Dana-Farber / Brigham and Women's Cancer Center

Managing and Preventing Thrombosis in Oncology Patients

Managing and Preventing Thrombosis in Oncology Patients

One of few dedicated services of its kind for oncology patients, the Anticoagulation Management Service at Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) provides expert care and anticoagulation management for patients undergoing cancer treatment.

“As thrombosis is the second leading cause of death among cancer patients, managing and preventing blood clots in this population is critical,” said hematologist Jean Marie Connors, MD, Medical Director of the Anticoagulation Management Service.

Case Study:

Management of Renal Vein Thrombosis in Metastatic Appendiceal Carcinoma

Background:
A 47-year-old man with metastatic, well-differentiated mucinous appendiceal carcinoma was being treated with FOLFIRI and bevacizumab chemotherapy. Restaging CT scan (Image 1) revealed new complete occlusion of the left renal vein, raising the question of bland thrombus versus tumor thrombus. His history was complicated by mild renal insufficiency with creatinine clearance of 40 ml/min and thrombocytopenia with platelet count of 70,000/ul.

Approach:
The DF/BWCC Anticoagulation Management Service was consulted regarding benefits of anticoagulation. Additional history revealed new intermittent dull left flank pain over the previous several weeks. Close review of CT images revealed minimal left renal parenchymal edema. Specialists in the Anticoagulation Management Service worked closely with gastrointestinal medical oncologists and determined that acute thrombus was more likely than tumor thrombus. The risks and benefits of anticoagulation in this patient with good performance status were discussed.

CT images revealed

The patient was started on full intensity low-molecular-weight heparin (LMWH) with careful monitoring of platelets and renal function. LMWH was decreased to intermediate intensity when platelets fell below 50,000/ul and was stopped when platelets dropped below 30,000/ul from effects of chemotherapy. Specialists in the Anticoagulation Management Service followed the patient’s lab results until platelets rose above 30,000/ul and restarted LMWH at that time.

Follow up:
Chemotherapy was continued. After two weeks, left flank pain completely resolved. On a re-staging scan three months later, partial flow through the left portal vein was noted (Image 2).

The Service, which has cared for more than 600 patients over the past five years, includes Dr. Connors, as well as a pharmacist, a nurse, and nurse practitioners. The team works in collaboration with patients’ oncologists, including gastrointestinal oncologists and hematologic oncologists who treat patients at high risk of thrombosis.

The Anticoagulation Management Service team:

  • Guides anticoagulation therapy, including dosing of warfarin and parenteral anticoagulation agents in relation to cancer drugs and drug changes, antibiotics, blood counts, and other factors;
  • Advises on length of anticoagulation therapy, interruption of anticoagulation therapy, and bridging for procedures;
  • Addresses bleeding complications and collaborates with cardiovascular specialists at Brigham and Women’s Hospital for patients who are in need of interventions, such as stenting to enable better blood flow in vessels near tumors or in patients who present with clots;
  • Provides patient education and support.

“We work hand-in-hand with oncologists to develop a strategy for each patient and make modifications together as needs change,” said Dr. Connors.

Research in Cancer-related Venous Thromboembolism

Dr. Connors has served as a principal investigator in regional and international anticoagulation studies, including the treatment of cancer-associated venous thromboembolism (VTE) and the role of markers in predicting recurrence in unprovoked VTE. She is currently piloting a study with DF/BWCC colleagues in hematologic malignancy using prophylactic anticoagulation in patients with acute lymphoblastic leukemia and is studying anticoagulation parameters in patients enrolled in this study who develop VTE.

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Upcoming CME Program

Breast Cancer — New Horizons, Current Controversies
July 11 – 13, 2013
Boston Marriott Long Wharf
Boston, MA

Course Directors:
Harold J. Burstein, MD, PhD;
Judy E. Garber, MD, MPH;
Barbara L. Smith, MD, PhD;
Eric P. Winer, MD

Offered by:
Dana-Farber/Brigham and Women’s Cancer Center, Massachusetts General Hospital Cancer Center, Harvard Medical School Department of Continuing Education

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Phone: (877) DFCI-BWH / (877) 332-4294
www.dfbwcc.org