By Kristen F. Bink, MSN, RN, AGCNS-BC, OCN®
Venous thromboembolism (VTE) is a potentially life-threatening event characterized by clots that form in the veins, and it is the second-leading cause of death for patients diagnosed with cancer. VTE affects up to 10% of the cancer population, making it essential for oncology providers to understand the associated risk factors and preventative measures. In addition, prompt recognition and treatment for VTE becomes crucial to patient care.
Knowledge of overall risk factors linked to the development of VTE is paramount: advanced age, obesity, smoking, tobacco use, sedentary lifestyle, major surgery, and hormonal therapies. Other risk factors include use of central venous catheters, abnormal blood cell counts, and hospitalizations. Furthermore, characteristics of cancer itself can be risk factors, such as advanced stage and bulky lymphadenopathy causing vascular compression. Additionally, malignant cells express procoagulant activity that promotes thrombin development.
Prevention and Recognition
Medications used to prevent VTE development are often very effective. However, studies on prophylactic anticoagulation in the oncology population show a lack of use in practice. The American Society of Clinical Oncology (ASCO) and NCCN have developed guidelines for VTE prevention, recognition, and treatment.
Pharmacologic prophylaxis is recommended for most hospitalized patients with cancer. When the risk of bleeding is a concern, mechanical prophylaxis is recommended. ASCO and NCCN also advise against the routine use of anticoagulation in the ambulatory setting, with a specific subgroup exception of patients with multiple myeloma receiving thalidomide, lenalidomide, or pomalidomide and high-dose dexamethasone.
Because of the considerable risk of VTE development, oncology providers should routinely assess risk for VTE. The Khorana Risk Score is an easy to use and validated tool that stratifies laboratory values and cancer type to determine those at highest risk of VTE development during chemotherapy treatment.
Regardless of whether prophylactic measures are used, nurses play a key role in teaching their patients about the risk of developing VTE and the signs and symptoms to report to their providers, such as unilateral swelling, tenderness, erythema, difficulty breathing, chest pain or discomfort, and lightheadedness. When there is clinical concern for a VTE, duplex ultrasonography or a computed tomographic pulmonary angiography are the preferred tests for establishing a prompt diagnosis. Once diagnosed, the goal of treatment is to prevent the development of another VTE, extension, or embolism while minimizing the risk of bleeding. Low molecular weight heparin is recommended for initial treatment of VTE and continued for six months as long term secondary prevention.
Oncology nurses are vital to patient care in prevention and recognition of VTE. Understanding and implementing current evidence based guidelines for VTE prevention is an essential part of oncology patient care.