Questions To Ask The Health Care Team
Talk with your health care team to learn more about your risk of developing a blood clot, how blood clot prevention will be included in your overall treatment plan, and what treatments are available if you develop a blood clot.
Consider asking the following questions:
Do I have a higher risk of a blood clot?
What can be done to prevent a blood clot before it starts?
What are the signs and symptoms of a blood clot?
If I have a blood clot or have had them before, what treatment do you recommend?
How long will I need this treatment?
What is my risk of bleeding with such treatment? Are there other side effects?
What health conditions or medications may interfere with the treatment for blood clots?
Who should I call if I have concerns about a symptom?
Discontinuation Of Causative/exacerbating Agents
One of the most critical components of the assessment of patients with bleeding is a thorough assessment of potential causative or exacerbating agents. Obviously, the medications that fall into this category cannot be fully discussed in this manuscript, but the most common medications for advanced cancer patients include NSAIDs and anticoagulants. Anti-inflammatories are often used to treat pain for patients with advanced cancer, but it is important to consider their anti-platelet and anti-coagulant properties that may exacerbate bleeding. Similarly, patients with advanced cancer are often on anticoagulants such as warfarin or enoxaparin, which necessitates the considerations of the risks of further bleeding against the risks of deep venous or pulmonary thromboembolism. Among patients on anticoagulation, patients with cancer develop bleeding complications at a higher rate than those without cancer . INR control is difficult in the setting of cancer treatments, so use of oral anticoagulation during the first year after cancer diagnosis can increase bleeding and other major cardiac adverse events .
The effect of chemotherapy agents and radiation therapy on thrombocytopenia should also be considered, as this may increase the risk of bleeding. If considered a critical contributor, these agents may be held to allow bone marrow recovery and resolution of thrombocytopenia.
Common Causes & Risk Factors For Blood Clots
In addition to chemotherapy, what other treatments and conditions may raise the risk of blood clots for people living with cancer? Some risk factors include:
- Cyanosis, a blue discoloration of the skin and lips
- Heart arrhythmias, abnormal heart rhythms
- Elevated respiratory rate and heart rate with a low blood pressure
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How Long Do Side Effects Last
Most side effects start to go away after cancer treatment ends and the healthy cells have a chance to grow again. How long this takes typically on a child’s overall health and the types and amounts of drugs and/or radiation they had.
Sometimes, though, cancer treatment can cause lasting changes to a growing body. These long-term side effects can include damage to the heart, lungs, brain, nerves, kidneys, thyroid gland, or reproductive organs. In some cases, kids and teens who’ve had some types of chemotherapy have a higher risk for a second type of cancer later in life.
Before treatment, the doctor will talk to you about your child’s risk of late effects and what precautions can be taken before treatment, if any. For example, some teens who undergo treatments that have fertility risks can take preventive measures like egg or sperm preservation.
How Are Blood Clots Treated
There are different ways blood clots are treated:
- Anticoagulants, commonly called blood thinners, help prevent clots from getting larger or travelling in the body. They help lower the risk of new blood clots from forming. The body then dissolves the clot on its own.
Most people do not require surgery. These procedures are only used in very special situations.
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Breast Cancer And Blood Clots
People with breast cancer have a higher risk of blood clots. Their risk is higher because of the cancer itself and some treatments for breast cancer.
If the cancer has spread to other parts of the body , this can also increase the risk.
Blood clots can be harmful but are treatable so its important to report symptoms as soon as possible. If you develop a blood clot during treatment, your treatment may be paused until the blood clot has been treated.
If you experience any of the following symptoms contact your treatment team or go to your local A& E department straight away:
- Pain, redness/discolouration, heat and swelling of the arm or leg
- Swelling, redness or tenderness where a central line is inserted to give chemotherapy, for example in the arm, chest area or up into the neck
- New or increased shortness of breath
- Pain or tightness in the chest
- Unexplained cough or coughing up blood
If You Have Cancer: Blood Clot Prevention And Treatment
Talk to your doctor about your risk of DVT and how to lower it. The best approach depends on things like the type of cancer you have, the treatment you need, and whether you’re in the hospital or at home.
- If your risk is high, your doctor may recommend that you:
- Take medications called anticoagulants or blood thinners
- Get moving as soon as possible after surgery
- Wear special tight socks called compression stockings that improve blood flow
- Use a cuff that automatically squeezes your legs to keep blood moving — a device called an intermittent pneumatic compression
If you do get DVT, your doctor will act quickly. You’ll probably get treatment with a blood thinner. You may need to use this medicine for many months or until after the cancer is gone.
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New Data New Guidelines
It is likely that little of this will trickle down into the clinic until the guidelines change, though.
Data from the latest two trials has now been sent on to the three organizations that create national guidelines for the treatment of cancer patients: the American Society of Clinical Oncology, the National Comprehensive Cancer Network and the American Society of Hematology. Recommendations from organizations like these set standards of care guideline recommendations also often determine whether commercial insurers are likely to reimburse for such treatment.
Lyman, whoâs chaired the ASCO guidelines on cancer and thrombosis for over a decade and also chairs the guidelines panel for ASH, said ASCO is poised to issue new recommendations on the prevention and management of blood clots this spring the other organizations will follow.
A senior lead for health care quality and policy at the Hutchinson Institute for Cancer Outcomes Research, or HICOR, Lyman is hopeful the new guidelines will help ease the burden this major cancer complication puts on patients and society.
âAs you can imagine, these arenât easy decisions,â he said. âYou canât prophylactically treat everyone getting chemo, but you can assess the risk. The panels will have to decide if anticoagulation should be done with heparin or one of the oral agents. There may be a forthcoming recommendation for ultrasound screening for high-risk patients, too.â
Situations That Raise The Risk
Having lung cancer alone increases the risk of developing blood clots, but some situations increase the risk further. Some of these include:
- Surgery can increase the risk of blood clots, but chest surgery and abdominal surgery are particularly problematic.
- Inactivity or prolonged bed rest
- Other lung diseases such as COPD
- Travel. Extended travel by car or plane increases the risk of blood clots. This can be a concern for those who need to travel long distances for treatment
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Blood Clots And Cancer Recurrence
When Stranathan showed up at the clinic, the doctors there confirmed his DVT with a Doppler ultrasound, gave him an immediate injection of a blood thinner known as heparin to dissolve it, then told him to contact his oncologist right away for a scan.
Blood clots, as it turns out, can also be a sign of cancer development or progression.
âThat was the first Iâd heard of it,â said the national patient advocate who didnât realize both his cancer type â and metastatic staging â put him at risk. âWhen they did the CT a week later, they found a new 1.2-centimeter tumor on my left lung.â
Clotting can also become a recurring problem. Stranathan was put on the blood thinner warfarin after the clot in his leg dissolved, but he quickly developed a second clot, which required additional treatment. Months later, two more clots ended up lodging in his lung as pulmonary emboli and nearly killed him, but his doctors were finally able to dissolve those and eventually he went back on heparin, which he now injects every morning and night.
âOnce youâre prone to clots, youâre always going to be prone to them,â he said.
Any of these scenarios can result in serious damage or death, one reason why thereâs an urgent need to stratify patients â figure out whoâs most at risk â and then find ways to reduce that risk. But thereâs also a need to raise awareness of the issue â both in clinicians and in patients, Lyman said.
SIGNS AND SYMPTOMS OF BLOOD CLOTS
If You Are In Hospital
If youre having an operation, you may be advised to stop taking particular medicines for a period of time before surgery.
If you need to stay in hospital, your risk of developing a blood clot should be assessed.
You may be given anti-embolism or compression stockings to wear which help the blood return towards the heart.
In some situations, for example straight after surgery, a device called an intermittent compression system is used to do this for a short time.
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Blood Clots: What Cancer Patients Need To Know
When Don Stranathanâs left leg became swollen after a long day of shoveling granite for a buddyâs new bocce ball court, he didnât think much of it. He even joked about it on Facebook.
âTypical me, I posted a pic and said, âI worked so hard, my legâs all swollen,ââ said the 66-year-old metastatic lung cancer patient from Santa Rosa, California. âThen somebody said, âDon, if you have lung cancer, thereâs a good chance that could be DVT, deep vein thrombosis. You should get that checked it could be serious.ââ
As it turned out, it was serious â and not just for Stranathan. Blood clots, also known as thrombi, or, when they break loose and lodge in the lung, venous thromboembolisms, are the next leading cause of death in cancer patients after cancer itself. They are a side effect of both treatment and the biological nature of the disease. Cancer thickens the blood, releasing substances that make it âstickyâ so clots form more easily, and treatment can exacerbate the risk. Surgeries immobilize patients, chemotherapy inflames the blood vessels and veins, and the blood becomes clogged with bits of dead cancer cells. In addition, anti-hormone therapies like Tamoxifen or targeted therapies like Avastin are known to encourage blood thickening or hypercoagulability.
How Can I Lower My Risk For Dvt
Before getting surgery or having a catheter placed in a central vein, ask your doctor about medicine to lower your chance of getting a blood clot. This medicine is called an anticoagulant or blood thinner.
If you have to stay in bed, try to do leg exercises in the bed. Get up and walk around as soon as you can.
Wear compression stockings to improve blood flow in your legs.
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Goals Of Care And Communication
Goals of care should be discussed as an integral part of considering therapies in patients at high risk of bleeding or suffering from its effects. Patients may find bleeding visible and disturbing, or it may have significant effects on their quality of life. It is also important to consider the patientâs estimated life expectancy, which may involve the use of prognostic models . The rapidity of control of bleeding should be considered, but so too should the comfort of the patient during the treatment process. For example, radiation therapy can usually control bleeding within 24â48 hours, but patients have to be comfortable lying on the treatment table for the planning and treatment process. Surgery too can help manage bleeding tumors, but the burden and duration of recovery should be considered in the context of the patientâs life expectancy and goals of care.
For patients at risk of catastrophic bleeding, patients and their families should be prepared for the visually and mentally disturbing effects of such an episode. Encourage the use of dark sheets, towels, blankets, and clothing to reduce the visual shock of seeing a massive bleed. Fast acting sedatives such as intravenous or subcutaneous midazolam should be available, and families should be instructed on their use if the patient is at home. Although terminal sedation may be appropriate for bleeding at the end of life, a catastrophic bleed may cause death rapidly and there may not be time for sedation.
New Oral Blood Thinners Are Studied
Two recently published clinical trials, CASSINI and AVERT, sought to determine whether oral blood thinners might be a better option for high-risk cancer patients seeking a preventive. The drugs â rivaroxaban tested in CASSINI and apixaban tested in AVERT â have both been approved by the Food and Drug Administration foratrial fibrillation, but there was no data on how they performed in cancer patients. There was also no data on whether they would promote excessive bleeding.
Current guidelines recommend against their routine use as a preventive due to a lack of data.
âUntil we have good safety and efficacy data in the cancer setting, the basic recommendation was to use heparin,â Lyman said.
The multi-institute CASSINI trial, which Lyman and Kuderer helped design, first screened participants for pre-existing blood clots then randomized them to either placebo or a daily rivaroxaban pill . In AVERT, high-risk cancer patients werenât scanned but simply randomized to receive either a placebo or apixaban.
While the CASSINI study found no significant reduction in blood clots in the 180-day trial period, it did find a significantly lower incidence of clots while patients were actively taking the drug. Adherence again was an issue, but the drug did seem to work when taken. The AVERT trial reported that the oral medication apixaban âsignificantlyâ reduced the number of blood clots in high-risk patients going through chemo.
ADVICE ABOUT BLOOD CLOTS FROM PATIENTS
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What Are The Signs Of Deep Vein Thrombosis And Pulmonary Embolism
Signs of deep vein thrombosis include the following:
- Swelling in one of the legs
- Pain or tenderness not caused by injury
- Warmth of the skin
- Redness or discoloration of the skin
Signs of a pulmonary embolism include the following:
- Shortness of breath or hard time breathing
- Sudden chest pain that worsens with a deep breath or cough
- Irregular or fast heartbeat
- Coughing up blood
If you experience any of these side effects, call 911 or go straight to the emergency department.
Finding And Managing Blood Clots
Blood clots can be found after a patient reports symptoms that suggest a blood clot. Other times, blood clots are found by accident when checking for other things.
In patients without cancer, calculating the chance of getting a blood clot, and having a special blood test can often be enough to rule out the presence of a blood clot.
In cancer patients, using these tests alone may not be as accurate and useful. Your health care team will get the information needed to decide if you will need one or more of them, plus additional tests, such as:
- Special blood tests
- A CT scan or other imaging test to look for blood clots
- A ultrasound scan to look for blood clots
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Recognize The Signs And Symptoms Of Blood Clots
Contact your cancer doctor if you experience any of these signs or symptoms of a blood clot.
Signs and symptoms of a blood clot in a persons leg or arm may include:
Pain or tenderness not caused by injury
Skin that is warm to the touch
Redness or discoloration of the skin
Seek immediate medical attention if you experience any of these signs or symptoms of a blood clot.
Signs and symptoms of a blood clot in a persons lung may include:
Chest pain that worsens with a deep breath or cough
Coughing up blood
Faster than normal or irregular heartbeat
What Is A Blood Clot
A blood clot is a collection of blood that can form inside a blood vessel . It can block the normal flow of blood. The medical name for a blood clot is thrombus.
Blood clots can develop in different parts of the body. When a blood clot forms in the deep veins of the leg it is called a deep vein thrombosis .
Part or all of a DVT can break off and travel around the body. It may travel through your heart to block part or all of the blood supply to the lungs. If this happens, its called a pulmonary embolism . DVTs and PEs together are sometimes called venous thromboembolism .
Doctors can successfully treat most blood clots when diagnosed. So it’s important to know about the symptoms of blood clots and report them to your doctor or nurse immediately.
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Being Less Active Due To Treatment
For some people, their breast cancer treatment can make them feel very tired and weak, or cause some muscle and joint pain. This means theyre not as physically active. If you have surgery, it may be difficult to move around as much as you would normally at first. See for more information.
Inactivity increases the risk of a blood clot as the normal action of the leg muscles helps squeeze the veins to return the blood back towards the heart.
Inactivity on long journeys, such as long-haul flights, can also increase the risk of developing a blood clot.
You can find out more about DVT and how to reduce your risk on the NHS website.