The clinical course of deep vein thrombosis in patients with gynecologic cancer

Predicting VTE and utility of thromboprophylaxis in metastatic and recurrent cervical cancer

OBJECTIVE

Patients with cervical cancer who are diagnosed with venous thromboembolism (VTE) have worse outcomes compared to those not affected. There has yet to be a reliable method to predict or prevent VTE in cervical cancer patients. Our objective is to describe the incidence of VTE in patients with recurrent and metastatic (r/mCC) and determine risk factors that may predict VTE in this setting.

METHODS

We performed an observational cohort study of 386 patients with r/mCC who received at least one line of systemic chemotherapy. We collected demographic, clinical, histologic data and Khorana scores for all patients. Inclusion and exclusion criteria were applied before analysis. Statistical analysis was performed using Pearson chi-square, Student's t-test, and Wilcoxon rank-sum.

RESULTS

232 patients were included for evaluation. Mean age was 49 years (range 20-83). The majority (167, 72%) of patients had squamous cell histology. 169 (72.8%) patients received treatment for recurrent disease and 63 (27.2%) for metastatic, stage IVB disease. 180 (78%) patients received prior radiation and 134 (58%) received bevacizumab. VTE was diagnosed in 89 (38%) patients. There were no statistically significant differences amongst clinical and pathologic characteristics between patients who developed VTE and those who did not. There was no significant association between BMI, Khorana score, radiation, bevacizumab, or immunotherapy and the development of VTE.

CONCLUSION

Approximately 40% of patients with r/mCC experienced a new VTE. There were no independent risk factors that could predict VTE in this population. Due to the overwhelmingly high incidence of VTE, prophylactic anticoagulation could be strongly considered in patients with r/mCC.

Predictive Factors of Deep Vein Thrombosis in Gynecologic Cancer Survivors with Lower Extremity Edema: A Single-Center and Retrospective Study

This study was conducted to examine predictive factors of deep vein thrombosis (DVT) in gynecologic cancer survivors with lower extremity edema (LEE). In the current single-center, retrospective study, there was a total of 315 eligible patients, including 80 patients with DVT and 235 without DVT. They were therefore divided into two groups: the DVT group (n = 80) and the non-DVT group (n = 235). Then, baseline and clinical characteristics of the patients were compared between the two groups. In our study, distant organ metastasis, advanced stage, lymphadectomy, and amount of intraoperative blood loss had a positive predictive value for the occurrence of DVT in gynecologic cancer survivors presenting LEE. In conclusion, our results indicate that it is necessary to consider the possibility of LEE arising from DVT in gynecologic cancer survivors with advanced-stage cancer, distant organ metastasis, lymphadectomy, and intraoperative blood loss over 1500 mL.

Circulating tumour cells and hypercoagulability: a lethal relationship in metastatic breast cancer

Purpose

Circulating tumour cells (CTCs) are a marker of poor prognosis and are associated with increased risk of venous thromboembolism in metastatic breast cancer (MBC). We aimed to determine if the presence of CTCs and plasma markers of hypercoagulability [thrombin–antithrombin III (TAT), fibrinogen and d-dimer] are biomarkers of survival in MBC.

Methods/patients

In a prospective study of MBC patients, CTC (CellSearch^®) enumeration and plasma TAT, fibrinogen and d-dimer measured prior to commencement of treatment for disease progression were correlated to overall survival.

Results

At study completion, of 50 MBC patients recruited (median age 59 years, range 36–82), 40 patients had died (median survival 417 days, range 58–2141). CTCs (≥ 1/7.5 ml) were identified in 16 patients (median number of cells per 7.5 ml, 3 (range 1–31) and were associated with systemic hypercoagulability (medians TAT: 8.1 vs. 5.2 ng/ml, p = 0.03; fibrinogen: 4.3 vs. 3.1 g/l, p = 0.03; d-dimer: 1327 vs. 683 ng/ml, p = 0.0001). At 1 year, of 16 patients with ≥ 1 CTC, 7 had died (44%), compared to 5 of 26 (19%) patients in the no-CTC group. The presence of ≥ 1 CTC was associated with a trend for reduced overall survival (median 455 days vs. 614 days, p = 0.15). Plasma TAT inversely correlated with survival and was significantly higher in patients dying within 1 year (median 9.8 vs. 5.2 ng/ml, p = 0.004) whilst d-dimer showed a trend for reduced 1-year survival (median 1211 vs. 817 ng/ml, p = 0.06). MBC patients with combined high d-dimer (≥ 895 ng/ml) and CTC positivity (≥ 1/7.5 ml whole peripheral blood) had significantly reduced survival (p = 0.04).

Conclusions

The correlation between CTCs, hypercoagulability and reduced survival in MBC suggests the coagulation system supports tumour cell metastasis and is, therefore, a potential therapeutic target.

Electronic supplementary material

The online version of this article (10.1007/s12094-019-02197-6) contains supplementary material, which is available to authorized users.

Rivaroxaban Used in the Treatment Patients With Gynecologic Cancer and Venous Thromboembolism: The Experience of Instituto Nacional de Câncer-Rio de Janeiro, Brazil

INTRODUCTION

Venous thromboembolism (VTE) is a major complication of malignant diseases and is a frequent cause of death in patients with cancer. Managing anticoagulation in these patients is challenging because of the high risk of recurrent VTE and bleeding events. Rivaroxaban is an oral anticoagulant that provides rapid onset of anticoagulation.

OBJECTIVE

The aim of this study was to describe the complications of rivaroxaban and potentially associated factors in patients with gynecologic cancer and VTE.

METHODS

This was an observational study in women with gynecological cancer who developed VTE and were treated with 15 and 20 mg rivaroxaban at Instituto Nacional de Câncer from July 2014 to July 2015.

RESULTS

Forty-one patients were treated with rivaroxaban. Most patients were younger than 60 years and presented cervical cancer; 58.5% of women did not have complications, thus remaining at a dose of 20 mg/d. Because of complications, 12.2% had the dose reduced to 15 mg/d, 12.2% had the drug suspended, 7.3% had progressive worsening of the disease with suspension of anticoagulation, and 9.8% progressed to death because of progression of the disease.

CONCLUSIONS

Rivaroxaban has been documented as a low-cost, easily controlled option compared with standard therapy. Most participants in this study had no complications. However, it was not possible to assess associations with statistical significance. Further analytical studies with larger samples are required to evaluate the safety and efficacy of this treatment in patients with gynecologic cancer.

Venous thromboembolism and mortality in breast cancer: cohort study with systematic review and meta-analysis

BACKGROUND

Breast cancer patients are at an increased risk of venous thromboembolism (VTE). However, current evidence as to whether VTE increases the risk of mortality in breast cancer patients is conflicting. We present data from a large cohort of patients from the UK and pool these with previous data from a systematic review.

METHODS

Using the Clinical Practice Research Datalink (CPRD) dataset, we identified a cohort of 13,202 breast cancer patients, of whom 611 were diagnosed with VTE between 1997 and 2006 and 12,591 did not develop VTE. Hazard ratios (HR) were used to compare mortality between the two groups. These were then pooled with existing data on this topic identified via a search of the MEDLINE and EMBASE databases (until January 2015) using a random-effects meta-analysis.

RESULTS

Within the CPRD, VTE was associated with increased mortality when treated as a time-varying covariate (HR = 2.42; 95% CI, 2.13-2.75), however, when patients were permanently classed as having VTE based on presence of a VTE event within 6 months of cancer diagnosis, no increased risk was observed (HR = 1.22; 0.93-1.60). The pooled HR from seven studies using the second approach was 1.69 (1.12-2.55), with no effect seen when restricted to studies which adjusted for key covariates.

CONCLUSION

A large HR for VTE in the time-varying covariate analysis reflects the known short-term mortality following a VTE. When breast cancer patients are fortunate to survive the initial VTE, the influence on longer-term mortality is less certain.

Venous Thromboembolism in Gynecological Malignancy

Objective

Venous thromboembolism (VTE) is a recognized complication of gynecological malignancy and represents a leading cause of morbidity and mortality in these patients. The review aimed to discuss the incidence, risk factors, and clinical presentation of VTE before examining the literature on the diagnosis, prevention, and management in the context of uterine, cervical, ovarian, and vulval cancers.

Methods/Materials

A literature search was performed using Ovid Medline and Embase with the following words: “gynecological malignancy,” “pelvic tumor,” “venous thromboembolism,” “deep vein thrombosis” and “pulmonary embolism.”

Results

The incidence of VTE in patients with gynecological malignancy ranged between 3% and 25% and was affected by several patient and tumor factors. Duplex ultrasonography is currently the first-line imaging modality for deep venous thrombosis with sensitivity and specificity of up to 95% and 100%, respectively. Low-molecular-weight heparin is currently the VTE prophylaxis and treatment of choice for patients with gynecological malignancy, although warfarin and unfractionated heparin play a role in selected circumstances. The relatively new direct oral anticoagulants including factor Xa inhibitors and direct thrombin inhibitors are increasingly being used, although further evaluations are required, particularly in cancer patients. Catheter-directed thrombolysis and percutaneous mechanical and surgical thrombectomy may have a role in treating patients with severe symptomatic iliocaval or iliofemoral deep venous thrombosis. Overall, VTE is a poor prognosis marker in patients with gynecological malignancy.

Conclusions

Gynecological malignancy–associated VTE is associated with significant morbidity, contributing to a large number of life years lost. Although promising new therapies are emerging, a 2-pronged approach is required to simultaneously target cancer-specific management and predict early on those who are likely to be affected. In the meantime, clinicians should continue to combine current guidelines with a multidisciplinary team approach to ensure that these complex patients receive the best evidence-based and compassionate care.

Platelet microparticle-mediated transfer of miR-939 to epithelial ovarian cancer cells promotes epithelial to mesenchymal transition

Epithelial ovarian cancer (EOC) patients frequently suffer from thrombocytosis, which leads to a poor prognosis. However, the mechanism underlying platelet regulation of biological behavior in EOC remains unclear. The associations between clinicopathological characteristics and thrombocytosis in 171 EOC patients were studied, preoperative thrombocytosis was significantly associated with the stage, metastasis scope, level of preoperative CA125 and overall survival. When SKOV3 cells were cocultured with platelet microparticles (PMPs), the expression of molecules associated with epithelial-mesenchymal transition (EMT) was increased. The proliferation and migration of SKOV3 cells were also enhanced. Based on the miRNA microarray of the PMPs derived between thrombin-stimulating and apoptotic platelets, we demonstrated that over-expression or complete knockdown of miR-939 in the SKOV3 cells strengthened or weakened EMT. Secretory phospholipase A2 type IIA (sPLA₂-IIa) has been shown to mediate PMPs intake by SKOV3 cells. The knockdown of sPLA₂-IIa in SKOV3 cells verified that PMPs were involved in crosstalk during the regulation of cancer cells by transferring miRNA. This study revealed an important role for PMPs in the crosstalk of platelets and cancer cells through miR-939 shedding mediated by sPLA₂-IIa, which enables EOC to undergo EMT and enhances cancer progression. Our findings pave the way for developing a novel therapeutic strategy for EOC targets such as PMPs, miR-939 or sPLA₂-IIa.

Significance of venous thromboembolism in women with cervical cancer

OBJECTIVE

To characterize risk factors of venous thromboembolism (VTE) and to examine effects of VTE on survival of women with cervical cancer.

METHODS

This is a retrospective study examining consecutive stage I-IV cervical cancer cases diagnosed between 2000 and 2014. Cumulative risk of VTE after cervical cancer diagnosis was evaluated by a time-dependent analysis, expressing adjusted-hazard ratio [HR] and 95% confidence interval [CI]. Survival analysis was performed to determine independent risk factors for progression-free survival (PFS) and disease-specific overall survival (OS).

RESULTS

VTE was recorded in 98 (12.3%, 95%CI 11.6-22.8) out of 798 cases with 1-, 2-, and 5-year cumulative incidences after cervical cancer diagnosis being 8.4%, 11.3%, and 18.7%, respectively. On multivariable analysis, advanced-stage disease (2-year cumulative risk, distant metastatic disease 44.8% [HR 4.13, 95%CI 1.06-10.7, P=0.003], and locally-advanced disease 13.4% [HR 2.46, 95%CI 1.17-4.43, P=0.004]) were independently associated with increased risk of VTE compared to early-stage disease (stage IA1-IB1 4.1%). In addition, low albumin level (HR per unit change, 0.59, 95%CI 0.40-0.85, P=0.005) and chemotherapy treatment (HR 2.46, 95%CI 1.30-4.66, P=0.006) remained independent risk factors associated with increased risk of VTE. On univariate analysis, VTE was significantly associated with decreased PFS (5-year rates, 22.3% versus 68.7%, P<0.001) and OS (5-year rates, 55.1% versus 90.0%, P<0.001). On multivariable analysis, VTE remained an independent prognostic factor associated with decreased PFS (HR 1.95, 95%CI 1.43-2.67, P<0.001) and OS (HR 3.54, 95%CI 2.04-6.13, P<0.001).

CONCLUSION

VTE represents aggressive tumor behavior and poor patient condition, and is an independent prognostic factor for decreased survival in women with cervical cancer.

Leg Pain and Gynecologic Malignancy

Gynecologic malignancies affect more than 83 000 women in the United States, each year. Because the disease involves the pelvis, many patients have side effects distal to this area in their lower extremities. The differential diagnosis of leg pain can be divided into vascular, neurologic, and musculoskeletal causes. In this review article, we address numerous etiologies of leg pain, reviewing the prevalence of disease, physical examination findings, diagnostic as well as treatment modalities.

Predictive model of venous thromboembolism in endometrial cancer

OBJECTIVE

To profile characteristics and survival of endometrial cancer patients who develop venous thromboembolism (VTE) and to establish a predictive model of VTE in endometrial cancer.

METHODS

Cases were identified using an institutional database between 2000 and 2011. VTE was correlated to clinico-pathological information and survival outcomes. Frequency and odds ratio (OR) of VTE were examined in a predictive model based on combination patterns of independent risk factors for VTE.

RESULTS

VTE was seen in 42 (8.1%, 95% CI 5.8-10.5) out of 516 cases subsequent to the diagnosis of endometrial cancer. Multivariate analysis identified 4 independent risk factors for VTE: elevated CA-125 (hazard ratio [HR] 5.38, p<0.001), extrauterine disease (HR 2.87, p=0.019), thrombocytosis (HR 2.11, p=0.04), and high risk histology (serous and clear cell, HR 2.09, p=0.049). VTE was the strongest variable for decreased progression-free survival (HR 4.28) and the second strongest variable for decreased overall survival (HR 5.65) in multivariate analysis. In a predictive model of VTE, the presence of multiple risk factors was associated with significantly increased risk of VTE: frequency of VTE, 1.4% if no risk factors, 0-9.3% (OR 1.0-4.2) if a single risk factor, 11.1-25.0% (OR 9.0-24.0) if two risk factors, and 42.9-46.2% (OR 54.0-61.7) if ≥3 risk factors.

CONCLUSION

VTE represents a surrogate for aggressive disease in endometrial cancer. Multiple risk factors of VTE in our predictive model demonstrated exceedingly high risk of VTE, suggesting that there may be a certain population of endometrial cancer patients who would benefit from long-term anti-coagulant prophylaxis to improve survival outcome.

Erythropoiesis stimulating agents, thrombosis and cancer

Venous thromboembolism (VTE) is common in cancer and is associated with both morbidity and mortality. Erythropoiesis stimulating agents (ESAs) were originally developed to correct anemia. Recent trials in cancer patients however, raise concerns over both increased VTE rates and the possibility of worse tumour outcomes and increased mortality with ESA use. The most common reason offered for explaining the possible negative impact of ESAs on cancer outcomes has been the stimulation of erythropoietin receptors on tumour cells. Despite an extensive literature, it is unlikely that most practicing appreciate the intricate relationship and interaction between the coagulation pathways, angiogenesis and tumour progression and ESA effects. This paper will review these connections and interactions and examine the hypothesis that other mechanisms may underlie the possible negative impact of ESAs on cancer outcomes.

The Risk of Cancer Progression in Women With Gynecological Malignancies and Thrombophilic Polymorphisms: A Pilot Case-Control Study

Cancer produces a hypercoagulable state, which might lead to thrombosis, and on contrary, unprovoked venous thromboembolism might be the manifestation of an occult cancer. In this pilot case-control study, we assessed the risk of gynecological malignant diseases related to the presence of the factor V Leiden and prothrombin G20210A polymorphisms. Fifty-two women underwent an operation for gynecological malignancy and were enrolled in the study. Women who underwent an operation for gynecological nonmalignant disease in the same days of cases were considered as controls. The presence of factor V Leiden and prothrombin G20210A was assessed in case and control groups. In all, 7 out of 52 cases were carriers of the 2 polymorphisms compared with 20 out of 198 controls (odds ratio = 1.3; 95% confidence interval, 0.6-3.0). The results were also similar when the risk was considered separately for the site of cancer. As for advanced and metastatic malignancies, the odds ratios were 2.3 (95% confidence interval, 0.9-6.0) and 3.3 (95% confidence interval, 1.0-11), respectively, compared to noncancer patients. When these 2 groups were compared to nonadvanced cancer group, the odds ratios for carriers of polymorphisms were 2.7 (95%confidence interval, 0.7-11.0) and 3.9 (95%confidence interval, 0.8-18.6) for advanced cancer and metastatic malignancies, respectively. Women with factor V Leiden or prothrombin G20210A polymorphisms who developed gynecological malignancy might present with a higher stage of cancer at the time of surgery. Larger case-control studies in similar cohort of patients are needed to confirm these findings.

Venous thromboembolism prevention in gynecologic cancer surgery: A systematic review

OBJECTIVES

Advanced age, pelvic surgery, and the presence of malignancy place gynecologic oncology patients at high risk for venous thromboembolism (VTE). This study was designed to systematically analyze the world's literature on VTE in these patients and determine the optimal prophylaxis regimen.

METHODS

Computerized searches of Pubmed, Ovid, DARE, ACP Journal Club, Cochrane Database of Systematic Reviews, and Cochrane Controlled Trials Registry 1966-2005 were performed, as well as EMBASE 1980-2005. Major conferences and target references were hand-searched. Inclusion criteria were randomized controlled trials (RCTs) evaluating VTE prophylaxis with heparin, low-molecular-weight heparin (LMWH), and sequential compression devices (SCD). The search yielded 278 articles; 11 met inclusion criteria. Data were abstracted by one author and analyzed with the Mantel-Haenszel method.

RESULTS

The analysis of heparin-versus-control revealed a significant decrease in DVT in patients receiving heparin (RR=0.58, 95% CI 0.35-0.95). There were no significant differences in EBL or transfusions between the two groups. In the 320 patients in the heparin vs. LMWH studies, there was no significant difference in DVT (RR 0.91, 95% CI 0.38-2.17), although power analysis demonstrated insufficient numbers to show a difference. No patient in either group required re-exploration for bleeding.

CONCLUSIONS

All gynecologic cancer patients should receive VTE prophylaxis. Although heparin, LMWH, and SCD have been shown to be safe and effective, due to the paucity of data in the gynecologic oncology literature, no one prevention modality can be considered superior at this time. Adequately powered RCTs are urgently needed to determine the optimal regimen in these high-risk patients.

Venous thromboembolism risk and management in women with cancer and thrombophilia

BACKGROUND

Venous thromboembolism (VTE) and its complications result in a high rate of morbidity and mortality.

OBJECTIVE

The aim of this study was to review the risk of VTE in women with cancer and other predisposing risk factors, as well as the management of these patients.

METHODS

Data for this review were identified by searches of MEDLINE, Current Contents, and references from relevant articles using the search terms venous thrombosis, venous thromboembolism, pulmonary embolism, anticoagulation, risk factors, cancer, thrombophilia, heparin, and warfarin. Abstracts and reports from meetings were included only when they directly related to previously published work. Only papers published in English between 1960 and 2005 were included.

RESULTS

VTE risk is increased in patients with cancer, with 15% of these patients developing VTE or disseminated intravascular coagulation. Understanding a patient's thromboembolic risk is essential because it affects the type and duration of antithrombotic therapy. The incidence of VTE is dependent on a number of factors, including tumor type, mode of treatment, surgical procedures, patient immobility, and thrombophilia. Progression and recurrence of VTE can be prevented by therapy with unfractionated or low-molecular-weight heparin (LMWH_ followed by warfarin for at least three months. In selected women with advanced cancer disease, a long-term course of LMWH in therapeutic doses is the treatment of choice.

CONCLUSIONS

In women with cancer, the clinical course is often complicated by VTE episodes. The risk of VTE increases in association with either inherited or acquired thrombophilic conditions. Appropriate management of throemboembolism in women with cancer has the potential to reduce the negative clinical outcomes related to these complications.

Low-molecular-weight heparins in the treatment of cancer-associated thrombosis: a new standard of care?

Cancer patients are twice as likely to develop postoperative venous thromboembolism (VTE) than non-cancer patients undergoing the same surgical procedure. Causes of cancer-associated thrombosis include: the capacity of tumor cells and their products to interact with platelets, clotting, and fibrinolytic proteins. Aggressive antitumor therapy with agents such as platinum compounds, high-dose fluorouracil, mitomycin-C, tamoxifen, and growth factors increase the risk of cancer-associated thrombosis. Despite the high risk of VTE in patients with cancer, thromboprophylaxis in surgical and medical oncology patients is low. Initial therapy of VTE in patients with cancer is low-molecular-weight heparin (LMWH) or unfractionated heparin. Long-term secondary prophylaxis of VTE is generally accomplished with oral anticoagulants, primarily warfarin. Evidence supports the use of LMWH for prevention and treatment of cancer-associated thrombosis because it is more easily administered, does not require laboratory monitoring, has a lower risk of adverse events, and is more cost effective than unfractionated heparin. In addition, the antineoplastic effects of LMWH have been demonstrated, including direct antitumor, antiangiogenic, and immune system modulatory action. Each LMWH is a unique biological entity having product-specific molecular and structural attributes; therefore, different LMWHs cannot be given interchangeably. Continued investigation of LMWH therapy in patients with cancer is warranted.

Venous thromboembolism syndrome in gynecological cancer

Venous thromboembolism (VTE) could be presented as an initial clinical feature in some cancer patients or a complication followed by various cancer treatments, which all indicates a poor outcome. This review focuses on elucidating the relationship of VTE and the main gynecological cancers including ovarian, endometrial, and cervical cancers. First, the general VTE information about gynecological cancer are introduced; second, the risk factors of VTE developing in gynecological cancer were discussed; third, we do a retrospective analysis on a novel treatment targeting coagulation cascade; and last, we analyze VTE as a remarkable complication followed by recombinant human erythropoietin and anti-vascular endothelial growth factor treatment in gynecological cancer patients. In summary, the interaction between the coagulation system and cancer progression is a novel promising area to be explored in the study of VTE in patients with gynecological cancer.

Futility: clinical decisions at the end-of-life in women with ovarian cancer

OBJECTIVE

The purpose of this article is to provide a review of the clinical meaning of futility, discuss current normative uses of futility assessments and propose guidelines for clinicians to use in dialogue regarding treatment decisions for patients with advanced ovarian cancers.

METHODS

We performed a MEDLINE literature search of relevant clinical articles for this review that discussed futility and the application to women with ovarian cancer.

RESULTS

Medical futility refers to treatments that serve no physiologic, quantitative or qualitative meaningful purpose. Despite the growth in options focused on symptom management rather than disease eradication, including hospice programs and the more recent development of palliative care programs, there is evidence that many patients continue to receive aggressive interventions, including chemotherapy, until days before their death. While the legal and moral acceptability of treatment limitation is well established, clarity in establishing goals of care, timing of the transition from cure to palliation and communication of specific decisions to withhold further aggressive interventions remain problematic for both patients and clinicians.

CONCLUSIONS

There continues to be a distinct need for both better understanding of the dynamics of patient choice and increased education of physicians in addressing end-of-life care planning. It is essential that we continue to test specific communication and supportive interventions that will improve our ability to help patients avoid the burden of futile therapy while maintaining hope.

Clinical disease course during the last year in ovarian cancer

OBJECTIVE(S)

The objective was to determine whether there were changes in the pattern and nature of hospitalizations during the last year that could be used in the assessment of whether chemotherapy should be continued.

METHODS

Retrospective data were collected from patients who died from ovarian cancer between 1/2000 and 12/2001. Charts from four hospitals were reviewed to abstract chemotherapy, reason for hospitalization, and the incidence of three significant clinical events (bowel obstruction, pleural effusion requiring thoracentesis, and abdominal ascites requiring paracentesis). Data were analyzed in 3-month intervals.

RESULTS

Sixty-two patient charts were reviewed. Quarterly admissions increased linearly over the year (7, 18, 27, and 47, P < 0.0001). Hospitalizations for ascites, bowel obstruction, and pleural effusion began increasing around 6 months preceding death. Twenty-two patients did not receive chemotherapy during the last 3 months. Of the 40 patients receiving chemotherapy in the last 3 months, over half were not hospitalized during the period 4-6 months before death, and a further 20% were hospitalized for nonsignificant clinical events. Approximately one-quarter of the patients, however, continued to receive chemotherapy following hospitalization for a significant clinical event.

CONCLUSION(S)

There were significant changes in the pattern and nature of hospitalization during the last 6 months that included hospitalizations for bowel obstruction, pleural effusion, or ascites. The occurrence of these events suggests that further chemotherapy should be realistically evaluated with the patient, which may reduce the number of patients who receive chemotherapy during their last few months of life.