Treatment Not Needed for DVT in Very Advanced Cancer Patients

About one third of patients with advanced cancer who are admitted to a specialized palliative care unit (SPCU) have deep vein thrombosis (DVT) on admission, but in these patients, DVT is not associated with either significant symptoms or survival, concludes a new study from the United Kingdom.

“Venous thromboembolism in the SPCU setting is considered of clinical relevance only if it confers a patient-reported symptom burden or contributes to distressing symptoms at the end of life,” corresponding author Miriam Johnson, MD, professor of palliative medicine, University of Hull, United Kingdom, and colleagues observe.

“Since our data suggest these deep vein thromboses confer a minimal symptom burden with no evidence that they shorten life, rethinking the utility of pharmacological thromboprophylaxis in this population would seem reasonable,” the authors state.

“Our data challenge current recommendations for prevention of venous thromboembolism in advanced cancer,” they conclude.

The study was published online February 1 in the Lancet Haematology.

The study included 343 patients with advanced cancer who were admitted to an SPCU in the United Kingdom and who underwent assessment for proximal DVT. Assessments were conducted using bilateral ultrasonography of the popliteal and femoral veins at the bedside by trained nurses within 48 hours of admission.

Of 273 patients with evaluable scans, 34% had femoral vein thrombosis, the investigators report. In the final multivariable model, lower-limb edema was an independent predictor of DVT.

In the study cohort, there was no association between the use of thromboprophylaxis and the risk for DVT on admission.

Having a DVT had no bearing on mean average survival time — for patients with DVT on admission, survival was 30.55 days, vs 31.38 days for those who did not have DVT on admission.

A post hoc analysis indicated that about one quarter of patients who did not have a history of DVT on admission were newly diagnosed with DVT after being admitted to the SPCU.

“Apart from limb oedema, our findings showed no effect of femoral vein thrombosis on experience of venous thromboembolism-related symptoms, and no effect of thrombo-prophylaxis on deep vein thrombosis risk,” the researchers observe.

No Symptomatic Burden

In an accompanying editorial, Per Morten Sandset, MD, PhD, and Anders Dahm, MD, PhD, both of the University of Oslo in Norway, couldn’t agree more with the authors’ conclusion.

True, the study did show that the prevalence of DVT in patients with advanced cancer is very high, they point out.

“However…because deep vein thrombosis in many of these patients did not cause symptoms in a setting where symptom relief and not prolongation of life is the focus, the symptomatic burden is more important than effects on mortality,” they argue.

Furthermore, Sandset and Dahm point out that guidelines from the American Society of Clinical Oncology indicate that anticoagulation is of “uncertain benefit” in patients such as those included in the study, who were receiving end-of-life or hospice care.

Those guidelines also state that anticoagulation is of uncertain benefit in patients whose life expectancy is very limited or in cases in which it does not reduce symptoms.

“The present study provides strong evidence supporting these recommendations,” the editorialists concur.

“Clearly, [these] findings suggest that venous thromboembolism is a manifestation of advanced cancer disease and that thromboprophylaxis is of limited value,” they conclude.

The study was funded by the National Institute for Health Research under its Research for Patient Benefit Programme. Johnson has disclosed no relevant financial relationships. Dahm has received personal fees from Merck Sharp & Dohme, Bristol-Myers Squibb, Bayer, and Novartis, as well as grants and personal fees from Pfizer. Sandset has disclosed no relevant financial relationships.

Lancet Haematol. Published online February 1, 2019. Full text, Editorial

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