Article of the Month
by Carla Ripamonti, MD
Thromboprophylaxis in patients receiving inpatient palliative care: a survey of present practice in Austria
Gartner V, Kierner KA, Namjesky A, et al.
Supportive Care Cancer 2012; 20:2183-2187
According to the data in the literature, the prevalence of venous thromboembolism (VTE) in cancer patients varies from 10% to 50% while one in every seven hospitalized cancer patients dies of pulmonary embolism. Moreover, VTE is a common complication in severely ill patients and it is an important cause of morbidity and mortality. National and international guidelines on the use of thromboprophylaxis (TP) have been produced, and TP use is considered a high level recommendation (grade IA) in immobile cancer patients. According to these guidelines most advanced cancer patients would require TP because they are at risk for VTE. Thus physicians increasingly use TP, and palliative care patients who are involved in decision making opt for getting TP.
In a prospective, cross-sectional study, the authors monitored use, indication, and contraindications of TP in 134 patients hospitalized in 21 palliative care units in Austria in 2010. All the inpatients entered the study without exclusion criteria and the evaluations were carried out twice during a three months interval by means of a questionnaire including questions about diagnosis, demographic data, presence/absence of TP, performance status, and state of consciousness.
Indications for TP were in agreement with the guidelines of the American Society for Clinical Oncology for TP in cancer patients. Indications for TP were: hospitalization due to sequels of advanced cancer together with immobility (Karnofsky index≤ 40) where most of the patients were “bedridden”. Contraindications for TP were: PTL < 50.000?L, a prothrombin time of < 40% of normal, overt bleeding, a serum creatinine of > 1.5 mg/dL and a KI of ≤20%.
Eighty-six percent of all units responded to the questionnaire. The patients mean age was 70 ? 15 years; fifty-one percent of patients were female.
Forty-seven percent of patients were on low molecular weight heparin on the day of the study for primary or secondary thromboembolism. TP had been withdrawn in 18% of the patients upon admission to the PC unit.
The use of TP was similar in cancer patients and in non-cancer patients (49% vs 42%) and in mobile (KI >40) and bedridden (KI ≤ 40) cancer patients (51% vs 46%). Eighty-seven percent of patients who had been involved in decision making opted for receiving TP.
More bedridden cancer patients had contraindications for prophylaxis compared to mobile cancer patients (35% vs 16%; p= 0.03) and low performance status was the most frequent contraindication among cancer patients (89%).
Why I chose this article
In the palliative care setting very few data are available on the use of thromboprophylaxis in advanced cancer patients. However, the results of this study show that:
1) about 50% of all cancer patients in palliative care units in Austria were treated with thromboprophylaxis,
2) low performance status was the most frequent contraindication for thromboprophylaxis.
This data is particularly interesting if we consider that in national and international guidelines, thromboprophylaxis (TP) has a high level recommendation (grade IA) in immobile cancer patients whose performance status is very low.
Probably data on cancer patients admitted in oncological clinics cannot be extrapolated to advanced, end-of –life cancer patients.
Further studies are necessary to better identify the characteristics of advanced cancer patients cared for in palliative care settings that need thromboprophylaxis
Carla Ripamonti, MD is Head of the Supportive Care in Cancer Unit, IRCCS Foundation, National Cancer Institute of Milan, Italy. Her bio may be found at: https://hospicecare.com/bio/carla-ripamonti . Dr. Ripamonti after serving many years as an IAHPC Board member was elected as a Lifetime Adviser to the Board of IAHPC