2007

To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) asks its medical experts to develop recommendations for specific areas of cancer care. ASCO developed a clinical practice guideline about preventing and treating blood clots for people with cancer. This patient guide is based on ASCO's recommendations.

As you read this guide, please keep in mind that every person treated for cancer is different. These recommendations are not meant to replace your judgment or that of your doctor. The final decisions you and your doctors make will be based on your individual circumstances.

Information in ASCO's patient education materials is not intended as medical advice or as a substitute for the treating doctor's own professional judgment; nor does it imply ASCO endorsement of any product, service, or company.

A blood clot (also called a thrombus) is a serious side effect of cancer and cancer treatment. It may develop in any vein (a blood vessel that carries blood to the heart), but it happens most often in the legs, thighs, or pelvis (lower abdomen). This is called deep vein thrombosis (DVT). A blood clot that breaks away from the place it formed and travels through the veins to a different site is called a thromboembolism. A pulmonary embolism (PE) is a blood clot in the lung, which is a potentially life-threatening condition.

Blood clots occur frequently in people with cancer and are becoming more common each year probably because of new, more intense treatments and certain medications. The risk of developing a blood clot is increased by:

• The cancer itself, especially cancers of the lung, kidney, brain, gastrointestinal (digestive) system, female reproductive system (such as uterine cancer), and blood (such as leukemia and lymphoma)



• Metastatic cancer (cancer that has spread to other areas of the body from the original organ)



• Cancer treatment, including surgery, chemotherapy, and hormone therapy. Antiangiogenic drugs (drugs that block the formation of new blood vessels), such as thalidomide (Synovir, Thalomid) and lenalidomide (Revlimid) may also raise the risk of blood clots.



• Treatment with erythropoiesis stimulating agents (drugs that help increase production of red blood cells), such as epoetin (Procrit, Epogen) and darbepoetin (Aranesp)



• Being in the hospital, since most patients are confined to bed and can't be physically active



• A history of blood clots



• Having other diseases or conditions in addition to cancer, such as obesity (having too much body fat), infection, kidney disease, lung disease, or a blood clot in an artery (a blood vessel that carries blood away from the heart)



• Older age



• Race/ethnicity (risk is higher for black people and lower for people of Asian-Pacific Islander descent)



• A condition that is inherited (comes from a relative, such as your mother or father), such as sickle cell disease or a clotting disorder such as factor V Leiden mutation (a condition that causes too much blood clotting)

The symptoms of DVT include pain, swelling, and redness of the calf, leg, or thigh. The symptoms of PE include shortness of breath, chest pain, quick breathing, a rapid heartbeat, coughing up blood, and fainting.

Blood clots can be prevented and treated with drugs. Anticoagulants are drugs that help break up blood clots or keep them from starting. (Coagulation is the clotting of the blood). Anticoagulants may raise a person's risk of bleeding, but otherwise are safe for most people. Typical anticoagulants include heparin, dalteparin (Fragmin), enoxaparin (Lovenox), fondaparinux (Arixtra), tinzaparin (Innohep), and warfarin (Coumadin). A doctor may use a non-drug method, called a mechanical method, in addition to the drug treatment for the prevention of blood clots. Mechanical methods include graduated compression stockings (a type of support hose); intermittent pneumatic compression (squeezing the legs through a sleeve connected to a machine), and mechanical foot pumps.

ASCO recommends the following for preventing and treating blood clots for patients with cancer:

• Patients hospitalized with cancer for surgery, chemotherapy, or any other reason should receive preventive treatment with an anticoagulant, as long as it is safe (the patient is not bleeding, for example).



• Patients who will undergo major surgery should get drugs to prevent blood clots and a mechanical method of prevention. They should receive this treatment within 24 hours after surgery.



• Patients who develop a blood clot should be treated with an anticoagulant for at least six months and even longer if they are receiving cancer treatment.



• Regular use of an anticoagulant for people with cancer who are not hospitalized and are receiving chemotherapy is not recommended, except for those with multiple myeloma being treated with thalidomide or lenalidomide along with chemotherapy.

People with cancer, especially those who are in the hospital and undergoing treatment, are at risk for blood clots. This serious health condition can usually be prevented and treated with an anticoagulant medication. These medications are generally safe, although there is a small risk of bleeding. Talk with your doctor to learn more about your risk of developing a blood clot and ways to prevent blood clots.

To learn more about blood clots, consider asking your doctor the following questions:

• Am I at increased risk for a blood clot?
  
  
• What can be done to prevent a blood clot before it starts?
  
  
• If I am at increased risk for a blood clot, what treatment do you recommend?
  
  
• 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?
  
  
• What health conditions or medications may interfere with the treatment for blood clots?
  
  
• Am I eligible for a clinical trial?
  
  
• Where can I find more information?

Read the entire clinical practice guideline published in the December 1, 2007 issue of the Journal of Clinical Oncology (JCO).

Cancer.Net: Managing Side Effects: Bleeding and Clotting Problems

Cancer.Net (www.cancer.net) is the comprehensive, oncologist-approved cancer information website from ASCO. Visit Cancer.Net to find guides on more than 120 types of cancer and cancer-related syndromes, clinical trials information, coping resources, information on managing side effects, medical illustrations, cancer information in Spanish, podcasts, the latest cancer news, and much more. For more information about ASCO's patient information resources, call toll free 888-651-3038.

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