Major UK study shows around 1 in 3 patients with advanced cancer admitted to specialist palliative care units have blood clots in their legs but these are not associated with serious symptoms or survival
Press release published
Blood clot treatment may be unnecessary for thousands of patients
A major new study published in The Lancet Haematology1 has shown that around one-third of patients with advanced cancer*, admitted to specialist palliative care units (SPCU) had a blood clot in the main vein of the leg (femoral vein deep vein thrombosis, or DVT).
Despite current thinking, the clots did not appear to shorten life, or be associated with clinically significant symptoms.
People more likely to have a DVT on admission were those who had had a DVT in the past, or who had been bedbound at any point during the previous 3 months. However, very few without a DVT on admission developed a clot during their stay.
The longitudinal multicentre study, led jointly by researchers at the Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull and Northern Ireland Hospice, Belfast in conjunction with co-investigators at the Marie Curie Palliative Research Centre, Cardiff University, is the first to demonstrate the true extent of the problem in people with advanced cancer and the impact on patient outcomes.
DVT is the commonest preventable cause of hospital death and prevention of hospital acquired thrombosis is a major health service focus and patient safety issue. People with cancer are at particular risk of DVTs and clinical guidelines recommend preventative medication for all with cancer if admitted to hospital unless there is a contraindication to anticoagulation or the patient is thought to be imminently dying. However, until now there have been no accurate figures for people with advanced disease admitted to SPCUs or information about the impact of DVTs on symptoms or survival.
The UK research group say these findings have significant implications for clinical practice worldwide, and challenge the current international recommendations for DVT prevention in people with advanced cancer, bringing into question whether these are appropriate for this group of patients. Preventative treatment on admission may be unnecessary for many, thereby reducing the risk of distressing bleeds (a complication of anticoagulant treatment) in this group of patients.
The high prevalence but low three-week incidence of DVTs in people with advanced cancer admitted to SPCUs suggests that preventative treatment at this stage may be too late, say researchers. Moreover, as the clots did not appear to shorten life, or cause clinically significant symptoms other than leg swelling, they question whether such intervention offers clinically meaningful benefit.
One of the Chief Investigators, Dr Clare White, Northern Ireland Hospice, Belfast, said:
“Patients approaching the end of their lives deserve the best care that can be provided, as often there is no second chance to get it right. This study should improve patient care through preventing patients like those in our study receiving clot prevention injections that are associated with minimal benefit and which might cause them harm.”
People with advanced cancer may experience a range of complex symptoms that require careful management and treatment. The last thing they need, when the aim is to improve the quality of their end of life, is having treatments that could cause more harm than good, creating more distress to them and their families; a previous study showed that around one in 10 cancer patients receiving DVT prevention medication experienced clinically-relevant bleeding (from distressing nose bleeds to internal bleeding).
Professor Miriam Johnson, Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, said:
“By the time a patient is admitted to a specialist palliative care unit, one third already had a femoral vein DVT and of those who didn’t, very few developed a DVT during their stay. In this group of patients – with evidence of deterioration and in the last one to two months of life – giving daily injections for DVT prevention doesn’t really make sense.”
Professor Simon Noble, Marie Curie Palliative Care Research Centre, Cardiff University, and co-first author, said:
“This important research suggests we can no longer adopt a ‘one size fits all’ approach to DVT prevention in cancer patients. By recognising that clot prevention needs different approaches through the cancer journey, allows us to deliver a more personalised individual approach to care.”
People with advanced cancer admitted to SPCUs may be differenprot to those with advanced cancer admitted to hospital – factors other than stage of cancer may have influenced the choice of admission. Therefore the results from this study do not inform treatment of people with advanced cancer admitted to hospitals, however, these data suggest that the hospital model of care may be inappropriate for those with advanced cancer admitted to a SPCU.
The HIDDen* study, published in The Lancet Haematology, was funded by the National Institute for Health and supported by terminal illness charity Marie Curie.
Notes to editor
About the research:
This release presents independent research funded by the National Institute for Health Research (NIHR) under itsResearch for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0614-34007). The views expressed are those of the author(s) and not necessarily thoseof the NHS, the NIHR or the Department of Health and Social Care.
1 Clare White, Prof Simon I R Noble, et al. Prevalence, symptom burden, and natural history of deep vein thrombosis in people with advanced cancer in specialist palliative care units (HIDDen): a prospective longitudinal observational study. The Lancet Haematology volume 6, Issue 2, February 2019, Pages e79-e88
HIDDen: Hospice Inpatient Deep vein thrombosis Detection prospective longitudinal observational study to explore the prevalence, symptom burden and nature history of venous thromboembolism in people with advanced cancer
* The longitudinal study involving 343 people with advanced cancer, admitted to five specialist palliative care units across the UK, who were not expected to die within five days). Each patient was assessed at baseline using a range of measures within 48 hours of admission and all measures were repeated weekly. New or worsening clinical symptoms and signs were reported to the clinical staff and survival was measured using routinely collected clinical record data.
Ultrasound scans were undertaken at the bedside by one of five specially trained nurses. As screening for DVT is not routinely undertaken in the specialist palliative care unit and hospice, ultrasound findings were blinded to participants and clinicians. However, the scan result could be given on request to the treating clinician if there was a clinical suspicion of DVT and the scan had been undertaken within the previous 24 hours.
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About Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull
The Wolfson Palliative Care Research Centre brings together researchers, health and social care professionals from a range of disciplines, patients, families and members of the public to find and help deliver the best palliative care services and treatments.
We conduct palliative care research, and provide education and information relevant to the needs of people living with and dying from serious illness, their families and communities. We aim to improve quality of life and reduce inequalities in care, especially those driven by socio-economic status and diagnosis.
Established in 2017 the Centre is building an international reputation for their focus on improving quality of life for people with life limiting illness and reducing current inequalities in access to palliative care. Its board of directors are drawn from Hull York Medical School and the School of Health and Social Work at the University of Hull and together with colleagues and professionals from a range of disciplines their work is already making a real different to patient’s lives – and their families too.
If you are inspired by our research and you would like to collaborate, visit or study with us, please do get in touch: WolfsonPallCare@hyms.ac.uk or visit www.hyms.ac.uk
About Marie Curie
Please note – we are now called ‘Marie Curie’ (not Marie Curie Cancer Care)
Marie Curie – care and support through terminal illness
Marie Curie is the UK’s leading charity for people with any terminal illness. The charity helps people living with a terminal illness and their families make the most of the time they have together by delivering expert hands-on care, emotional support, research and guidance.
Marie Curie employs more than 2,700 nurses, doctors and other healthcare professionals, and with its nine hospices around the UK, is the largest provider of hospice beds outside the NHS.
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