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Cancer Associated Thrombosis

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Dr. Peter Gross speaks about blood clots and how they can complicate a cancer patient's quality of life and long-term survival.

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Cancer Associated Thrombosis

  1. 1. Cancer Associated Thrombosis
  2. 2. Cancer Associated Thrombosis Peter L. Gross MD MSc FRCP(c) Associate Professor, Medicine McMaster University Site Chief, Clinical Thrombosis, Juravinksi Hospital and Cancer Centre Hamilton, ON Email: peter.gross@taari.ca Twitter: @platelet144
  3. 3. World Thrombosis Day • October 13 – the birthday of Dr. Rudy Virchow who was a pioneer in describing thrombosis
  4. 4. Cancer associated Thrombosis (CAT) • Thrombosis is abnormal clotting of blood in the blood vessels. • This can occur more frequently in patients with cancer • Most of these clots are in veins, not arteries. • Artery clots cause heart attacks and strokes • Vein clots cause deep vein thrombosis (DVT) and/or Pulmonary embolism (PE) – Together these are called venous thromboembolism (VTE)
  5. 5. The Burden of VTE in patients with cancer Stein PD, et al. Chest. 1995;110:978-981, Sandler DA, et al. J R Soc Med. 1989;82:203- 205, Nicolaides AN, et al. Int Angiology. 2006;25:101-106, Khorana AA et al: J Throm Haemost 2007; 5: 632-635, Lyman GH et al: J Clin Oncol 2009; 27: 4821-4826, Lyman GH: Cancer 2011; 117; 1334-1349 Fatal PE is the leading cause of sudden death among hospitalized patients and contributes to up to 10% of in-hospital deaths 70%* Cancer progression 71% Thromboembolism 9% Infection 9% Respiratory failure 4% Bleeding 1% Aspiration 1% Other 6% Unknown 4% VTE accounts for approximately 10% of deaths in ambulatory cancer patients receiving chemotherapy * Undetected PE
  6. 6. Some facts about Cancer Associated Thrombosis (CAT)? • Patients with cancer are at an elevated risk of VTE (4-7x more likely) • Can occur at any time during the cancer journey • Most frequently in the first 3-6 months after being diagnosed with cancer • Sometimes, a VTE occurs a few months before a diagnosis of cancer is made • A common complication that can be prevented and treated effectively, especially if diagnosed early Lee AYY, and Levine MN. Circulation. 2003 Jun 17;107(23 suppl 1):I-17-I-21.
  7. 7. Is CAT Serious? • Higher mortality among cancer patients with VTE than without • Can delay treatment or trigger changes in cancer treatment regimen • Can prolong hospitalization • Can compromise outcomes after surgery • 1 -10% of cancer patients develop a blood clot, but the risk of developing CAT is not the same for all cancer patients • Anticoagulation treatment for CAT is associated with a higher risk of bleeding complicationsCarrier M, et al.. Curr Oncol 2015; 22:49-59; Heit JA, Silverstein MD, Mohr DN, et al. Arch Intern Med. 2000 Mar 27;160(6):809–15; Heit JA, Silverstein MD, Mohr DN, et al. Arch Intern Med. 1999 Mar 8;159(5):445–53; Sørensen HT, Mellemkjær L, Olsen JH, et al. NEJM. 2000 Dec 21;343(25):1846–50; Prandoni P, Lensing AWA, Büller HR, et al. NEJM. 1992 Oct 15;327(16):1128–33; Sørensen TIA, et al. NEJM . 1988 Mar 24;318(12):727–32; Chew HK, Wun T, Harvey D, et al. Arch Intern Med. 2006 Feb 27;166(4):458–64; Khorana AA, et al. Journal of Thrombosis and Haemostasis. 2007 Mar 1;5(3):632–4; Connolly GC, and Francis CW. Hematology. 2013 Dec 6;2013(1):684–91. Van Doormaal, Frederiek F., et al. " Thromb Haemost 101.4 (2009): 762-769.
  8. 8. Why do patients with cancer get VTE? • Cancer itself – Squishing vessels – Secreting clotting substances • Treatment – Chemotherapy (some more than others) – Radiation – Hormones – Lines (IVs) • Being ill – Bedrest – Dehydration – “inflammation”
  9. 9. Risks
  10. 10. Risks
  11. 11. Risks
  12. 12. Risks
  13. 13. DVT
  14. 14. DVT
  15. 15. DVT symptoms
  16. 16. Arm DVT
  17. 17. Arm DVT Symptoms
  18. 18. Arm DVT Symptoms
  19. 19. Circulation
  20. 20. Circulation
  21. 21. Pulmonary Embolism (PE)
  22. 22. PE Symptoms
  23. 23. PE Symptoms
  24. 24. PE Symptoms
  25. 25. These symptoms are URGENT!
  26. 26. Tests for VTE • For DVT – Ultrasound • For PE – CT scan with contrast (special protocol) – VQ scan (nuclear medicine- like a PET scan)
  27. 27. Treatment for VTE • Anticoagulants (“blood thinners”) – Stop the clot from growing and breaking off – acceptable risk of bleeding • Fibrinolytics (“clot busters”) – Dissolves the clot – Very high bleeding risk • Mechanical – IVC filters • Only when cant use anticoagulants • Frequent complications
  28. 28. Treatment for VTE
  29. 29. Treatment for VTE
  30. 30. Treatment for VTE
  31. 31. Treatment for VTE - warfarin
  32. 32. Treatment for VTE - warfarin
  33. 33. Treatment for VTE
  34. 34. A misconceptions: Anticoagulants are not clot busters, the body is!
  35. 35. Anticoagulants are not clot busters, the body is! • This means that reimaging (CT or US) is not needed usually. • Symptoms do not go away quickly, can take weeks • Worsening symptoms require reimaging, and are treated with higher doses of anticoagulants. – This occurs in about 10% of patients with CAT usually in the first month after diagnosis of the VTE.
  36. 36. Prevention of VTE -Compression stockings -anticoagulants
  37. 37. Prevention of VTE More aggressive approaches when the risk is high: – In hospital – After surgery – Very long flights or drives
  38. 38. Thanks and resources http://www.thrombosiscanada.ca http://www.vteproblemsolved.ca http://www.vtesimplified.ca http://www.clotsmatter.ca http://survivornet.ca
  39. 39. Canadian Cancer Survivor Network Contact Info Canadian Cancer Survivor Network 1750 Courtwood Crescent, Suite 210 Ottawa, ON K2C 2B5 Telephone / Téléphone : 613-898-1871 E-mail jmanthorne@survivornet.ca or mforrest@survivornet.ca Web site www.survivornet.ca Instagram: @survivornet_ca Twitter: @survivornetca Facebook: www.facebook.com/CanadianSurvivorNet Pinterest: http://pinterest.com/survivornetwork/

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