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Putting Evidence Into Practice: Prevention and Management of Bleeding in Patients With Cancer

Barbara Holmes Damron
Jeannine M. Brant
Heather Blair Belansky
Patricia J. Friend
Susan Samsonow
Anna Schaal
CJON 2009, 13(5), 573-583 DOI: 10.1188/09.CJON.573-583

The primary cause of bleeding in patients with cancer is thrombocytopenia and it commonly is attributed to myelosuppressive chemotherapy, radiation therapy, or bone marrow infiltration of the malignancy. Oncology nurses have a critical role to play in the prevention and management of bleeding in patients with cancer. As part of an Oncology Nursing Society Putting Evidence Into Practice (PEP) project team, the authors of this article reviewed the current literature to identify effective interventions in the prevention and management of bleeding in patients with cancer. The authors evaluated research studies conducted since 1991, current clinical practice guidelines, and systematic reviews. The literature was reviewed, synthesized, and developed into evidence tables that were ultimately published in a PEP card. All data were reviewed by experts in the field of thrombocytopenia. The Prevention of Bleeding PEP card was unveiled at the 8th Annual Institutes of Learning in November 2007.


Amar, D., Grant, F.M., Zhang, H., Boland, P.J., Leung, D.H., & Healey, J.A. (2003). Antifibrinolytic therapy and perioperative blood loss in cancer patients undergoing major orthopedic surgery. <i>Anesthesiology</i>, 98(2), 337-342.

American Heart Association & American National Red Cross. (2005). Guidelines for first aid. <i>Circulation</i>, 112(24, Suppl.), IV-196-IV-203.

Amsterdam, A., Jakubowski, A., Castro-Malaspina, H., Baxi, E., Kauff, N., Krychman, M., et al. (2004). Treatment of menorrhagia in women undergoing hematopoietic stem cell transplantation. <i>Bone Marrow Transplantation</i>, 34(4), 363-366.

Avvisata, G., Tririndelli, M.C., & Kakanaporn, C. (2003). Thrombocytopenia and hemorrhagic risk in cancer patients. <i>Critical Reviews in Oncology/Hematology</i>, 15(48, Suppl.), S13-S16.

Brenner, B., Hoffman, R., Balashov, D., Shutluko, E., Culic, S.D., & Nizamoutdinova, E. (2005). Control of bleeding caused by thrombocytopenia associated with hematologic malignancy: An audit of the clinical use of recombinant activated factor VII. <i>Clinical and Applied Thrombosis/Hemostasis</i>, 11(4), 401-410.

Cairo, M.S., Davenport, V., Bessmertny, O., Goldman, S.C., Berg, S.L., Kreissman, S.G., et al. (2005). Phase I/II dose escalation study of recombinant human interleukin-11 following ifosfamide, carboplatin and etoposide in children, adolescents and young adults with solid tumours or lymphoma: A clinical, haematological and biological study. <i>British Journal of Haematology</i>, 128(1), 49-58.

Callow, C.R., Swindell, R., Randall, W., & Chopra, R. (2002). The frequency of bleeding complications in patients with haematological malignancy following the introduction of a stringent prophylactic platelet transfusion policy. <i>British Journal of Haematology</i>, 118(2), 677-682.

Castaman, G., Bona, E.D., Schiavotto, C., Trentin, L., D'Emilio, A., & Rodeghiero, F. (1997). Pilot study on the safety and efficacy of desmopressin for the treatment or prevention of bleeding in patients with hematologic malignancies. <i>Haematologica</i>, 82(5), 584-587.

Chiusolo, P., Salutari, P., Sica, S., Scirpa, P., Laurenti, L., Piccirillo, N., et al. (1998). Luteinizing hormone-releasing hormone analogue: Leuprorelin acetate for the prevention of menstrual bleeding in premenopausal women undergoing stem cell transplantation. <i>Bone Marrow Transplantation</i>, 21(8), 821-823.

Dean, A., & Tuffin, P. (1997). Fibrinolytic inhibitors for cancer-associated bleeding problems. <i>Journal of Pain and Symptom Management</i>, 13(1), 20-24.

Desuter, G., Hammer, F., Gardiner, Q., Gregoire, V., Machiels, J.P., Hamoir, M., et al. (2005). Carotid stenting for impending carotid blowout: Suitable supportive care for head and neck cancer patients? <i>Palliative Medicine</i>, 19(5), 427-429.

Dorticus, E., Pavon, V., Jaime, J.C., Reboredo, M., Lopez Saura, P., Berlanga, J., et al. (2003). Successful application of epidermal growth factor for treatment of hemorrhagic cystitis after bone marrow transplantation. <i>Bone Marrow Transplant</i>, 31(7), 615-616.

Gabay, M. (2006). Absorbable hemostatic agents. <i>American Journal of Health System Pharmacy</i>, 63(13), 1244-1253.

Hadorn, D.C., Baker, D., Hodges, J.S., & Hicks, N. (1996). Rating the quality evidence for clinical practice guidelines. <i>Journal of Clinical Epidemiology</i>, 49(7), 749-753.

Heddle, N.M., Cook, R.J., Sigouin, C., Slichter, S.J., Murphy, M., & Rebulla, P. (2006). A descriptive analysis of international transfusion practice and bleeding outcomes in patients with acute leukemia. <i>Transfusion</i>, 46(6), 903-911.

Hensley, M.L., Schuchter, L.M., Lindley, C., Meropol, N.J., Cohen, G.I., Broder, G., et al. (1999). American Society of Clinical Oncology clinical practice guidelines for the use of chemotherapy and radiotherapy protectants. <i>Journal of Clinical Oncology</i>, 17(10), 3333-3355.

Hicks, K., Peng, D., & Gajewski, J.L. (2002). Treatment of diffuse alveolar hemorrhage after allogeneic bone marrow transplant with recombinant factor VIIa. <i>Bone Marrow Transplant</i>, 30(12), 975-978.

Iraha, Y., Murayama, S., Toita, T., Utsunomiya, T., Nagata, O., Akamine, T., et al. (2006). Self-expandable metallic stent placement for patients with inoperable esophageal carcinoma: Investigation of the influence of prior radiotherapy and chemotherapy. <i>Radiation Medicine</i>, 24(4), 247-252.

Isaacs, C., Robert, N.J., Bailey, F.A., Schuster, M.W., Overmoyer, B., Graham, M., et al. (1997). Randomized placebo-controlled study of recombinant human interleukin-11 to prevent chemotherapy-induced thrombocytopenia in patients with breast cancer receiving dose-intensive cyclophosphamide and doxorubicin. <i>Journal of Clinical Oncology</i>, 15(11), 3368-3377.

Johnsson, E., Lundell, L., & Liedman, B. (2005). Sealing of esophageal perforation or ruptures with expandable metallic stents: A prospective controlled study on treatment efficacy and limitations. <i>Diseases of the Esophagus</i>, 18(4), 262-266.

Kakizawa, H., Toyota, N., Naito, A., & Ito, K. (2005). Endovascular therapy for management of oral hemorrhage in malignant head and neck tumors. <i>Cardiovascular and Interventional Radiology</i>, 28(6), 722-729.

Kalmadi, S., Tiu, R., Lowe, C., Jin, T., & Kalaycio, M. (2006). Epsilon aminocaproic acid reduces transfusion requirements in patients with thrombocytopenic hemorrhage. <i>Cancer</i>, 107(1), 136-140.

Khojasteh, N.H., Zakerinia, M., Ramzi, M., & Haghshenas, M. (2000). A new regimen of MESNA (2-mercaptoethanesulfonate) effectively prevents cyclophosphamide-induced hemorrhagic cystitis in bone marrow transplant recipients. <i>Transplantations Proceedings</i>, 32(3), 596.

Kurzrock, R., Cortes, J., Thomas, D.A., Jeha, S., Pilat, S., & Talpaz, M. (2001). Pilot study of low-dose interleukin-11 in patients with bone marrow failure. <i>Journal of Clinical Oncology</i>, 19(21), 4165-4172.

Lodge, J.P., Jonas, S., Oussoultzoglou, E., Malago, M., Jayr, C., Cherqui, D., et al. (2005). Recombinant coagulation factor VIIa in major liver resection: A randomized, placebo-controlled, double-blind clinical trial. <i>Anesthesiology</i>, 102(2), 269-275.

Lumachi, F., Brandes, A.A., Burelli, P., Basso, S.M., Iacobone, M., & Ermani, M. (2004). Seroma prevention following axillary dissection in patients with breast cancer by using ultrasound scissors: A prospective clinical study. <i>European Journal of Surgical Oncology</i>, 30(5), 526-530.

Meirow, D., Rabinovici, J., Katz, D., Or, R., Shufaro, Y., & Ben-Yehuda, D. (2006). Prevention of severe menorrhagia in oncology patients with treatment-induced thrombocytopenia by luteinizing hormone-releasing hormone agonist and depo-medroxyprogesterone acetate. <i>Cancer</i>, 107(7), 1634-1641.

Norfolk, D.R., Ancliffe, P.J., Contreras, M., Hunt, B.J., Machin, S.J., Murphy, W.G., et al. (1998). Consensus Conference on Platelet Transfusion, Royal College of Physicians of Edinburgh, 27-28 November 1997. Synopsis of background papers. <i>British Journal of Haematology</i>, 101(4), 609-617.

Pereira, J., & Phan, T. (2004). Management of bleeding in patients with advanced cancer. <i>Oncologist</i>, 9(5), 561-570.

Ropka, M.E., & Spencer-Cisek, P. (2001). PRISM: Priority Symptom Management project phase I: Assessment. <i>Oncology Nursing Forum</i>, 28(10), 1585-1594.

Schiffer, C.A., Anderson, K.C., Bennett, C.L., Bernstein, S., Elting, L.S., Goldsmith, M., et al. (2001). Platelet transfusion for patients with cancer: Clinical practice guidelines of the American Society of Clinical Oncology. <i>Journal of Clinical Oncology</i>, 19(5), 1519-1538.

Schuchter, L.M., Hensley, M.L., Meropol, N.J., & Winer, E.P. (2002). 2002 update of recommendations for the use of chemotherapy and radiotherapy protectants: Clinical practice guidelines of the American Society of Clinical Oncology. <i>Journal of Clinical Oncology</i>, 20(12), 2895-2903.

Seaman, S. (2006). Management of malignant fungating wounds in advanced cancer. <i>Seminars in Oncology Nursing</i>, 22(3), 185-193.

Sesterhenn, A.M., Iwinska-Zelder, J., Dalchow, C.V., Bien, S., & Werner, J.A. (2006). Acute haemorrhage in patients with advanced head and neck cancer: Value of endovascular therapy as palliative treatment option. <i>Journal of Laryngology and Otology</i>, 120(2), 117-124.

Shpilberg, O., Blumenthal, R., Sofer, O., Katz, Y., Chetrit, A., Ramot, B., et al. (1995). A controlled trial of tranexamic acid therapy for the reduction of bleeding during treatment of acute myeloid leukemia. <i>Leukemia and Lymphoma</i>, 19(1-2), 141-144.

Siersema, P.D. (2005). Treatment of esophageal perforations and anastomotic leaks: The endoscopist is stepping into the arena. <i>Gastrointestinal Endoscopy</i>, 61(7), 897-900.

Siersema, P.D. (2006). Therapeutic esophageal interventions for dysphagia and bleeding. <i>Current Opinion in Gastroenterology</i>, 22(4), 442-447.

Slichter, S. (2004). Relationship between platelet count and bleeding risk in thrombocytopenic patients. <i>Transfusion Medicine Reviews</i>, 18(3), 153-167.

Srisupundit, S., Kraiphibul, P., Sangruchi, S., Linasmita, V., Chingskol, K., & Veerasarn, V. (1999). The efficacy of chemically-stabilized chlorite-matrix (TCDO) in the management of late postradiation cystitis. <i>Journal of the Medical Association of Thailand</i>, 82(8), 798-802.

Stanworth, S.J., Hyde, C., Heddle, N., Rebulla, P., Brunskill, S., & Murphy, M.F. (2004). Prophylactic platelet transfusion for haemorrhage after chemotherapy and stem cell transplantation. <i>Cochrane Database of Systematic Reviews</i>, 4, CD004269.

Tepler, I., Elias, L., Smith, J.W., II, Hussein, M., Rosen, G., Chang, A.Y., et al. (1996). A randomized placebo-controlled trial of recombinant human interleukin-11 in cancer patients with severe thrombocytopenia due to chemotherapy. <i>Blood</i>, 87(9), 3607-3614.

Tsimberidou, A.M., Giles, F.J., Khouri, I., Bueso-Ramos, C., Pilat, S., Thomas, D.A., et al. (2005). Low-dose interleukin-11 in patients with bone marrow failure: Update of the M.D. Anderson Cancer Center experience. <i>Annals of Oncology</i>, 16(1), 139-145.

Tsuboi, K., Kishi, K., Ohmachi, K., Yasuda, Y., Shimizu, T., Inoue, H., et al. (2003). Multivariate analysis of risk factors for hemorrhagic cystitis after hematopoietic stem cell transplantation. <i>Bone Marrow Transplantation</i>, 32(9), 903-907.

Veerasarn, V., Boonnuch, W., & Kakanaporn, C. (2006). A phase II study to evaluate WF 10 in patients with late hemorrhagic radiation cystitis and proctitis. <i>Gynecological Oncology</i>, 100(1), 179-184.

Veerasarn, V., Khorprasert, C., Lorvidhaya, V., Sangruchi, S., Tantivatana, T., Narkwong, L., et al. (2004). Reduced recurrence of late hemorrhagic radiation cystitis by WF 10 therapy in cervical cancer patients: A multicenter, randomized, two-arm, open-label trial. <i>Radiotherapy and Oncology</i>, 73(2), 179-185.

Wanko, S.O., Broadwater, G., Folz, R.J., & Chao, N.J. (2006). Diffuse alveolar hemorrhage: Retrospective review of clinical outcome in allogeneic transplant recipients treated with aminocaproic acid. <i>Biology of Blood and Marrow Transplantation</i>, 12(9), 949-953.

Wenger, U., Johnsson, E., Bergquist, H., Nyman, J., Ejnell, H., Lagergren, J., et al. (2005). Health economic evaluation of stent or endoluminal brachytherapy as a palliative strategy in patients with incurable cancer of the oesophagus or gastro-oesophageal junction: Results of a randomized clinical trial. <i>European Journal of Gastroenterology and Hepatology</i>, 17(12), 1369-1377.