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

1. Cancer Associated Thrombosis

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. World Thrombosis Day
• October 13 – the birthday of Dr. Rudy Virchow
who was a pioneer in describing thrombosis

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. 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. 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. 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. 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. Risks

10. Risks

11. Risks

12. Risks

13. DVT

14. DVT

15. DVT symptoms

16. Arm DVT

17. Arm DVT Symptoms

18. Arm DVT Symptoms

19. Circulation

20. Circulation

21. Pulmonary Embolism (PE)

22. PE Symptoms

23. PE Symptoms

24. PE Symptoms

25. These symptoms are URGENT!

26. Tests for VTE
• For DVT
– Ultrasound
• For PE
– CT scan with contrast (special protocol)
– VQ scan (nuclear medicine- like a PET scan)

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. Treatment for VTE

29. Treatment for VTE

30. Treatment for VTE

31. Treatment for VTE - warfarin

32. Treatment for VTE - warfarin

33. Treatment for VTE

34. A misconceptions: Anticoagulants are
not clot busters, the body is!

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. Prevention of VTE
-Compression stockings
-anticoagulants

37. Prevention of VTE
More aggressive approaches when the risk is
high:
– In hospital
– After surgery
– Very long flights or drives

38. Thanks and resources
http://www.thrombosiscanada.ca
http://www.vteproblemsolved.ca
http://www.vtesimplified.ca
http://www.clotsmatter.ca
http://survivornet.ca

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/