THIS MONTH’S EDITOR’S CHOICE FROM PALLIATIVE MEDICINE …
Ann Hutchinson and Miriam Johnson from the Hull York Medical School, University of Hull, England, explain the background to their longer article selected as ‘Editor’s choice’ in the May 2019 issue of Palliative Medicine.
Clinicians are rightly concerned that the burden of long-term injectable anticoagulation in people with cancer and thrombosis is significant. We therefore interviewed 37 people with cancer-associated thrombosis about their experiences of taking anticoagulants in the form of injections and/or tablets. The patients interviewed were taking part in the select-d trial (investigating the relative efficacy and safety of rivaroxaban [tablet] and dalteparin [injection]) run by the University of Warwick.
Patients told us that they found tablets convenient but that they found injections were acceptable in the context of having cancer, especially if they were supported to overcome their initial worries about self-injection. Despite drawbacks such as scarring and bruising around the injection site, they said the injections were a small price to pay to treat the life-threatening blood clots.
“You’re just feeling that you’re actually doing something, it’s a step forward. It’s contributing, me stomach’s not good at this moment, but if I keep injecting me leg’s going down, I can see, look, it’s turning back to what it were.”P4
Although patients find taking tablets easier, many would only choose tablets over injections only if they were as safe and effective as the injections.
“If a tablet would serve the same purpose then I would certainly sooner take a tablet, but … if the injections are an advantage then it’s worth putting up with the discomfort. “P11
An additional finding, confirming other reports and a recent European survey of over a thousand people with cancer, was that although cancer patients have a four- to five-fold greater risk of getting blood clots than the general population, most of our study participants did not know that they were at increased risk. Importantly, neither did they know the signs and symptoms for which they should seek medical help; hence they delayed seeking life-saving treatment.
“I’d been in pain with my leg for a good week or so, but you just think it’s part of the cancer.” P2
Based on what patients told us we recommend that:
- Clinicians take both clinical guidelines and patient preference into account when deciding what treatment to offer for blood clots, without undue worry that injections may be too burdensome for patients.
- All patients should be informed soon after their cancer diagnosis of their increased risk of blood clots and the danger signs and symptoms.
If you are working with cancer patients, please let them know the signs and symptoms that should trigger seeking medical help quickly; they should not assume these are due to the cancer or other medical conditions.
READ THE FULL ARTICLE IN PALLIATIVE MEDICINE
This post relates to the longer article, ‘Oral anticoagulation is preferable to injected, but only if it is safe and effective: An interview study of patient and carer experience of oral and injected anticoagulant therapy for cancer-associated thrombosis in the select-d trial’ by Ann Hutchinson, Sophie Rees, Annie Young, Anthony Maraveyas, Kathryn Date and Miriam J Johnson, published in Palliative Medicine 2019 Volume: 33 issue: 5, page(s): 510-517. Article first published online: November 29, 2018. https://journals.sagepub.com/doi/10.1177/0269216318815377 Issue published: 1 May 2019.
- Read earlier Palliative Medicine Editor’s Choice posts on the EAPC blog.
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JOIN US AT #EAPC2019 IN BERLIN: ‘GLOBAL PALLIATIVE CARE – SHAPING THE FUTURE’ 23 TO 25 MAY 2019
Dr Ann Hutchinson and Professor Miriam Johnson will both be attending the congress. Do come along to see their posters on breathlessness (PO2-038) and needs assessment in cancer patients (PO2-366) on Friday, May 24. View the full interactive congress programme here. The final programme is also now online! Register here.