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Recurrent Venous Thromboembolism in Cancer

May 6, 2014

Recurrent Venous Thromboembolism in Cancer

  1. David Green, MD, PhD

VTE recurred significantly more often in patients with active cancer than in those without cancer.

  1. David Green, MD, PhD

Patients with malignancies are at increased risk for venous thromboembolism (VTE), and when VTE does occur, cancer patients are more likely to have recurrences. However, giving anticoagulant prophylaxis to avoid new thrombotic events could be complicated by major hemorrhage. To estimate the risks for VTE recurrence and anticoagulant-associated bleeding, investigators studied 2316 patients without active cancer and 477 patients with active cancer residing in Olmsted County, Minnesota.

VTE recurred more often in patients with cancer than in those without cancer (cumulative recurrence rate at 1 year, 26.7% vs. 10.0%; P<0.001). Mortality was significantly worse among cancer patients with pulmonary emboli compared with those with deep vein thrombosis (90-day cumulative mortality, 67.2% vs. 30.7%, P≤0.001).

Multivariate analyses showed that significant predictors for VTE recurrence (hazard ratios) were stage IV pancreatic cancer (6.38), brain cancer (4.57), myeloproliferative or myelodysplastic disorders (3.49), and ovarian cancer (3.22). Additional disorders predicting recurrences were other stage IV cancers (2.85), lung cancer (2.73), neurological disease with leg paresis (2.38), and cancer stage progression (2.14). Among patients with active cancers, those with ≥1 predictor had a significantly increased risk for recurrent VTE compared with those without predictors (HR, 3.02; P<0.001). Recurrent VTE increased the risk for death almost threefold (HR, 2.7).

The 1-year cumulative risk for major bleeding for patients taking anticoagulants was 4.0%; half of these bleeds occurred within the first 7 days of treatment. The risk for bleeding was increased with heparin (HR, 3.6) but not warfarin. Bleeding increased the risk for death more than twofold (HR, 2.3).

Comment

This study is unique in that it assessed recurrent venous thromboembolism and death in a large population with diverse malignancies. Because patients with advanced stage cancers and myeloproliferative or myelodysplastic disorders are at the highest risk for thrombotic events, they should be enrolled in clinical trials to examine the safety and efficacy of prolonged anticoagulant prophylaxis. However, launching such trials should be delayed until antithrombotics that are readily reversible become available.

  • Disclosures for David Green, MD, PhD at time of publication Consultant / Advisory board Altor Bioscience Grant / Research support NIH

Citation(s):

Reader Comments (1)

Raul Altman Physician, Hematology, Buenos Aires, Argentina

Mainly in patients with malignant disease which developed DVT dose adjustment based on therapeutic effect may be more appropriate than fixed dose therapy when the new oral anticoagulant (NOACs) are indicated. Clinical trials are needed to find the cut-off for safety/ thrombosis prevention/s (increased risk of hemorrhage or exhibiting low anticoagulation effect). We found that the ratio of normal plasma/patient plasma clotting time using Russell’s viper venom, and in the presence of phospholipids and calcium reagent (R-C) results were reasonably sensitive for rivaroxaban and likely also sensitive
for other FX inhibitors (Altman and Gonzalez Thrombosis Journal 2014, 12:7)

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