Supportive Care for Blood Disorders Associated with Cancer
For patients with blood disorders, supportive care most often refers to efforts such as blood transfusions, anticoagulant use, and drug management strategies. In such cases, health care providers must consider the treatment options that have the best efficacy but also must ensure that side effects and symptoms are manageable.
In two presentations, Gerald Soff, MD (Memorial Sloan Kettering Cancer Center, New York, NY) and Chatree Chai-Adisaksopha, MD (McMaster University, Hamilton, Ontario, Canada), each discussed results from studies evaluating care management strategies for anticoagulant use.
Thrombocytopenia is a condition that commonly occurs in patients with cancer, characterized by a deficiency of platelets in the blood. This condition is commonly managed by prescribing anticoagulants, but such medications carry the risk of recurrent thrombosis or major bleeding. In his presentation, “Research Provides Guidance for Anticoagulation Management in the Setting of Thrombocytopenia in Cancer Patients,” Dr Soff discussed the results of a study that evaluated the effectiveness of Memorial Sloan Kettering Cancer Center (MSK) guidelines for low-molecule-weight heparin (LMWH), an anticoagulant used to manage thrombocytopenia.
In the retrospective study, 102 patients with a collective 143 episodes of thrombosis were analyzed. All were treated with LMWH between 2011 and 2013. Results showed that dosing of LMWH was reduced in 20 episodes, withheld in 89, and managed with reduction or withholding in 27 episodes. None of the patients experienced recurrent thrombosis or major bleeding when the guidelines were followed. Therefore, Dr Soff stated that his team’s findings support the safety and efficacy of following the MSK guidelines for LMWH. In addition, he stressed the importance of educating health care providers about the use of the guidelines as well as the dangers of anticoagulant use. More research will be needed to evaluate whether similar strategies would be equally effective for other oral anticoagulants.
Dr Chai-Adisaksopha presented data on the use of another anticoagulant drug, warfarin. The standard treatment for cancer patients who develop blood clots is 3–6 months of therapy with LMWH, but less data are available regarding the best strategies for treatment of clots that continue for longer than 6 months.
In her presentation, “Switching to Warfarin after 6-Month Completion of Anticoagulant Treatment for Cancer-Associated Thrombosis,” Dr Chai-Adisaksopha shared findings from a study to compare the continued use of LMWH and warfarin. A total of 1502 patients with cancer-associated thrombosis were evaluated in the study; all had completed treatment with LMWH for 6 months. Patients were then divided into two groups; patients in one group continued to receive LMWH, and those in the second group switched to warfarin. The two drugs resulted in highly similar outcomes. There was no significant difference in the rates of recurrent thromboembolism. The incidence of major bleeding was 2.6% with LMWH, only 0.1% higher than that observed with warfarin. The rates of bleeding were also similar between the two groups, with a 6.7% incidence of total bleeding with LMWH versus 7% with warfarin. Therefore, Dr Chai-Adsaksopha suggested that warfarin is an acceptable alternative to LMWH for patients with cancer-associated thrombosis. Because warfarin can be taken orally, whereas LMWH is taken by self-administered injection, the former is the preferred option for most patients.
These two presentations help to validate and challenge traditional norms associated with anticoagulant use for patients with cancer-associated thrombocytopenia. Guidelines are an important facet of care, but they must be thoroughly evaluated to ensure that they result in optimal outcomes. In addition, as demonstrated by Dr Chai-Adsaksopha’s analysis of the best therapy for patients in whom symptoms persist beyond 6 months, it is necessary for new research to address any gaps that may exist in such guideline recommendations.