Management of venous thromboembolism in far-advanced cancer: current practice

OBJECTIVES: Venous thromboembolism (VTE) is common in advanced cancer. Guidelines suggest that indefinite anticoagulation be considered for patients with ongoing active cancer. There are no data on the management of cancer-associated thrombosis (CAT) at the end of life or when to stop anticoagulation as death approaches. We reviewed current practice and associated symptoms at the end of life for patients with advanced cancer who had been anticoagulated for VTE. METHODS: Data on patients attending a regional CAT service were cross-referenced with death notifications. Hospital, hospice and community notes were reviewed to evaluate the end-of-life care within the context of VTE management. Data specific to discontinuation of anticoagulation, complications of anticoagulation and symptoms associated with VTE were recorded. RESULTS: 214 patients died over a 2-year period; 98 (46%) home, 59 (27%) hospice, 53 (25%) acute hospital and 4 (2%) community hospital. 108 (50%) continued low-molecular-weight heparin (LMWH) until death, 23 (11%) up to 7 days prior to death, 23 (11%), 1 week to 1 month 29 (13.5%), over 1 month 40 (18%). Clinically relevant non-major bleeding occurred in 9/131 (7%) of the patients who continued LMWH to death or 7 days up to death. No symptoms attributable to VTE were recorded. CONCLUSION: The majority of CAT patients with metastatic disease remain anticoagulated up to or within days of death. Despite the limitations of retrospective data across healthcare settings, it appears that anticoagulation as death approaches confers a significant bleeding risk without additional benefit of preventing VTE symptoms.