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.
Highlights
Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment
If on one hand surgery and medical treatment, catheters, chemo-radiotherapy and co-morbidities contribute to increase thrombosis risk [31], on the other some co-morbidities and/or chemotherapy-related side effects, such as renal or hepatic insufficiency and thrombocytopenia, can affect the efficacy and safety of anticoagulation [32]. These factors associated with age and ECOG (Eastern Cooperative Oncology Group) performance status, indicative of the patient’s level of function and mobility [33,34] are parameters that drive all decision making processes in cancer patients at risk for venous thromboembolism (VTE) and which should indicate those who might benefit from thromboprophylaxis and those who are fit for receiving it
Caravaggio trial) assessing the efficacy and safety of apixaban during the initial 6-month treatment of venous thromboembolism in patients enrolled without limitation of cancer type and anticancer treatment in order to be consistent with the cancer distribution in the general population, demonstrated a noninferiority of this direct oral anticoagulants (DOACs) (10 mg twice daily for the first 7 days, followed by 5 mg twice daily) as compared to subcutaneous dalteparin, in terms of recurrent VTE (5.6% vs. 7.9%, respectively) and major bleeding (3.8% vs. 4.0%, respectively), including gastrointestinal ones [77]
Summary
In the new era of personalized medicine, one of the recognized priorities regards the role of integration of early supportive and palliative care with cancer-directed treatments, the so-called “simultaneous care” [1]. If on one hand surgery and medical treatment, catheters, chemo-radiotherapy and co-morbidities contribute to increase thrombosis risk [31], on the other some co-morbidities and/or chemotherapy-related side effects, such as renal or hepatic insufficiency and thrombocytopenia, can affect the efficacy and safety of anticoagulation [32] These factors associated with age and ECOG (Eastern Cooperative Oncology Group) performance status, indicative of the patient’s level of function and mobility [33,34] are parameters that drive all decision making processes in cancer patients at risk for VTE and which should indicate those who might benefit from thromboprophylaxis and those who are fit for receiving it. The study showed that only an exhaustive information by the clinical staff with respect to clinical intervention and process was capable to guarantee compliance to anticoagulant treatment and distress reduction [45]
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