VTE Treatment and Secondary Prevention in Cancer Patients

CancerThrombosis.org :: Treatment and Secondary Prevention: 

"The American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer
Key recommendations for secondary prevention of recurrent VTE19"

• LMWH is the preferred approach for the initial 5 to 10 days of anticoagulant treatment of the cancer patient with established VTE

• LMWH given for 6 months is also the preferred approach for long-term anticoagulant therapy. Vitamin K antagonists with a targeted INR of 2 to 3 are acceptable for long-term therapy when LMWH is not available

• After 6 months, indefinite anticoagulant therapy should be considered for selected patients with active cancer, such as those with metastatic disease and those receiving chemotherapy

• The insertion of a vena cava filter is only indicated for patients with contraindications to anticoagulant therapy and in those with recurrent VTE despite adequate long-term therapy with LMWH

• For patients with CNS malignancies, anticoagulation is recommended for established VTE as described for other patients with cancer. Careful monitoring is necessary to limit the risk of hemorrhagic complications. Anticoagulation should be avoided in the presence of active intracranial bleeding, recent surgery, preexisting bleeding diathesis such as thrombocytopenia (platelet count <50 coagulopathy="" font="" l="" or="">

• For elderly patients, anticoagulation is recommended for established VTE as described for other patients with cancer. Careful monitoring and dose adjustment is necessary to avoid excessive anticoagulation and further increase in the risk of bleeding

For full article including great summary charts and diagrams as well as other key player guidelines, click here.

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Watson Arrives in Medicine: First Stop Oncology and Chemotherapy Recommendations

Jeopardy vs Watson Computer History Museum (Photo credit: iChris)

English: IBM's Watson computer, Yorktown Heights, NY (Photo credit: Wikipedia)

Watson arrives in medicine, first stop oncology and chemotherapy recommendations:

From iMedical Apps"

" IBM and MD Anderson announced the development of a prototype of a platform designed to provide treatment recommendations for and help guide the management of oncology patients."

"By identifying and weighing data-driven connections between the attributes in a patient’s profile and the knowledge corpus of published medical literature and guidelines in Watson, MD Anderson’s Oncology Expert Advisor can provide evidence-based treatment and management options that are personalized to that patient, to aid the physician’s treatment and care decisions."

Read the full story here.

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Long-Term Treatment With Imatinib Affected Bone Mineral Density - Cancer Network

Crystal structure of the c-abl kinase domain (green) in complex with Sti-571 (imatinib, red). Rendered with Accelrys DS Visualizer Pro 1.6 and edited in the GIMP. Conformation and style made to match Image:Bcr abl sti.jpg, originally created by Mxpule for use in Wikipedia. (Photo credit: Wikipedia)

Long-Term Treatment With Imatinib Affected Bone Mineral Density - Cancer Network by Leah Lawrence: 

Highlights:

"A majority of patients on imatinib(Drug information on imatinib) for treatment of gastrointestinal stromal tumor (GIST) or chronic myelogenous leukemia (CML) had low or absent levels of osteocalcin, a bone marker secreted by osteoblasts, and about 50% of patients had a decrease in bone mineral density, signaling that long-term treatment may affect bone health in these patients.

The results were published in Leukemia Research.

Berman and colleagues enrolled 28 patients with either CML or GIST, and prospectively analyzed levels of osteocalcin and serum N-telopeptide of type 1 collagen(Drug information on collagen) (NTX), a marker of bone resorption. Patients were on imatinib for a median of 31 months at baseline. Nineteen patients completed measures of bone mineral density at baseline, 1 year, and 2 years.

Ninety-five percent of the patients were found to have low levels of osteocalcin, and 37% of patients had no measurable amounts at least once during the study period.

Eleven patients (58%) had normal NTX levels. Only four patients (21%) had elevated levels of NTX, and four patients had low levels of NTX.

At 2 years, DEXA scans indicated that 47% of patients had a decrease in bone mineral density and 32% had no change. Seven of the nine patients with decreases saw significant changes at the total hip.

“Imatinib appears to halt or at least decrease bone growth,” Berman said. “Bone is always growing or remodeling. It slows when you are older, in postmenopausal women particularly, but it is always a living organ.”

***
Of course, current practice is to give imatinib indefinitely. The authors, then, suggest careful monitoring of bone density and should the patient have indication of loss, consider therapy with calcium and vitamin D. They stated hormone therapy may need to be started. The role of bisphosphonates will also have to be later established.

Full article - click here

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Oral Rinse Doxepin Relieves Painful Mucositis in Head and Neck Cancer

English: Doxepin Polski: Doxepin - Doksepina (Photo credit: Wikipedia)

The ASCO Post: "Doxepin oral rinse significantly improved oral mucositis in patients treated with radiation therapy for head and neck cancer according to results of a phase III trial presented at the 54th Annual Meeting of the American Society for Radiation Oncology (ASTRO) in Boston. However, the improvement was modest."

Study Details

"N09C6 was a double-blind, randomized, placebo-controlled trial of 140 patients with head and neck cancer who had oral mucositis pain scores above 4 (out of 10). Patients with head and neck cancer were enrolled between December 2010 and May 2012 and treated with radiation at doses above 50 Gy involving more than one-third of the oral cavity. Patients assigned to doxepin used an oral rinse at a dosage of 25 mg in 5 mL of water for 1 minute on day 1; patients then crossed over to the other treatment arm on day 2. Continued treatment with doxepin was allowed on an as-needed basis.

Pain was measured by the area under the curve (AUC) on a pain scale over time. On day 1, doxepin-treated patients reported a pain reduction to –9.1 vs –4.7 for placebo recipients (P = .0003). Crossover data from day 2 showed similar findings, with an AUC pain score of –7.9 in the doxepin group vs –5.6 in the placebo group (P = .009).

Doxepin was well tolerated, but was associated with more stinging and burning (mean pain score of 3.7 for doxepin vs 1.1 for placebo) as well as an unpleasant taste (mean unpleasant taste score at 5 minutes of 2.9 for doxepin vs 1.6 for placebo), and caused greater drowsiness (mean drowsiness score of 3.9 for doxepin vs 2.8 for placebo). During the optional continuation phase, the majority of patients (64%) elected to continue doxepin."

64% of patients chose to continue doxepin after study completion.

*Click here to see full article.

***
From Oncology Times:

"Patients were asked to rate their pain at baseline and at 5, 15, 30, 60, 120, and 240 minutes later. The median pain score at baseline was 5.5 points, “which is the point at which it starts to interfere with eating and drinking,” he said.

During the four-hour period after the drug was administered, pain scores dropped an average of one point in the  placebo group compared with two points for the doxepin group, a significant difference, he said. After the two-day period two-thirds of patients elected to continue doxepin."

--

“There are many, many local institutional recipes for mouth rinse and numbing rinses, so it is nice to see a controlled trial. However, the trial looks at only one single aspect of oral mucositis -- pain, and I would like to have seen swallowing and other endpoints evaluated as well.”

He also questioned how clinically meaningful “a transient improvement of one point on a 10-point pain scale really is to patients who are already on narcotics. Perhaps the same could be achieved by giving them one extra pill when they have breakthrough pain, rather than introduce an entire new class of drugs with its own set of side effects.”

The fact that patients on placebo improved one point on the pain scale could be just “a wonderful testament to the placebo effect,” Harari added.

The bottom line: Before the doxepin rinse is considered for widespread use, there should be a Phase III trial comparing the rinse with an extra narcotic capsule or with a numbing rinse, rather than placebo, he said."

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Cancer Patients Health and Wellbeing Resources - Great programs available for Alberta patients

The following is just a sampling of some fantastic programs available to cancer patients in Alberta:


1. Wellspring


"At Wellspring, people living with cancer tell us what helps them the most – having access to information, receiving support, and learning new ways to cope. Wellspring Calgary exists to inform, support, and empower patients, families and caregivers by helping them to address the fear, isolation, disruption and practical problems which cancer can bring to our lives. All of our programs, services and resources are offered free of charge and without referral."


Website: http://www.wellspringcalgary.ca/


Sampling of programs offered free of charge:

• Peer Support - One-to-one support with trained volunteers who are cancer survivors or have been caregivers to a person with cancer to assist you through your cancer journey, for as long as you need
• Energy Programs - Reiki, Reflexology, Therapeutic Touch are gentle and soothing approaches to promoting health and well-being.
• Relaxation and Visualization - Also known as "Guided Imagery", uses mindfulness-based imagery and scripts to help reduce stress and achieve a sense of relaxation and calm.
• Expressive Arts - Class options include Chinese Calligraphy, Watercolor Techniques, Contemplative Arts Mixed Media, Journaling and more.
• Yoga - Yoga combines body awareness techniques through gentle stretching and movement with meditative and breathing exercises. It can help reduce stress as well as help you to achieve a sense of calm and well-being.
• Brain Fog - Brain fog, chemo brain and chemo fog are informal terms used to describe the cognitive deficits often associated with cancer and cancer treatment. Brain fog is an educational and experiential program that introduces participants to cognitive enhancement strategies.
• Healthy Steps - Moving you to Better Health with the Lebed Method, is a therapeutic research-based exercise and movement program designed to help you thrive!
• Return to Work Program - An eight-week program that covers: personal readiness to work, managing health, employment standards and legal rights and the management of finances and benefits.

2. Thrive Centre (University of Calgary Faculty of Kinesiology)


What: An innovative fitness facility aiming to empower and improve the quality of life of people affected by cancer. It is free for use for cancer patients, survivors and their support people. The gym is monitored by exercise specialists and volunteers who have specific cancer and exercise training.


Location Link


http://www.kin.ucalgary.ca/healthandwellnesslab/Site/Free_Fitness_Centre.html

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