There are different recommendations about the prophylactic anticoagulation in ambulatory cancer patients. Some risk-scores already exist. Do you use these scores or do you screen your patients carefully and go for immediate treatment in case of VTE? What is your clinical reality?
Hello! I'm not answering your question. Your question just make me thinking of another.
I'm not sure if thrombosis can block up cancer metastasis just as thrombosis do in local infection of pathogens. If so, how should we balance the risk between thrombosis and metastasis? I'm not very familiar with tumor metastasis. Maybe there is an answer somewhere already.
Hi, thanks for your thoughts.
There is no benefit for cancer patients with thrombosis regarding lowering metastasis, but there are considerations about the increase and migration of circulating cancer cells due to microthrombosis. Hence probably lowering metastasis due to the use of heparins by avoiding microclotting, clotting system activation, VEGF release and so on ...
Maybe I didn't made it clear. In the early stage of infection, the innate immunity and local micro-thrombosis could prevent the spreading of pathogens through blood. In a similar way, tumor at early stage may induce microthrombuses in capillaries around it. Hoping these can block blood transfering of tumor cells, only if the blood coagulation is normal. It's my immature idea. Thank you for reply!
Except for Immunomodulator agents used in Multiple Myeloma like lenalidomide/thalidomide with risk factors and/or combination chemotherapy with high dose dexamethasone or others, I don't think there is any indication of anticoagulation in ambulatory patients receiving chemotherapy
In conventional practice anti-coagulation is only given to cancer patients who have other predisposing factors for thrombus formation. But I see the point you are trying to make, though I seriously do not think it's valid, and haven't seen any literature suggesting so.
Hello Dr Pelzer.
Don't think there is a need to use VTE prophylaxis in an ambulatory cancer patient only because he is under QT.
If he is submitted to surgery then I use 4 weeks of pos-op prophylaxis with LWMH even if the patient can walk properly. In the case of a VTE event, like a DVT, then I will continue LWMH until there is an active oncologic disease. However the definition of active oncologic disease, in my opinion, is not easy, but some guidelines state the need for any kind of oncologic treatment in the last 6 months as being an active cancer.
You must not forget that some cancer patients may need urgent surgery, and if they are under oral anticoagulants (ex. warfarin) it will be a problem with high risk for hemorrhage.
Best regards
Carlos
Cancer patients do have a tendency to manifest procoagulant effects. The presence of cancer procoagulant or various cytokines circulating in the blood of cancer patients may trigger activation of blood leading to a procoagulant condition. Given the presence of predisposing factors there could be a tendency to form clots. However, in this patient there is a lack of one single predisposing factor and that is the lack of immobility, however, he may still harbor other predisposing factors that can lead to thrombosis. Prophylactic anticoagulation is a better approach in preventing thromboembolic complications. One would like to be cautious rather than be sorry and prescribe anticoagulation after a thrombotic episode.
Song Gong is making a point of blocking the vessel with thrombosis and stop metastases. If it were to happen the patient must be quite lucky. However, the thrombosis does not have such a predilection, the clot can go any where in the body and cause thrombosis. Secondly, the tumors may express VEGF which will promote the growth of more microcapillaries for the growth of the tumor.
You are correct there are RCTs demonstrating a reduction in the rate of VTE with prophylactic strategy, but this is not yet recommended for routine use by the guideline bodies.
The problem is that in the general oncology population the NNT is not that encouraging (>50); overall I am also not sure we adequately know the cost effectiveness of this, the use of LMWH is not too patient friendly, and we are all familiar with bad outcomes...
So for routine management our centre does not use this approach. It will be interesting to see if the risk factor based approach will be more encouraging.
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