**8. Consequences of cancer-associated thrombosis**

As depicted above in this chapter, the implications of diagnosis of VTE in a patient with cancer are many:


Available data on the incidence of post-thrombotic syndrome in patients with cancer is scarce. However, approximately 30% of patients with DVT subsequently develop this chronic, frequently disabling condition within 5 years of the event. Of those, 8.1% will have severe post-thrombotic manifestations (Prandoni et al, 1997b) (8). It is expected that the incidence of the syndrome in cancer patients would be higher in view of adverse patient and treatment related factors. Symptoms of post-thrombotic syndrome include debilitating leg pain, swelling, and fibrosis. Severe manifestations may result in debilitating leg ulceration, mobility problems, and the need for long-term nursing care.

f. Pulmonary Hypertension

Pathophysiology and Clinical Aspects of 98 Venous Thromboembolism in Neonates, Renal Disease and Cancer Patients

prophylaxis?

cancer are many:

prevent recurrent VTE?

VTE to improve survival?

cancer has not been determined.

e. Post-Thrombotic Syndrome

**8. Consequences of cancer-associated thrombosis** 

3. Should patients with cancer undergoing surgery receive preoperative VTE

4. What is the best treatment for patients with cancer with established VTE to

5. Should patients with cancer receive anticoagulants in the absence of established

As depicted above in this chapter, the implications of diagnosis of VTE in a patient with

a. Mortality: cancer diagnosed at the same as or within a year of an episode of VTE is associated with 3-fold increase in mortality at one year. Moreover, the mortality rate in hospitalized cancer patients is higher when they develop VTE. For ambulatory cancer patients, initiating treatment with chemotherapy, VTE and arterial thrombosis has been reported to account for 9% of death. The risk of dying from fatal PE in cancer patient

undergoing surgery is 3-fold higher than similar surgery in non-cancer patients. b. Bleeding complications: cancer patients with VTE and treated with anticoagulants are at two-fold greater risk of bleeding complications than patients with VTE but no cancer. c. Negative impact on healthcare resources: in a retrospective study Etting LS et al (Arch Int Med 2008) reported that the average cost of hospitalization for the index DVT episode in cancer patients in USA was \$20065 in 2002 and the attributable hospital stay was 11 days. d. Recurrence rate of VTE in a patient with cancer is 3-fold more frequently than in patients without cancer. Prandoni et al (32) performed a prospective cohort study of consecutive patients with incident VTE and compared the incidence of recurrence and bleeding for those with and without cancer at the time of VTE. Patients were given heparin followed by warfarin. The 12-month cumulative incidence of recurrent VTE in the group with cancer was 20.7% (95% CI 15.6–25.8%) vs. 6.8% (95% CI 3.9–9.7%) in those without malignancy. The rate of recurrence was directly associated with tumor burden as prospectively assessed by the investigators. This study also confirmed that the risk of major bleeding was also higher for patients with extensive cancer on warfarin anticoagulation. Compared to patients without cancer, patients with cancer have a higher risk of thrombosis and recurrent thrombosis. Recent evidence from wellconducted clinical trials shows that cancer patients may benefit from a longer duration of prophylaxis after surgery and that treatment with long-term LMWH is more effective than conventional oral anticoagulant therapy. Randomized studies have shown that prolonged (6 months) treatment with LMWH results in both lower VTE recurrence rates and less bleeding. Thus, LMWH is the therapy of choice for treatment of VTE in patients with cancer. However, the optimal duration of therapy for patients with active

Available data on the incidence of post-thrombotic syndrome in patients with cancer is scarce. However, approximately 30% of patients with DVT subsequently develop this chronic, frequently disabling condition within 5 years of the event. Of those, 8.1% will have severe post-thrombotic manifestations (Prandoni et al, 1997b) (8). It is expected that the incidence of the syndrome in cancer patients would be higher in view of adverse patient and Pulmonary hypertension is a life-threatening condition associated with fatigue, chest pain, peripheral swelling, and increased mortality. Recent studies suggest that 4–5% of patients develop pulmonary hypertension within years after symptomatic PE, Pengo et al, 2004 (216).
