Download June 2010 - Mountainside

Jose Barba, M.D.
Medical Director
VIRGINIA HARKNESS SAWTELLE DEPARTMENT OF
Radiation
Oncology
Newsletter
1 Bay Avenue, Montclair, New Jersey “Dedicated to providing the latest information on new developments in
the research and treatment of cancer.”
973-429-6096 Cancer
and
Thrombosis
by
Cornel Mircea, MD
Attending Physician
Hematology/Oncology
Mountainside Hospital
Cancer is a prothrombotic pathologic state. Cancer and
anticancer therapies are frequently complicated by vascular events
including deep vein thrombosis and pulmonary embolism, both
described as venous thromboembolism (VTE). Arterial events such
as stroke and myocardial infarction were often also observed with
chemotherapy regimens containing antiangiogenic agents.
It has long been recognized that patients with cancer were
at increased risk for thrombosis. In 1865 Armand Trousseau first
described patients with thrombophlebitis as the presenting sign of
visceral malignancy, later known as Trousseau’s syndrome. It is
well known that from pathogenesis standpoint, 1) Stasis through
bed rest and immobility, or vessel compression by mass; 2) Blood
components such as procoagulants produced by tumors and macrophages, and inflammatory cutokines; and 3) Vessel damage by direct tumor invasion, indwelling catheters, chemotherapy, antiangiogenesis agents and erythropoietin, all represent increased risk for
thrombosis (Virchow’s Triad). Among the molecules controlling
hemostasis, Tissue Factor (TF) was indicated as the most likely
candidate to explain cancer procoagulant activity. TF is transmembrane glycoprotein that is essential for hemostasis; it binds the coagulation serine protease factor VII/VIIa to form a bimolecular
complex that functions as a primary initiator of coagulation in vivo.
TF/FVIIa complex activates both FX and FIX and leads to generation of thrombin and fibrin; thrombin also activates platelets by
cleavage protease-activated receptors (PARs). TF is constitutively
expressed at high levels in the adventitial fibroblasts of vessel wall
and this facilitates the rapid activation of coagulation cascade after
injury. TF can also be induced in smooth muscle cells and endothelial cells of the vessel wall under various pathological conditions,
resulting in prothrombotic state. TF is also well represented in tissues like brain, heart, kidney, and placenta.
TF is expressed by all types of cancer. TF:FVIIa-PaR2 signaling
pathway promotes tumor growth and tumor angiogenesis.
Vol. II, No. 19
June 2010
The level of TF varies among different types of cancer and
increases with advanced cancer stage. Tumor cells themselves are
likely to be an important source of the elevated levels of circulating
TF. Treatment of patients with chemotherapy and/or radiation may
promote TF expression and/or release of TF-positive Microparticles
(MPs), resulting in increased levels of circulating TF.
Several studies have shown that tumor cell TF plays an
important role in hematogenous metastasis, probably via activation
of both the coagulation cascade and platelets. TF expression by
tumor cells is under transcriptional control of oncogens and tumor
suppressor genes, such as members of the EGFR family, RAS, p53,
and PTEN.
Clinical risk factors for cancer-associated thrombosis are
shown in Table (1). Cancer of the pancreas, stomach, uterus, kidney, lung, primary brain tumors, and also patients with hematologic
malignancies are associated with the highest rates of VTE. Advanced stage of cancer is also associated with increased risk of
VTE. Chemotherapy is associated with two- to six-fold increased
risk of VTE compared with the general population.
Thalidomide has been associated with high rates of VTE
when given in combination with dexamethasone or chemotherapy;.Lenalidomide is also associated with high rates of VTE, and
Bevacizumab with increased risk for arterial events.
Increased risk for VTE was also noted with erythropoiesisstimulating agents for anemia, RBC transfusions and even with
platelets transfusions.
A validated risk model for chemotherapy-associated VTE
showed that site of cancer (very high risk for stomach and pancreatic CA), prechemotherapy platelet count>350,000, Hbg<10 or use
of ESF, prechemo leukocyte count>11,000, and body mass>35kg/
m2, were predicative for high risk as a score>3.
Cancer patients with VTE have a two-fold or greater increase in mortality compared with cancer patients without VTE,
even after adjusting for stage.
Recommendations for VTE prophylaxis by ASCO and
NCCN panels in all hospitalized patients with cancer are to use
low-dose UFH, LMWH, or Fondaparinux, in the absence of contraindications. For VTE prevention in the surgical cancer patient a)
initial prophylaxis with LMWH or UFH or Fondaparinux and adding pneumatic venous compression in highest risk patients; b) prolonged prophylaxis continue up to 4 weeks for major abdominal or
pelvic surgery for cancer with high risk features (i.e. residual disease, obesity, or prior VTE. Prophylaxis is not recommended in the
ambulatory cancer patient or cancer patients with central venous
catheters.
VIRGINIA HARKNESS SAWTELLE DEPARTMENT OF RADIATION ONCOLOGY NEWSLETTER
The Staff of the Mountainside Hospital Physical Therapy Department
the transition from the TCU to home. At the
The Physical Therapy Department at
end of their stay, the therapists work to make
Mountainside Hospital is comprised of a
sure the patient has their assistive devices
group of dedicated professionals that emphaand other medical equipment necessary to
size a team approach to patient care. The
increase function within the home. The paPhysical Therapy department includes theratient will then be discharged, but their treatpists treating in three distinct settings; Acute
ment does not end at this point.
Care, the Transitional Care Unit (TCU) and in
Once the patient leaves the TCU,
the Outpatient gym.
In the Acute Care setting, the therathey are safe enough to function within their
home, but the patient still needs to address
pists address the early mobility concerns of
other functional needs. The Outpatient PT
the recently hospitalized patient. A Physical
team focuses on full return to function within
Therapist will evaluate patients with a variety
the community and active participation in
of diagnoses, mostly total joint replacements,
lifelong exercise all while working toward
strokes, general debility and amputation.
Regardless of the diagnosis, all patients in the
patient specific goals. Whether the goal is
pain free movement, return to distance walkAcute Care setting have dropped below their
baseline level of function and need to work on Front Row: Sheila Parana PT, Susan Ciuppa PTA, Joseph Patanella PT,
ing, getting back on the golf course or resuming exercise class at their local fitness facilambulation, transfers, balance and bed mobil- Gloria Gallera-Durana PT Second Row: Brian Ownes PT, Paul Pumphrey PT, Joe Biland PT, Debbie Matthews PT, Jana Osias PTT
ity, the outpatient team adapts their plan of
ity in order to be safe within their home and
with the community. A typical stay in this setting is 4 days/3 nights, during care to tailor the needs of the patients’ unique goals. During this stage of
which the Physical Therapists and Physical Therapy Assistants will address their recovery, the patient will be instructed in a combination of stretching,
the needs of the patient so that they can be safely discharged to home. If the strengthening, agility and functional activities, along with specific manual
Acute Care team decides that the patient is not yet ready to be discharged to therapy techniques to optimize biomechanical function. Upon discharge,
home, they will recommend transfer to a sub-acute facility. One such facil- the patient receives a packet of exercises prescribed specifically for their
condition and ability.
ity is the Mountainside Hospital Transitional Care Unit.
At Mountainside Hospital, the Physical Therapy team works toOn the Transitional Care Unit (TCU), patients can stay for up to
eight days. During their stay, the therapists focus on patients mobility needs gether from the day of their admittance to Acute Care unit until their disin their home and short community distances. Bed mobility, transfers, bal- charge from outpatient therapy. By remaining in constant communication
ance are addressed in order to get the patient out of bed so that they may during the patient’s time in the hospital, the team is able to ensure the highwork on more functional tasks, such as ambulation, stair negotiation and est level of care was administered and the highest level of function was
training with assistive devices. While on the TCU, the patient family mem- achieved.
bers are often encouraged to participate in training sessions in order to ease
CLINICAL RISK FACTORS FOR CANCERASSOCIATED THROMBOSIS
Patient demographics
-Older age
-Race (higher in African Americans, lower in AsianPacific Islanders)
Patient comorbidities
-Obesity, infection,
renal disease,
pulmonary disease, arterial
thromboembolism
-Prior history of VTE
-Inherited
prothrombotic
mutations (factor V
Leiden,
prothrombin
gene mutation)
Cancer-related factors
-Primary site of cancer
(gastrointestinal, brain,
lung, gynecologic,
renal, hematologic)
-Initial period after
diagnosis
-Metastatic disease
Treatment-related factors
Page 2
Join us as we celebrate you.
-Major surgery
Cancer Survivor’s Day
-Hospitalization
“Spice of Life”
-Chemotherapy
Sunday
June 6, 2010
-Hormonal therapy
Mountainside
Hospital
-Antiangiogenic therapy (thalidomide, lenalidomide,
Bayberry Café
bevacizumab)
12:30pm to 2:30pm
-Erythropoiesis-s timuTo register, please call 1-888-973-4MSH
lating agents
-Central venous catheters
Unconfirmed risk factors
Congratulations to the First of Winner of the
-Elevated
2010 Care Award
prechemotherapy plateJanice Shareef, transporter in the Environlet count
mental Services Department, won the Care Award in
-Elevated C-reactive
January 2010. Janice is known for going above and
protein
beyond her duties, engaging not only the patients she
-Myeloid growth factors
transports but everyone she encounters. Janice has an ability to reas-Bevacizumab (for
sure, calm, and let her patients’ know that there
venous disease)
are truly cared for.
Janice has been providing excellent and
compassionate care to the Radiation Oncology
patients.
National Cancer Survivors Day (June 6)
Layout by Krystle Hernandez
June 2010