Cancer Associated Thrombosis Training for Allied Health Professionals
Patient education in and, prevention and management of Cancer Associated Thrombosis (CAT) is an important aspect of supportive management and long-term health of cancer patients and is advised in multiple guidelines (Key et al. 2020, Lyman et al. 2021). However, there is evidence across western health systems that the provision of quality service remains an unmet need (Noble et al. 2015, Noble et al. 2020). Allied Health Professionals (AHPs) such as pharmacists and nurses already play a crucial role in management of multiple aspects of the cancer journey.
There are exemplar CAT services in the NHS provided by teams in which the patient facing individual is an AHP (Palmer et al. 2013, Power 2020) but these services have developed impromptu and are based on the expediency of local resource with no underpinning training.
We have developed educational materials for AHPs and cancer patients which will help fill the current gap in knowledge and provide a competency for the management of CAT.
Background
CAT is the second leading cause of death in patients with cancer, after the tumour itself. The annual death rate for venous thromboembolism (VTE) in the cancer population is 448 per 100,000; a 47-fold increase over the general population (Khorana et al. 2007). VTE also causes significant morbidity in patients with cancer which can lead to hospitalisation and the delay of cancer treatment. Additionally, the standard treatment for VTE, anticoagulation, is associated with an increased risk of bleeding (Raskob et al. 2018, Young et al. 2018).
The prevention and treatment of CAT is an important aspect in the management of the long-term health of patients with cancer. When caring for the ambulant patient healthcare professionals (HCPs) need to be aware of the increased risk of CAT including the use of risk assessment scores and the risk-benefit profile of recommending anticoagulation.
HCPs face multiple challenges in the management of patients with cancer and CAT:
- Risk factors for VTE are often heterogenous from one patient with cancer to the other.
- Clinical requirements and guidelines that provide guidance on the duration and type of treatment when prescribing anticoagulation treatment must be adhered to.
- The novel direct oral anticoagulants (DOACs) have presented complex risk/benefit ratios.
- Background cancer treatment and co-morbidity related factors (e.g. low platelets, periodic liver or kidney insufficiency etc.) add to the complexity.
Need for a CAT Training Programme
Recent advancements in the field of CAT management (e.g. use of DOACs, introduction of clinical guidelines and requirement of formal follow-up of all patients with CAT) are drivers for a dedicated, bespoke CAT service.
For these services to be implemented AHPs need to be able to identify ambulant patients at risk of CAT, risk stratify those that will benefit from anticoagulation treatment and advise type, dose and duration of treatment tailored to the individual patient.
References
- Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, et al. (2020), Journal of clinical oncology: official journal of the American Society of Clinical Oncology, 38: 496 520.
- Khorana AA, Francis CW, Culakova E, Kuderer NM, Lyman GH. (2007), Journal of thrombosis and haemostasis: JTH, 5: 632-4.
- Lyman GH, Carrier M, Ay C, Di Nisio M, Hicks LK, Khorana AA, et al. (2021), Blood advances, 5: 927 74.
- Noble S, Prout H, Nelson A. (2015), Patient preference and adherence, 9: 337 45.
- Noble S, Nelson A, Scott J, Berger A, Schmidt K, Swarnkar P, et al. (2020), Research and Practice in Thrombosis and Haemostasis, 4: 154 60.
- Palmer J, Bozas G, Stephens A, Johnson M, Avery G, O’Toole L, et al. (2013), BMC health services research, 13: 235.
- Power K. (2020), The Pharmaceutical Journal
- Raskob GE, van Es N, Verhamme P, Carrier M, Di Nisio M, Garcia D, et al. (2018), N Engl J Med, 378: 615-24.
- Young AM, Marshall A, Thirlwall J, Chapman O, Lokare A, Hill C, et al. (2018), Journal of clinical oncology: official journal of the American Society of Clinical Oncology: 36: 2017-23.