Venous Thromboembolism in Cancer Patients on Simultaneous and Palliative Care

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.

2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS)

“…Patients undergoing surgery and those who are hospitalized or in prolonged bed rest require thromboprophylaxis with low-dose anticoagulation. 298,299,[592][593][594] The ENOXACAN (Enoxaparin and…”

Handheld Ultrasound (HHUS): Potential for Home Palliative Care

“…Cancer is associated with an increased risk of thromboembolism, which may be further increased by co-morbidities and immobility [57]. However, thromboembolism is also a frequent complication among non-cancer palliative care patients [58].…”

Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer

“…Finally, Riondino et al [ 20 ] and Zabrocka et al [ 21 ] address the issue of venous thromboembolism in particular settings of cancer care: the transition from active to palliative care, and end-of-life care, respectively. Based on the most recent NICE (National Institute for Health and Care Excellence) guidelines, thromboprophylaxis should be considered for patients receiving palliative care, always taking into account several factors, including risk of bleeding, estimated life expectancy, and the views of the patient and their caregivers.…”

“…Other factors to be considered include the lack of palliative benefits or any unreasonable burden of thromboprophylaxis (e.g., painful injections or frequent monitoring with phlebotomy). Nonetheless, from the analysis by Riondino and colleagues, it emerges that the prevalence of VTE among palliative care unit patients is significant (35 to 50%), and its occurrence is perceived as a physically and emotionally distressing phenomenon that overlaps with the underlying malignancy and strongly decreases QoL [ 20 ]. 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 and psychological distress related to thrombosis [ 21 ].…”

“…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 and psychological distress related to thrombosis [ 21 ]. In light of the above, Riondino et al emphasize that an early integration of VTE preventive strategies in a “simultaneous care program” might help overcoming the problem of deciding in favor or against thromboprophylaxis in the context of palliation [ 20 ]. However, specific decision-making tools are needed to avoid under-treatment, and since the continuum of care paradigm is in constant change, a major effort should be made in this area to achieve a broad consensus on how to manage VTE [ 20 ].…”