Treatment or prophylaxis of thromboembolic disease in frail sufferers with cancer therefore requires a carefully tailored approach. or thromboembolism. Frailty in patients with cancer results from overlapping domains of aging, Eastern Cooperative Oncology Group (ECOG) status, type of cancer, poly-pharmacotherapy, cognitive impairment, blood disorders, and reduced life expectancy (Table 3). Table 3 Factors contributing to frailty in patients with cancer-associated thrombosis (CAT). thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Factors /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Assessment /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Impact on Patient Management /th /thead AgePatients aged 75Frailty assessmentECOG br / Nutritional status br / MobilityLoss of body weight br / Swallowing disorders br / Monitoring barriersNo food interaction with LMWH compared to oral anticoagulants br / LMWH preferred in case of severe swallowing disorders br / Oral anticoagulants more practical than LMWHType of cancerPancreas br / Multiple myelomaLMWH for VTE prophylaxis and treatment br / LMWH if concomitant use of IMiDsComorbiditiesRenal impairment br / Hepatic impairmentLMWH or DOAC in patients with CrCl 15 mL/min ( 30 mL/min for dabigatran) br / LMWH preferred to oral anticoagulantsPoly-pharmacotherapy br / Antineoplastic treatment br / Supportive therapiesNumber of drugs br / Increased thromboembolic events with IMiD in patients with myeloma br / Drug-drug interactionsPrioritize antineoplastic treatment in patients receiving 5 drugs. br / LMWH on a case-by-case basis br / LMWH preferred to oral anticoagulantsCognitive impairmentPoor treatment complianceNo oral anticoagulants unless systematic follow-up visits br / LMWH to be preferred for adherence purposesBlood disorders br / Anemia br / ThrombocytopeniaIncreased risk of VTE br / Increased bleeding risk Risk of falls LMWH or oral anticoagulantsReduced life expectancyTo be consideredConsider avoiding anticoagulants in case of life expectancy 6 months Open in a separate window ECOG = Eastern Cooperative Oncology Group; LMWM = low-molecular-weight heparin; DOAC = direct oral anticoagulant; CrCl = creatinine clearance; VTE = venous thromboembolism; IMiD = immunomodulatory drugs; VTE = venous thromboembolism. 3.1. Aging Cancer and frailty are associated with advanced age. Frailty in community-dwelling adults increases with age, affecting 11% of the elderly over the age of 65 years and 25% of those over the age of 85 years [26]. Aging is usually a supplementary factor that contributes to frailty in patients with CAT, making the management of anticoagulant treatment complex. The use of concomitant anti-cancer therapies (chemotherapy, hormones, immuno-modulatory or anti-angiogenic drugs), central venous catheter (CVC) placement, and invasive cancer surgery further increase the thrombotic risk and expose patients to potential drug interactions. The risk of VTE recurrence is L-Glutamic acid monosodium salt usually higher in patients with advanced-stage cancer receiving chemotherapies and sub-cutaneous growth factors [27]. Elderly patients (aged 75) with cancer are at particularly high risk of bleeding not L-Glutamic acid monosodium salt due only to age and renal dysfunction, but also to the more frequent side effects from cancer therapy and a generally frailer situation [28]. 3.2. Eastern Cooperative Oncology Group The ECOG scale of performance status is a consistent and convenient manner for measuring the impact of cancer on the patients capabilities (Table 4) [29]. A high ECOG grade of 3C4 may result from advanced age, cancer progression, malnutrition, or falls that compromise patients autonomy and contribute to frailty. Table 4 ECOG performance status (adapted from Oken et al.) [29]. thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Grade /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ ECOG Performance Status /th /thead 0Fully active, able to carry on all pre-disease performance without restriction1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work2Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours3Capable of only limited self-care; confined to bed or chair more than 50% of waking hours4Completely disabled; cannot carry on.The IMWG frailty score was predictive of mortality, treatment discontinuation, and non-hematologic toxicities. or thromboembolism. Frailty in patients with cancer results from overlapping domains of aging, Eastern Cooperative Oncology Group (ECOG) status, type of cancer, poly-pharmacotherapy, cognitive impairment, blood disorders, and reduced life expectancy (Table 3). Table 3 Factors contributing to frailty in patients with cancer-associated thrombosis (CAT). thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Factors /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Assessment /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Impact on Patient Management /th /thead AgePatients aged 75Frailty assessmentECOG br / Nutritional status br / MobilityLoss of body weight br / Swallowing disorders br / Monitoring barriersNo food interaction with LMWH compared to oral anticoagulants br / LMWH preferred in case of severe swallowing disorders br / Oral anticoagulants more practical than LMWHType of cancerPancreas br / Multiple myelomaLMWH for VTE prophylaxis and treatment br / LMWH if concomitant use of IMiDsComorbiditiesRenal impairment br / Hepatic impairmentLMWH or DOAC in patients with CrCl 15 mL/min ( 30 mL/min for dabigatran) br / LMWH preferred to oral anticoagulantsPoly-pharmacotherapy br / Antineoplastic treatment br / Supportive therapiesNumber of drugs br / Increased thromboembolic events with IMiD in patients with myeloma br / Drug-drug interactionsPrioritize antineoplastic treatment in patients receiving 5 drugs. br / LMWH on a case-by-case basis br / LMWH preferred to oral anticoagulantsCognitive impairmentPoor treatment complianceNo oral anticoagulants unless systematic follow-up visits br / LMWH to be preferred for adherence purposesBlood disorders br / Anemia br / ThrombocytopeniaIncreased risk of VTE br / Increased bleeding risk Risk of falls LMWH or oral anticoagulantsReduced life expectancyTo be consideredConsider avoiding anticoagulants in case of life expectancy 6 months Open in a separate window ECOG = Eastern Cooperative Oncology Group; LMWM = low-molecular-weight heparin; DOAC = direct oral anticoagulant; CrCl = creatinine clearance; VTE = venous thromboembolism; IMiD = immunomodulatory drugs; VTE = venous thromboembolism. 3.1. Aging Cancer and frailty are associated with advanced age. Frailty in community-dwelling adults increases with age, affecting 11% of the elderly over the age of 65 years and 25% of those over the age of 85 years [26]. Aging is usually a supplementary factor that contributes to frailty in patients with CAT, making the management of anticoagulant treatment complex. The use of concomitant anti-cancer therapies (chemotherapy, hormones, immuno-modulatory or anti-angiogenic drugs), central venous catheter (CVC) placement, and invasive cancer surgery further increase the thrombotic risk and expose patients to potential drug interactions. The risk of VTE recurrence is usually higher in patients with advanced-stage cancer receiving chemotherapies and sub-cutaneous growth factors [27]. Elderly patients (aged 75) with cancer are at particularly high risk of bleeding not due only to age and renal dysfunction, but also to the more frequent side effects from cancer therapy and a generally frailer situation [28]. 3.2. Eastern Cooperative Oncology Group The ECOG scale of performance status is a consistent and convenient manner for measuring the impact of cancer on the patients capabilities (Table 4) [29]. A high ECOG grade of 3C4 may result from advanced age, cancer progression, malnutrition, or falls that compromise patients autonomy and contribute to frailty. Table 4 ECOG performance status (adapted from Oken et al.) [29]. thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Grade /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ ECOG Performance Status /th /thead 0Fully active, able to carry on all pre-disease performance without restriction1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work2Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours3Capable of only limited self-care; confined to bed or chair more than 50% of waking hours4Completely disabled; cannot carry on any selfcare; totally confined to bed or chair Open in a.Chen et al. stratification models appear to have little accuracy in very elderly patients with VTE [25]. 3. Factors Contributing to Frailty in Patients with Cancer-Associated Thrombosis Frailty in patients with cancer results from the combination of multiple factors that may increase the risk of L-Glutamic acid monosodium salt bleeding or thromboembolism. Frailty in patients with cancer results from overlapping domains of aging, Eastern Cooperative Oncology Group (ECOG) status, type of cancer, poly-pharmacotherapy, cognitive impairment, blood disorders, and reduced life expectancy (Table 3). Table 3 Factors contributing to frailty in patients with cancer-associated thrombosis (CAT). thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Factors /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Assessment /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Impact on Patient Management /th /thead AgePatients aged 75Frailty assessmentECOG br / Nutritional status br / MobilityLoss of body weight br / Swallowing disorders br / Monitoring barriersNo food interaction with LMWH compared to oral anticoagulants br / LMWH preferred in case of severe swallowing disorders br / Oral anticoagulants more practical than LMWHType of cancerPancreas br / Multiple myelomaLMWH for VTE prophylaxis and treatment br / LMWH if concomitant use of IMiDsComorbiditiesRenal impairment br / Hepatic impairmentLMWH or DOAC in patients with CrCl 15 mL/min ( 30 mL/min for dabigatran) br / LMWH preferred to oral anticoagulantsPoly-pharmacotherapy br / Antineoplastic treatment br / Supportive therapiesNumber of drugs br / Increased thromboembolic events with IMiD in patients with myeloma br / Drug-drug interactionsPrioritize antineoplastic treatment in patients receiving 5 drugs. br / LMWH on a case-by-case basis br / LMWH preferred to oral anticoagulantsCognitive impairmentPoor treatment complianceNo oral anticoagulants unless systematic follow-up visits br / LMWH to be preferred for adherence purposesBlood disorders br / Anemia br / ThrombocytopeniaIncreased risk of VTE br / Increased bleeding risk Risk of falls LMWH or oral anticoagulantsReduced life expectancyTo be consideredConsider avoiding anticoagulants in case of life expectancy 6 months Open in a separate window ECOG = Eastern Cooperative Oncology Group; LMWM = low-molecular-weight heparin; DOAC = direct oral anticoagulant; CrCl = creatinine clearance; VTE = venous thromboembolism; IMiD = immunomodulatory drugs; VTE = venous thromboembolism. 3.1. Aging Cancer and frailty are associated with advanced age. Frailty in community-dwelling adults increases with age, affecting 11% of the elderly over the age of 65 years and 25% of those over the age of 85 years [26]. Aging is a supplementary factor that contributes to frailty in patients with CAT, making the management of anticoagulant treatment complex. The use of concomitant anti-cancer therapies (chemotherapy, hormones, immuno-modulatory or anti-angiogenic drugs), central venous catheter (CVC) placement, and invasive cancer surgery further increase the thrombotic risk and expose patients to potential drug interactions. The risk of VTE recurrence is usually higher in patients with advanced-stage cancer receiving chemotherapies and sub-cutaneous growth factors [27]. Elderly patients (aged 75) with cancer are at particularly high risk of bleeding not due only to age and renal dysfunction, but also to the more frequent side effects from cancer therapy and a generally frailer situation [28]. 3.2. Eastern Cooperative Oncology Group The ECOG scale of performance status is a consistent and convenient manner for measuring the impact of cancer on the patients capabilities (Table 4) [29]. A high ECOG grade of 3C4 may result from advanced age, cancer progression, malnutrition, or falls that compromise patients autonomy and contribute to frailty. Table 4 ECOG performance status (adapted from Oken et al.) [29]. thead th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ Grade /th th align=”center” valign=”middle” style=”border-top:solid thin;border-bottom:solid thin” rowspan=”1″ colspan=”1″ ECOG L-Glutamic acid monosodium salt Performance Status /th /thead 0Fully active, Rabbit Polyclonal to TOP2A able to carry on all pre-disease performance without restriction1Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work2Ambulatory and capable of all self-care but unable to carry out any work activities; up and about more than 50% of waking hours3Capable of only limited self-care; confined to bed or chair more than 50% of waking hours4Completely disabled; cannot carry on any selfcare; totally confined to bed or chair Open in a separate window 3.3. Cancer Disease Patients with recently diagnosed active cancer are at much higher risk of VTE recurrence and bleeding compared to patients with only a.
Treatment or prophylaxis of thromboembolic disease in frail sufferers with cancer therefore requires a carefully tailored approach