Two Killer Complications:Thromboembolism and Cancer-Related Pain

Written by Dr. Keith I. Block, MD

With my recent blogs, I hope you are starting to understand why I believe an integrative medical plan can save your life.  Yes, while most cancer patients don’t die from their disease, they unfortunately and unnecessarily can die from the complications associated with the disease and its related treatments.  This posting will focus on methods for preventing two of the most deadly complications:  emboli and pain!

Let’s start with thrombosis, which simply refers to the formation or presence of a blood clot in a blood vessel.  Virtually all patients with active cancer show some degree of increased blood viscosity, or “sticky blood.”  When it comes to illness and particularly cancer, we recognize that blood tends to coagulate more readily than that found among healthy people.  Your blood’s “stickiness” can predispose you to blood-clotting imbalances that are surprisingly common and, if ignored, can escalate into a full-blown clinical or even life-threatening crisis.

One of those clotting crises is a life-threatening condition called venous thromboembolism (VTE) – the blocking of a blood vessel by a blood clot dislodged from its site of origin.  This most commonly manifests as deep vein thrombosis of the leg that can break loose, travel and lead to a pulmonary embolism.  Symptoms can include leg pain, swelling or fluid build-up (edema), reddening of the skin, and warmth in the affected area.  Additionally, one can develop a sudden change in breathing or experience acute chest pain.  This is an emergency and should be treated as such. Unless clot-dissolving or blood-thinning drugs are given quickly, an embolism in the lungs can be fatal.  VTE is among the primary causes of death in cancer patients undergoing surgery, with a three-fold increased risk of dying for surgical patients who develop VTE.

The most common treatment for the home treatment of VTE is to use low-molecular-weight heparin, because this will reduce further risk and generally enable a patient to maintain a higher quality of life.  Some patients will be placed on warfarin (Coumadin), though if the situation demands long term management, there’s a risk of becoming resistant to this drug over time.  All forms of anticoagulant therapy carry a potentially high risk of bleeding, and the length of time your physician decides to keep you on these medications requires balancing the risk of a VTE recurrence with the risk of continuing therapy.  Some experts have proposed using low intensity warfarin over long periods of time in order to prevent recurrences of VTE, but this remains a matter of some debate because of the continued risk of minor bleeding.  Of interest, there is some evidence to suggest that long term use of anti-coagulation therapy provides an additional strategy for combating cancer progression and metastases.

Factors that typically seem to trigger VTE in the context of cancer are:  prolonged hospitalization, major surgery, trauma, catheter overuse, and leg fracture.  In general, the less mobile you are, the more likely you are to develop a VTE.  In the general population, hospitalization for any medical illness increases the risk of VTE by approximately eight-fold, and approximately 25% of all cases of VTE are associated with hospitalization.

Thus, movement and gravity are critically important when it comes to preventing excessive coagulation and clotting disorders like VTE.  If you’ve recently had surgery, you will want to get out of your hospital bed soon or have your legs moving and massaged in order to improve circulation.  A post surgical device, referred to as an SCD or sequential compression device, is used immediately post-operatively in order to reduce the risk of clot formation (These devices, or routine massage, also promote healing and keeps your muscles from atrophying.  This is a common problem among bedridden patients).  When you rest in bed or in a chair, keep your legs elevated to prevent blood from pooling in the lower extremities.  Coughing to get rid of excess mucus and deep breathing exercises can also help reduce the risk of pulmonary embolism.  Other devices exist that mimic the action of blowing up balloons, which can also assist in keeping movement in the lungs reducing both embolic risk and pneumonia.  Finally, based on my 30+ years of clinical experience, following a healthy anti-inflammatory and anti-coagulable diet prior to and following surgery or hospitalization may help lessen the risk of VTE even further.

The “Fifth Vital Sign” - Overcoming Cancer-Related Pain

The problem of cancer-related pain, which is referred to as the “fifth vital sign” for people with cancer, impacts about one-third of all cancer patients, and about two-thirds of all patients with advanced cancer.  Almost half of all patients with lung cancer experience severe pain, which is a major cause of treatment failure.  For each individual, the type and intensity of pain is unique.  How you perceive and rate your own pain is highly subjective, as is the meaning it may have for you.  This is why an individualized assessment and management plan is critical to overcome pain, particularly cancer-related pain.

Your physician should first attempt to determine the source of your pain.  He or she will probably begin by asking you a number of specific questions about the nature of the pain, including where you feel it, the degree of pain, whether it is localized or diffuse, whether it is dull or sharp, when it occurs during the day, and how long it lasts.  Also, are there some bodily movements that appear to make the pain feel worse, while others make it feel better?  After this basic assessment, tests or scans can be done to help determine the physical cause of the pain, and whether surgery may be needed.

There are many different analgesics to choose from, and there are many pharmaceutical alternatives to morphine.  You will need to consult with your doctor to determine the right medication, the proper dose, and the right schedule and route of administration (by mouth, suppository or injection).  If the pain is severe, unrelenting or not improving, you may need an expert in pain management.  If you cannot locate a pain clinic or pain expert, try the anesthesiology department at your local hospital.  I generally lean toward physicians that have also been trained in acupuncture.  It is generally a sign that they are more integrative and comprehensive with their approach to care.  Make sure you are fully informed about any side effects the analgesics may cause—many cause nausea and constipation, both of which can be managed.  Fortunately, contrary to popular belief, these drugs are generally not addictive, as long as they are managed by a treating physician and used properly.

As I suggested, many cases of cancer-related pain can also be controlled – if not completely, than to a great extent – with complementary therapies such as acupuncture and even hypnosis.  Deep relaxation, hypnotic suggestion (including self-hypnosis), and guided imagery appear to have the strongest impact on cancer-related pain management.  These methods can be especially helpful if tolerance or resistance to pain medications develops, as well as provide some relief from the anxiety and distress commonly associated with a cancer diagnosis and the related treatments.  In addition, such strategies can help a patient feel more empowered and in control, and often positively impact their ability to handle pain.  Biofeedback, meditation, massage, specific exercise systems like meridian stretching and anything that promotes belly laughing such as comedians or funny movies are other useful pain-relief strategies, though not as extensively studied as the ones I mentioned above.

If medications and complementary therapies are unable to manage pain, other interventions may be recommended.  These may include a nerve block (injection given into or near the nerve), cutting the nerve, or an epidural injection in order to numb a particular area around the spine.  These are more radical strategies for pain control, and you should only move to these after less invasive strategies have been attempted.  Your medical team will have to determine whether they are appropriate and feasible for you.  But do be sure to include an integrative medical expert as part of your team.  You will be surprised how much these less aggressive approaches can help.

Comments

[Donna]

Very interesting article Dr. Block. Thank you for writing about this.

The thrombosis section made me think of me and my health history. I had a varicose vein removed from my leg several years ago. This last year I was dx'd with bladder cancer. I was told that it was a slow growing variety so it makes me wonder. There may be a correlation between the two? Also, I have noticed that since I started taking flax oil and garlic supplements I have felt so much better. I guess that my blood is "less sticky"? Very interesting

When I took 6 weeks of MMC chemo last summer I was fine until the last two doses. They were very painful. Is there a way to reduce the pain of MMC through supplement or prescription or other?

[David Stewart]

Dr Block,
Re pain management, I have Stage IV NSCLC adenocarcinoma with bone mets. I am 13 months post-diagnosis. Radiation to WB, ribs, spine, pelvis. Gamma Knife for brain met recurrence. In 2nd Course of Carbo/Taxol after 1st line ended in Sept. I have pain well controlled by 15mg Oxycodone 2x day and occasional accupuncture. At that dosage of Oxycodone I do not feel groggy/ dizzy or really any side effects. Should I be concerned this drug is hampering my immune system or otherwise be trying to manage pain without using pain drugs?
Thanks,
D
PS i keep your book at my bedside table and refer to it often. Thanks for all you do to advance cancer tx

[constipation remedies]

Dr. Block. it's a great article.

Thanks for writing and keep update.

[Stephane Ben-Soussan]

nice post dr.block..

[Stephane Ben-Soussan]

I just wanted to write a little bit about a clinical trial that my friend is participating in. He is 45 years old and have been diagnosed with lung cancer. Unfortunately the cancer treatments have not yet cured his disease, but he hopes they will some day soon. In the mean time, he is participating in a clinical trial to help with his pain. The pain from his cancer is pretty severe so he hopes this helps. He just saw his doctor the other day and he told him about the trial. He was told about the medication, the side effects, and the potential benefits. Then he signed the consent form. In this trial he will be taking a medication that is already on the market, but it is in a new form. From what they told him, he will need to keep a diary of how his pain is controlled and how much different doses of the medicine help. He will be allowed to take his normal pain meds if needed, but hopefully he won’t need both things. He is supposed to start the trial sometime next week and I will write again when I have more information.

[Stephane Ben-Soussan]

my brother had 5 surgeries on his left arm for removal of Stage | Melanoma & Squamous Cell Carcinoma. That was 5 years ago, but the deep bruising pain remains. Is this normal or anything must be done?

[A.Goldberg]

your article was very interesting. We shouldn't underestimate the power of Graduated compression stockings. They can really help us to prevent serious diseases such as Deep Vein Thrombosis, Varicose veins, Spider veins on our legs, etc. Actually with few simple steps we could really improve our leg health. Consistency is the key!