These episodes may range from low-grade oozing to major episodic bleeding or even catastrophic bleeds. Bleeding can be caused by the cancer itself, as with local tumor invasion, abnormal tumor vasculature, or tumor regression. It may also be related to the anti-tumor treatments including prior radiation therapy or chemotherapy. It can be exacerbated by immunotherapies such as bevacizumab, nonsteroidal anti-inflammatories drugs NSAIDs , and anticoagulants that are routinely used in cancer patients.
Patients may also be predisposed to bleeding due to thrombocytopenia from the malignancy or induced by chemotherapy. There is limited literature studying palliative treatments for hemostasis in the context of advanced cancer, and no randomized therapeutic trials. Randomized trials are difficult in this setting, given the complex patient population, the variety of sites affected by bleeding, and the variety of treatment modalities involving multiple medical specialties. Most studies examine a single modality, and there are no consistent definitions of bleeding or treatment response.
Existing literature is also inconsistent in outcome measures, time points, and method assessment. Much of the literature is retrospective, so there is inherent difficulty in standardizing endpoint definition and evaluation. Goals of care should be discussed as an integral part of considering therapies in patients at high risk of bleeding or suffering from its effects. Patients may find bleeding visible and disturbing, or it may have significant effects on their quality of life.
The rapidity of control of bleeding should be considered, but so too should the comfort of the patient during the treatment process. For example, radiation therapy can usually control bleeding within 24β48 hours, but patients have to be comfortable lying on the treatment table for the planning and treatment process.
For patients who suffer a major episode of bleeding but are not at the end of life, establishment of intravenous access, stabilization with fluids, and hemodynamic monitoring may allow investigation into the cause of bleeding. Analysis should include a complete blood count, coagulation profile, and a complete metabolic panel with assessment of liver enzymes and function. Possible contributing factors including comorbidities, medications, and recent therapeutic interventions should be examined.
