Ep. 25 – Blood Clot Risk in Cancer Care with Dr. Joseph Caprini | A Petite Series

[00:00:00]

[00:00:02] Welcome and Setup

[00:00:02] S4OM/S4OE – Kathleen Lisson: Hi, I’m Kathleen Lisson, and I’m with the Society for Oncology Massage and Aesthetics, S4OM and S4OE. Thanks for joining us for our micro podcast, where we bring you short conversations with clinicians, researchers, and practitioners in oncology and supportive care. I’m talking with Dr. Caprini. He is a vascular surgeon with a special interest in blood clots. Let’s get started. Hello, Dr. Caprini. Welcome to the podcast, and we’re happy to have you here. So we’re gonna talk about what oncology massage therapists should know about blood clots, and then what we can share with our clients who are cancer survivors

[00:00:48] Joe Caprini: Thank you very much. First of all, it’s a great honor to be here and to talk about this subject, and I’ve had a long interest in risk assessment and its importance [00:01:00] in preventing serious and fatal blood clots. And so let’s talk today about recognizing thrombotic risk, definitions, and collaborative clinical coordination, what you all should know as massage therapists.

[00:01:13] Why Cancer Raises Clot Risk

[00:01:13] Joe Caprini: First of all, cancer derives a four to 12 higher VTE rate. VTE means venous thromboembolism, and VTE, what that is blood clots, DVT, that form in the legs, the arms, the abdomen. That’s blood clots or deep vein thrombosis,

[00:01:33] Joe Caprini: and then those clots can migrate to the lungs, causing pulmonary emboli, and collectively refer to… We refer to that as venous thromboembolism. Now, during COVID, there was an exception to pulmonary emboli because not all the clots in the lungs came from somewhere else in the body. Because of the nature of COVID attacking the lungs, there were some clots that formed right in the lungs, so that would be [00:02:00] pulmonary thrombosis.

[00:02:01] Joe Caprini: In any event, one in five VTE events occur in people living with cancer, and VTE is a major contributor to non-cancer mortality in people undergoing cancer care. So not only do you have to worry about the patients a- and their cancers and that causing a problem, but also getting blood clots. And the important thing to remember and why you have to know about this is because oftentimes in cancer patients, there’s a, what we call a disease-free intervals, or even they may have residual cancer, but they’re living a relatively normal life and enjoying life.

[00:02:39] Joe Caprini: So that can get interrupted if they get a blood clot. That can ruin everything, so it’s very important that we guide these people properly.

[00:02:47] High Risk Windows in Treatment

[00:02:47] Joe Caprini: Now, the highest window around developing a blood clot is at the initial staging and the launch of systemic therapy in cancer patients. Now the first to six to 12 [00:03:00] months represent an increased risk.

[00:03:03] Joe Caprini: And the, the risk is sharply elevated across active treatment. And that, that includes surgery, radiation, chemotherapy, all those things add to the risk of a person developing a blood clot in addition to their baseline risk, which is the cancer. And the risk dec- after long term, the risk declines substantially after remission.

[00:03:25] Joe Caprini: Yet, so when a patient’s in remission, so this is their disease-free interval, so to speak, survivors can retain a modestly elevated b- baseline risk for a long time. So it’s important to evaluate that risk. We’ll get to that in, in a little bit.

[00:03:41] Cancer Types and Risk Tiers

[00:03:46] Joe Caprini: So there’s three tiers that, that we use to talk about the risk of of DVT in cancer patients.

[00:03:48] Joe Caprini: The first tier is those at very high risk, and that’s pancreatic and gastric cancers. These two cancers drive the highest rates of tissue factor release, [00:04:00] mucins, and systemic vascular activation. Now tier two is elevated, but not as critical. Brain, lung, ovarian, gynecologic, renal, bladder, lymphoma, myeloma, and acute myelogenous leukemia.

[00:04:17] Joe Caprini: Each carries distinct thrombotic burdens requiring heightened therapist awareness, looking for symptoms. We’ll talk about that and get back to that. That’s important, what you can do to identify some of these things. And then metastatic versus localized. Distant metastatic spread dramatically ex- escalates VTE probability compared to those that have organ-confined disease.

[00:04:41] Therapy and Patient Risk Factors

[00:04:41] Joe Caprini: So if you have residual disease in an organ and it’s being treated, that’s not as high risk as if it has spread Now, systemic therapies, chemotherapy, anti-angiogenic k- agents, kinase inhibitors, immunotherapy, hormonal therapy, and erythropoiesis-stimulating [00:05:00] agents all are factors that compound the risk of a blood clot.

[00:05:06] Joe Caprini: Recent surgical procedures, inpatient hospitalizations, and central venous access devices, ports or PICC line PICC lines induce local endothelial injury and increase the risk of a clot. And a prior history of DVT, a family history of DVT, which is the most frequently forgotten risk factor, older age, obesity, reduced mobility, anemia, renal disease, and inherited thrombophilia defects also amplify the basic risk.

[00:05:39] Joe Caprini: So there’s a lot of things that increase the chance of a blood clot in these patients, and you need to be aware of those because if the patient’s at very high heightened risk, they need to do something about that in terms of prophylaxis. Okay.

[00:05:53] Khorana Score and Referrals

[00:05:56] Joe Caprini: Now they have a CARANA score, which is a score of that’s used for pat- outpatients with cancer, [00:06:00] and a score of two or higher flags elevated risk before chemotherapy begins.

[00:06:05] Joe Caprini: And this is graded by the very high risk is stomach or pancreatic cancer. High risk is lung, lympho- lymphoma, gynecologic or testicular cancer. And what the CARANA score looks at is the pre-therapeutic platelet count, the hemoglobin, the leukocyte count, and body mass index. And a combination of all of those things, you score the patient, and if the patient has a score of two or more, then that’s a sufficient risk to putting them on some kind of prophylaxis.

[00:06:37] Joe Caprini: And of course, that has to be done with the doctors, but it’s, you can always help to identify these these things by referring the patient. So every patient that you see should have an evaluation by their physician for the CARANA score Now, for a massage therapist, the context. drives the safety considerations,

[00:06:59] Massage Therapist Safety Role

[00:06:59] Joe Caprini: So [00:07:00] you should ask about the cancer type, the stage or spread, recent diagnosis, treatment, surgery, hospitalization, and prior VTE. So you can see there’s a lot of patients that are gonna be at high risk for developing a blood clot. And recognize that a risk score or anticoagulation plan belongs to the oncology team, not the massage therapist.

[00:07:23] Joe Caprini: So it’s your duty to advise the patients that they should be consulting with their oncology team about their risks of blood clot. And use the client’s care team and local escalation protocol when new or unexplained concerns arise. Do not diagnose D- VTE in the treatment room So After having said all of that, I think it’s important for us to talk about what can be done specifically in terms of the all of these factors.

[00:07:56] Joe Caprini: And it’s a lot of complicated things, but what we, what the goal for the [00:08:00] therapist is to know enough about the patient to identify that they may be at increased risk, and to ask them to counsel with their doctors that they should examine their individual score for blood clots.

[00:08:13] Caprini Tool and Prevention Options

[00:08:13] Joe Caprini: And I very highly recommend for all of you massage therapists to have in your toolkit the following website: www.caprini, C-A-P-R-I-N-I, riskscore, all one word, .org.

[00:08:30] Joe Caprini: And you can go onto that site. It’s all free. We keep no information on the site. I pay for it privately. There’s no connection or any economic issues here or drug companies or anything like that. But you can go and take the patient-friendly risk assessment, and you should encourage y- your patients that you’re treating with massage therapy to go there and to take their risk assessment, print it out, and take it to their doctor.

[00:08:57] Joe Caprini: And the, the risk assessment will also [00:09:00] have possible recommendations depending upon their level of risk. So I think that’s a really important thing to do in terms of trying to protect these patients from not getting a blood clot. So under certain circumstances, they could be given anticoagulants and, one of the things that’s popular these days are the newer anticoagulants, which are pills.

[00:09:20] Joe Caprini: They don’t necessarily need to have an injection. And based on that taking a pill a day or two, may decrease their chance of getting a blood clot, and often may not interfere with other therapies and so forth. So that’s my message to you, and w- we can also have a further discussion as we go forward.

[00:09:38] S4OM/S4OE – Kathleen Lisson: Wonderful. Thank you so much, Dr. Caprini.

[00:09:41] Family History Matters

[00:09:41] S4OM/S4OE – Kathleen Lisson: I think for, from my experience in knowing you for a couple years now and having that conversation which I have every holiday with my family at Thanksgiving or Christmas about is there a family history of blood clots, I think it’s a very important thing [00:10:00] for my family and then all my clients to al- also have that conversation because often if it’s what they don’t know that they won’t be able to communicate with their doctor, and there may be some things in their family’s medical history and their medical history like history of multiple miscarriages that can actually increase their risk score.

[00:10:23] S4OM/S4OE – Kathleen Lisson: And if they don’t think about it and bring it to their doctor won’t be able to treat them effectively. So that’s why I think the Caprini Risk Score website is so valuable for everyone to know, and also as massage therapists share with our clients.

[00:10:38] Joe Caprini: I- as there’s something very important that I’d like to emphasize here about that family history I would encourage everybody to sit down now And do that, and talk with the family members and get information, network with your family. Because if you have an acute problem, let’s say you need surgery suddenly for a problem,

[00:10:58] Joe Caprini: Nobody’s gonna talk about your [00:11:00] family history. You’ll wanna know what you’re have- what kind of surgery you’re having, how long it’ll take, how much pain are you gonna be in, how long is the rehabilitation? Will I ever be the same? If it’s cancer, will you get the cancer? What are my chances of surviving?

[00:11:13] Joe Caprini: They’re just a few of a million questions you’ll have at the time of a sickness, an illness, an injury, or a surgery, especially when cancer is involved. So that’s why this information is never collected, because there hasn’t been an attempt, and that’s one of my major initiatives going forward and trying to teach younger people, network with your families.

[00:11:35] Joe Caprini: And I will tell you something, that works. We, I was involved with a project with Global Thrombosis Forum, which is a forum that was started by these two individuals that they had their grandson died of a blood clot, and they started a foundation to educate high school students about blood clots.

[00:11:53] Joe Caprini: And we took a group of high school students, and they filled out the Caprini score, and they took it home to their [00:12:00] families, and they networked. And w- the results in 2,000 questionnaires, 25% of them reported a family history of thrombosis. Now, when you go to, out, pick any clinical trial you want, and you take a look how many people in that clinical trial had a family history of thrombosis, one to 2% at most.

[00:12:18] Joe Caprini: It’s not collected, and simply because of what I said before. There’s no time to collect that during the acute episode. If you don’t collect this information now while there’s no emergency, and you’re in a stable state even if you have cancer, it doesn’t make any difference.

[00:12:33] Joe Caprini: If you’re in a stable state, you ought to find out your score, network with your family, and go over it with your doctor to make sure that you have it right. And I think that’s a really key message. I wanna say one more thing.

[00:12:46] A Tragic Case Study

[00:12:46] Joe Caprini: There’s Emily Atkins, who was a young person. She was 23 years old.

[00:12:50] Joe Caprini: She fractured her ankle. They repaired it, a very good surgeon, and she died of a fatal blood clot. What? Young, healthy girl? Simple procedure? [00:13:00] There were three family members with a family history of thrombosis, one who died, and nobody asked a question. She didn’t know enough to ask the question. That’s important.

[00:13:09] Joe Caprini: And the doctors were preoccupied with other things and didn’t know to ask the question. So very important to tell each and every one of your patients, find out your risks and share them with your doctor, because the doctors that are taking care of you, like that orthopedic surgeon, may be too busy with other considerations that they, th- they don’t get around to that.

[00:13:30] Joe Caprini: It’s not their fault totally

[00:13:32] S4OM/S4OE – Kathleen Lisson: Thank you. Yeah, thank you so much.

[00:13:34] Therapists as Patient Educators

[00:13:36] S4OM/S4OE – Kathleen Lisson: I think we have a it’s a blessing for us as oncology massage therapists, I feel that we have the most time together giving people regular massages. We have the most time together with our clients that are in survivorship, so this is an excellent health message to communicate to them.

[00:13:55] Closing and Resources

[00:13:55] S4OM/S4OE – Kathleen Lisson: thank you so much, Dr. Caprini, for taking the time to share your insights with us [00:14:00] today.

[00:14:00] Joe Caprini: Thank you very much again. It was a great honor to be with all of you, and you can always ask me a question through my website

[00:14:07] S4OM/S4OE – Kathleen Lisson: If you’d like to learn more about oncology safe care, you can find us at www.s4om.org or check out the full library of interviews on our YouTube channel at s4om.org. We hope today’s conversation gave you something valuable to take with you. Thanks for listening, and we’ll see you next time

[00:14:31] ​