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.
Highlights
Cancer is among well-recognized risk factors for venous thromboembolism (VTE) [1]
Advanced cancer patients are at increased risk for VTE, taking into account their diagnosis and usually poor performance status, resulting in a decreased level of activity or even immobilization [3]
Several trials have shown that Novel oral anticoagulants (NOACs) are effective and safe for the treatment of VTE [37], and cancer patients-subgroup analysis of these trials has revealed that NOACs are non-inferior to Vitamin K antagonists (VKAs)
Summary
Cancer is among well-recognized risk factors for venous thromboembolism (VTE) [1]. The relative risk of VTE in cancer patients compared to patients without cancer ranges between 4 and 7 [2]. Ethical factors likely play a major role in this approach since thromboprophylaxis (TPX) may be perceived as one of the ways of postponing the natural death, which would not be in line with the philosophy and foundations of palliative care It still remains questionable whether TPX can affect life expectancy in this group of patients. One prospective randomized study showed no statistically significant survival benefit of prophylactic nadroparin in hospitalized palliative care patients with an estimated life expectancy of ≤6 months [11]; only 20 patients were enrolled in the study Another challenging aspect is the degree of symptom relief by TPX, which is difficult to estimate due to the lack of standardized tools for QoL assessment. This paper reviewed the data on TPX in palliative care and hospice patients and summarized the updated recommendations on the TPX in this population
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