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Management of venous thromboembolism in far-advanced cancer: current practice
  1. Simon Noble1,
  2. Sophie Banerjee2 and
  3. Nikki Jane Pease3
  1. 1Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
  2. 2Department of Oncology, Barts Health NHS Trust, London, UK
  3. 3Department of Palliative Medicine, Velindre Cancer Centre, Cardiff, UK
  1. Correspondence to Professor Simon Noble, Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff CF14 4YS, UK; NobleSI1{at}cardiff.ac.uk

Abstract

Objectives Venous thromboembolism (VTE) is common in advanced cancer. Guidelines suggest that indefinite anticoagulation be considered for patients with ongoing active cancer. There are no data on the management of cancer-associated thrombosis (CAT) at the end of life or when to stop anticoagulation as death approaches. We reviewed current practice and associated symptoms at the end of life for patients with advanced cancer who had been anticoagulated for VTE.

Methods Data on patients attending a regional CAT service were cross-referenced with death notifications. Hospital, hospice and community notes were reviewed to evaluate the end-of-life care within the context of VTE management. Data specific to discontinuation of anticoagulation, complications of anticoagulation and symptoms associated with VTE were recorded.

Results 214 patients died over a 2-year period; 98 (46%) home, 59 (27%) hospice, 53 (25%) acute hospital and 4 (2%) community hospital. 108 (50%) continued low-molecular-weight heparin (LMWH) until death, 23 (11%) up to 7 days prior to death, 23 (11%), 1 week to 1 month 29 (13.5%), over 1 month 40 (18%). Clinically relevant non-major bleeding occurred in 9/131 (7%) of the patients who continued LMWH to death or 7 days up to death. No symptoms attributable to VTE were recorded.

Conclusion The majority of CAT patients with metastatic disease remain anticoagulated up to or within days of death. Despite the limitations of retrospective data across healthcare settings, it appears that anticoagulation as death approaches confers a significant bleeding risk without additional benefit of preventing VTE symptoms.

  • cancer associated thrombosis
  • venous thromboembolism
  • anticoagulation
  • end of life care
  • metastatic
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Footnotes

  • Contributors SN codevised the study, contributed to data collection, analysis and wrote the first draft of the manuscript. SB undertook data collection, data analysis and contributed to the writing of the final manuscript. NJP codevised the study, contributed to data collection, analysis and write up of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as online supplementary information.

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