Tackling Cancer Associated Thrombosis: A Multi-Professional Approach

Introduction

Thromboembolism is a leading cause of death in people with cancer; second only to the cancer itself. There is an urgent need to raise the profile of cancer associated thrombosis amongst not only patients but staff treating people with cancer.

Aims

This project aimed to educate cancer patients about their thrombotic risk and to improve both the prevention and treatment of cancer associated thrombosis.

Methods

A review of attitudes and use of thromboprophylaxis was performed in a large, UK-based, teaching hospital; prior to and following the introduction of a new strategy to improve knowledge of cancer associated thrombosis. The study was performed between March and July 2018, with the strategy fully implemented by May 2018. This strategy included a three pronged approach: the introduction of a regular teaching programme for nurses, pharmacists and doctors; the implementation of new guidelines relating to cancer associated thrombosis; and the use of educational videos and posters within patient areas. The knowledge of clots/thrombosis of people with cancer, discussions with staff concerning thrombotic risk and use of tinzaparin thromboprophylaxis at a high risk dose (4500 units) were all investigated. Cancer patients admitted to the hospital were eligible for the study only if they had been admitted for at least 24 hours, this allowed staff the opportunity to discuss the risk of thrombosis with them. A typical one week period was chosen to complete each part of the study, the second week occurred two months after the introduction of the new strategy. A p value of <0.05 was considered significant and was calculated using a Chi-square test.

Results

A total of 91 patients were included in the study (42 prior to the intervention and 49 following). They included a mix of both out-patients (32/42, 74% prior to intervention and 25/49, 51% following) and in-patients (10/42, 26% prior to and 24/49, 49% following). Median age was 65 years (range 21 - 87 years) prior to intervention and 67 years (range 21 - 86 years) following. For those admitted to hospital, the median length of admission was 3 days (range 1-84 days) prior to intervention and 4 days (range 2-33 days) following. Overall there was a slight male preponderance (55% both prior to intervention and following). People with a range of cancer types were interviewed. In the cohort prior to intervention the most common cancer sites were: lung (8/42), bowel (8/42) and skin (7/42). Following the intervention the most common were: breast (6/49), skin (5/49) and lung (4/49). A higher proportion of people questioned before the intervention had known metastases (29/42, 69% prior to and 22/49, 45% following; p<0.05).

Generally people with cancer had a good knowledge of venous thromboembolism and this remained high following the intervention (39/42, 93% to 41/49, 84%; p=0.18). There was a significant increase in the number of people who had discussed thrombotic risk with a healthcare professional during their hospital admission or out-patient treatment (12/42, 24% to 24/49, 51%; p<0.05).

The use of tinzaparin thromboprophylaxis in those eligible to receive it, remained high following the intervention (13/16, 81% to 16/17, 91%, p=0.26) and the appropriate use of a higher risk dose (4500 units) rose significantly (1/13, 8% to 12/16, 75%, p<0.001).

Conclusion

The use of a multi-professional approach to preventing and treating cancer associated thrombosis increased discussion between staff and patients regarding thrombosis and improved accuracy of thromboprophylaxis dosing. Our results strongly support the use of a strategy based on regular training and patient education.