Thromboprophylaxis in the End-of-Life Cancer Care: The Update

Evaluation of the Use of Anticoagulotherapy in Cancer Patients in Palliative Care Residence

Background

Several patients admitted to palliative care residences are on anticoagulotherapy (AC). Given the risks of venous thromboembolism (VTE) and bleeding, the decision to continue or stop AC on admission remains clinically challenging.

Objectives

To determine the prevalence of AC use and incidence of suspected VTE and bleeding events in palliative care patients.

Methods

Retrospective cohort study including all deceased patients at a Canadian palliative care residence over two years.

Results

Among the 453 patients' charts reviewed (369 with cancer), 183 (40%) were on AC at admission or <30 days earlier. Only 64 (35%) continued AC, with 78% discontinuing it during their stay. Demographic parameters were similar in the AC and non-AC groups. The incidence of suspected VTE was lower in patients pursuing AC post-admission than in those who stopped: (4.6% vs. 6.7%) and, conversely, the incidence of bleeding was higher in patients on AC: (10.8% vs. 7.6%), though these differences were not statistically significant. The risk of death in cancer patients within 72 hours of suspected VTE or bleeding event was 80% and 30%, respectively. Patients on AC had a 33% reduced risk of VTE but a 44% increased risk of bleeding.

Conclusion

This study provides information on the AC use in palliative care patients. In term of survivorship, it suggests a possible advantage to continue AC to prevent a symptomatic or distressing death. Given the low incidence of events, larger powered studies will be necessary to further characterize the risks/benefits of pursuing AC in patients in palliative care residences.

Venous Thromboembolism in Women with Cancer with an Additional Focus on Breast and Gynecological Cancers

Cancer-associated venous thromboembolism (VTE) is common in women with cancer. Many clinical practice guidelines provide guidance for prevention and treatment; however, there are no specific recommendations for women. This is unfortunate because the proportion of women with breast- and gynecological cancers is high among patients with cancer-associated VTE. Thromboembolism often heralds cancer progression and poor prognosis and should—besides adequate anticoagulant management—also prompt reassessment and, if necessary, changes in cancer treatment. Recently, the new class of direct-acting oral anticoagulants (DOACs) has started to replace low-molecular-weight heparin as standard thromboprophylaxis and therapy in cancer patients. They are very effective, but they also carry a relevant risk of bleeding. Therefore, despite their ease of use, not every tumor patient qualifies for a DOAC, and this is especially true for gynecological tumor patients. Each prescription must be weighed individually. This review addresses specific aspects of VTE prophylaxis and management in women with cancer. Every physician who treats breast and gynecological cancers should be familiar with prophylaxis, diagnosis, and therapy of cancer-associated VTE. At the same time, patients should be informed by their physician what symptoms to look for and whom to contact if these symptoms occur, even outside of office hours and on weekends.

Risks, diagnosis, and management of recurrent cancer-associated thrombosis (CAT): a narrative review

This paper aims to provide a narrative review of the risks, diagnosis, and management of recurrent venous thromboembolism (VTE) in cancer patients. There is an established association between cancer and VTE, with cancer being a major risk factor for VTE. A history of VTE, short duration of oral anticoagulation, and a proximal DVT are all associated with increased risk for recurrent VTE. Studies have shown that certain cancers (e.g., metastatic genitourinary, lung, and colorectal cancers) are associated with recurrent VTE. Published literature shows that cancer is prothrombotic, and various mechanisms have been postulated as pathways for increased thrombogenesis and hence recurrent VTE in cancer. The symptoms, signs, laboratory information, and imaging results for the diagnosis of recurrent VTE are similar to those of an initial VTE. Management of recurrent VTE involves using low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). Vitamin K antagonists (VKA) or inferior vena cava (IVC) filters are less commonly used.

Cancer-associated venous thromboembolism and the non-vitamin K antagonist oral anticoagulants: a review of clinical outcomes and patient perspectives

INTRODUCTION

Cancer-associated venous thromboembolism remains an important but challenging aspect in the treatment of patients with cancer. Recently, alternatives to injection of low-molecular-weight heparin (LMWH) have been introduced, the non-vitamin K antagonist oral anticoagulants (NOACs), which could potentially alleviate patients from burdensome daily injections.

AREAS COVERED

This review discusses the available evidence exploring the role of NOACs in the treatment and secondary prevention of cancer-associated venous thromboembolism, from randomized trials, observational data, contemporary guideline recommendations, and patient perspectives.

EXPERT OPINION

Edoxaban, rivaroxaban, and apixaban have proven attractive alternatives to LMWH for the treatment of cancer-associated venous thromboembolism. Contemporary guidelines have promptly endorsed the use of NOACs in patients with most cancer types. Nonetheless, issues remain regarding bleeding risk, interactions with medical cancer treatment, and the effectiveness and safety for extended treatment periods. There are head-to-head comparisons of the NOACs, and therefore no data favoring the use of one NOAC over the others. Patient's preferences are highly diverse and should be part of routine considerations when weighing risks and benefits associated with various available anticoagulant drugs.