Assessment and management of thrombotic complications

Abstract

Venous thromboembolism (VTE) is a common complication of cancer and its treatments and may confer a significant symptom burden on patients. Sometimes such symptoms are attributed to other cancer-associated pathologies and may thereby go undiagnosed as a VTE and not be treated. Rather than being one single entity, cancer-associated thrombosis (CAT) is a highly heterogeneous phenomenon which will vary with primary cancer, stage, and treatment regimen. The treatment of CAT has many challenges since anticoagulation is often associated with a high rate of VTE recurrence and bleeding. While there are several classes of anticoagulants currently available, each have their perceived benefits and downsides. These become more complex with disease progression with little robust data to inform management in the advanced cancer population and at the end of life. Furthermore, a significant proportion of patients seen by specialist palliative care teams comprise a population who were excluded from the major CAT trials. It is common to encounter cases where the evidence is lacking, such as recurrent VTE, thrombocytopenia, and bleeding. Other challenges and uncertainties lie with the role of VTE prevention in hospices and specialist palliative care units, where patients are highly thrombotic but the benefits or risks of thromboprophylaxis are unclear. This chapter presents the most up-to-date data pertaining to the treatment and prevention of CAT with particular emphasis on patients nearing the end of life.