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Survivorship by Dr. Jeannine McCune
Hello everyone, I wanted to follow-up on Dr. West’s post about cancer survivorship a few days ago. The term “cancer survivorship” can mean lots of different things to different people. In this post, cancer survivors are those patients who finished their cancer treatment and are now being followed to see if their cancer returns and if they have any long-term side effects to the cancer treatment.
One important thing for all cancer survivors is to have a summary of your cancer treatment. A one page summary about your specific treatments – surgery, radiation, and chemotherapy. There is no established guidelines for what the summary should state for lung cancer survivors. This summary will help you as time goes on and you get further away from your cancer treatment. It will also help other health care professionals taking care of you as it’ll be a quick summary of your treatment. Another important thing is to get the contact person and number for medical records of where you received your cancer treatment. That way, if you need to get your medical records, you’ll already know who to talk to.
In terms of what you can expect, there is very little information about long-term side effects to cancer treatments for lung cancer. Most of the information about cancer survivorship is obtained from adults who survived highly childhood cancer or from breast cancer survivors. Especially as we have more lung cancer cancer survivors, it will be really important that we get more information about their health after the treatment to try to keep healthy. A great example is the “how to quit smoking” post.
This is my first post, so please tell me if you need more information or explanation. I look forward to working with you all!
-Dr. McCune
Heparins and Cancer Survival, Part 2
Continuing on the issue of heparins potentially improving survival of cancer patients, other studies have suggested a survival benefit for low molecular weight heparin (LMWH) in cancer patients. The Malignancy and Low-Molecular-Weight Hepatin Therapy study (MALT, a bit of a stretch) by Klerk and colleagues (abstract here) enrolled 302 patients with an advanced solid tumor (defined as a cancer that could not be treated curatively) to six weeks of a LMWH called nadroparin/Fraxiparine injected under the skin (subcutaneously, or SC) twice daily, or a placebo injection for six weeks. There was a significant survival difference favoring the recipients of the active drug (median survival 8 vs. 6.6 months, hazard ratio (HR) of 0.75 (25% improvement in survival)) that was more impressive in the patients who had a better prognosis (predicted to have a survival of more than 6 months when they were entered onto the trial) (15.4 vs. 9.4 months, HR 0.64, or 36% improvement in survival):
(click to enlarge)
Not surprisingly, however, there was also a trend toward an increased number of major bleeds in patients who received blood thinner treatment compared with those on placebo (3% vs. 1%). Continue reading
Heparins and Cancer Survival, Part 1
In a prior post we touched on some reasons why heparins, blood thinners that are given IV or under the skin (subcutaneously), may have direct anti-tumor effects that could improve cancer outcomes, and another post covered the mixed results with the oral anticoagulant (blood thinner) coumadin in cancer, most notably SCLC. Heparins are divided into unfractionated heparin, which contains a broad range of proteins that can be quite variable in the degree of blood thinning achieved, is most typically administered as a continuous IV infusion (some settings use unfractionated heparin in a subcutaneous (under the skin) injection), and usually requires at least daily monitoring with lab tests, and low molecular weight heparin (LMWH), which is a more filtered product that produces a more reliable amount of blood thinning activity and, depending on the particular formulation, are given once or twice daily as a subcutaneous injection. Although still requiring injections and quite expensive, the work on heparins over the last several years has indicated that LMWH is as or more effective than unfractionated heparin in treating established blood clots and preventing new ones, and LMWH allows for safe outpatient treatment in many settings (although some situations, such as pulmonari emboli, are still most commonly treated conservatively with inpatient management). This typically resolves once heparin is discontinued. Over the past decade, more and more of the use of unfractionated heparin has switched over to LMWH of one brand or another. Aside from bleeding complications, which are always a risk with blood thinners, 10-20% of patients receiving heparin develop heparin-induced thrombocytopenia (HIT), or low blood counts from heparin, which is an immune-mediated condition in which a person who has been on heparin (most commonly unfractionated heparin, but this can occur with LMWH as well) develops antibodies to heparin that cross-react with platelets, leading to a potentially serious decline in the platelet count in patients who remain on heparin. So there can be negative consequences with these agents, so we’ll need to carefully explore the favorable and unfavorable findings with this class of drugs in cancer management. Continue reading
Coumadin/Warfarin and Lung Cancer Survival
Although in the last few years there has been a greater focus on low molecular weight heparins (LMWHs), which are injected, the oral anticoagulant (blood thinner) has been studied in this capacity and is certainly widely used in clinical practice for patients with blood clots due to its oral administration, which is desirable particularly if treatment may be indefinite. This agent interferes with several proteins involved with the body’s normal mechanism for blood clotting, which is good if you need to heal a wound, but it’s a delicate balance that is harmful if people develop clots more often than they’re needed, which is often the case with cancer. We know that cancer patients who develop a blood clot are at a higher risk of a recurrent blood clot than other people who don’t have cancer but have a blood clot.
Although heparin has been more extensively studied in this setting, there is some limited evidence that coumadin may have some direct inhibitory effects on tumor growth and metastatic spread (abstract here). Typically, the results in actual people are more complicated. In 1984, a large trial with 431 patients from the VA system with a wide range of cancer types (lung, head and neck, colon, and prostate cancer) were randomized to receive chemotherapy with either life-long coumadin or a placebo (abstract here). There were no significant differences in overall survival for the general cancer population, but among the 50 patients with SCLC, median survival was doubled (50 vs. 24 weeks, p = 0.03). Here are the survival curves for coumadin vs. placebo with NSCLC and SCLC:
(click to enlarge) Continue reading
Do Anticoagulants (Blood Thinners) Improve Survival in Cancer?
Blood clots are a common problem in cancer, including lung cancer, and several studies have shown that this contributes to diminished survival in cancer patients (abstract here):
(click to enlarge)
Once a blood clot has been detected, most typically a deep vein thrombosis (DVT) that is commonly detected in the leg, or a pulmonary embolus (PE) (clot in the lung), the standard treatment is blood thinners, usually starting with either “unfractionated” heparin, the older form that is given through an ongoing IV and requires frequent checks of the level of blood thinning and adjustment, or “low-molecular weight heparin” (LMWH), which includes just active pieces of the heparin protein, for which there are several brands that are given once or twice daily as a subcutaneous (under the skin) injection and have a more reliable level of blood thinning, so constant monitoring of the level of blood thinning is not required. Patients commonly transition to the oral blood thinner warfarin/coumadin after several days, largely due to the convenience of maintaining a prolonged blood thinning effect with an oral treatment instead of daily injections (and keeping an IV drip of unfractionated heparin going indefinitely, requiring constant checks of the blood, isn’t feasible). LMWH is also very expensive, while coumadin is quite inexpensive.
The American College of Cancer Physicians (ACCP) actually recommends that patients stay on subcutaneous LMWH (an agent known as dalteparin/Fragmin, based on some trial results we’ll review) for 3-6 months for the majority of cancer patients who develop a blood clot (ACCP reference here). While there isn’t an established optimal duration of keeping blood thinners going after a blood clot in a patient, it is generally felt that the underlying cancer continues to put a patient at greater risk for future blood clots, so blood thinners are often recommended to continue as long as a person has active cancer (so if someone has been treated and has no evidence of disease, it’s considered appropriate to discontinue blood thinners (anticoagulation). Continue reading
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