catherine's Hospice, Scarborough, UK
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21
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Tran QN. Review Article: Role of Palliative Low-Molecular-Weight Heparin for Treating Venous Thromboembolism in Patients With Advanced Cancer. Am J Hosp Palliat Care 2010; 27:416-9. [DOI: 10.1177/1049909110361244] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with cancer are at risk of developing venous thromboembolism ([VTE]; deep venous thrombosis, and pulmonary embolism). Although vitamin K antagonists had originally been used to treat VTE in these patients, low-molecular-weight heparins (LMWH) have been shown to be more effective and safe for patients with cancer-associated thrombosis. In cancer patients with advanced disease where curative therapy is no longer the intent of treatment, continued anticoagulation for VTE for palliative purposes continues to remain a controversial topic as no large randomized trials have been conducted to guide clinicians in this setting. This review summarizes the data available for treating VTE in cancer patients receiving palliative services.
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Affiliation(s)
- Quy N.H. Tran
- Department of Internal Medicine, Division of Hematology and Oncology, University of California at Davis, Medical Center, Sacramento, CA, USA,
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