Analysis of clinical factors affecting the rates of fatal pulmonary embolism and bleeding in cancer patients with venous thromboembolism

Abstract

BackgroundIn cancer patients with symptomatic venous thromboembolism (VTE) (deep-vein thrombosis (DVT) and/or pulmonary embolism (PE)), clinical factors that influence the benefit-risk balance of anticoagulation need to be identified so treatment intensity and duration can be optimally adjusted for the individual patient.MethodsUsing clinical data for cancer patients with VTE obtained from the RIETE registry, we compared how rates of fatal PE and fatal bleeding during and after anticoagulation vary depending on patients‘ clinical characteristics.ResultsData were analysed from the 10,962 cancer patients with VTE (5,740 with PE with or without DVT; 5,222 with DVT alone) in RIETE registry as of March 2016. Fatal PE occurred in 2.18% of patients, while fatal bleedings occurred in 1.55%. During the 12 months from initial VTE, fatal PE was the most common cause of death, after disseminating cancer, and bleeding the fourth most common. In patients initially presenting with PE, fatal PE during anticoagulation was 4-fold more frequent than fatal bleeding (204 vs 51 deaths) and occurred mostly during the first month of treatment (196/223, 88%). In patients initially presenting with DVT, fatal PE was 3-fold lower than fatal bleeding during (25 vs 85 deaths) and after anticoagulation treatment (8 vs 37 deaths). During the 12-month follow-up, other characteristics of cancer patients with VTE were identified as more common in fatal cases of PE and/or bleeding than in surviving cases.InterpretationBaseline clinical characteristics may determine anticoagulation outcomes in cancer patients with VTE and should be further investigated as possible factors for guiding changes in current practices of anticoagulation, such as adjusting anticoagulation intensity and duration in selected patients.

Management of venous thromboembolism in patients with cancer

“…The lower risk of dying from PE in patients initially presenting with DVT can be attributed to the fact that DVT patients most likely recurred as DVT. The daily doses of LMWH therapy did not appear to account for differences in outcomes between patients presenting with DVT alone or with PE, and the rate of fatal bleeding was similar over time . Thus, our data suggest that a key factor in determining the intensity and duration of anticoagulant therapy should be the initial presentation of VTE.…”

“…Fatal PE occurred early after the initial event and mostly during the first month of anticoagulant therapy, before reaching close to maximum at 3 months, after which very few cases occurred . In contrast, cases of fatal bleeding occurred throughout the 12 months, with just less than half of cases within the first month of treatment.…”

“…For patients initially presenting with PE, subsequent PE was the most prominent cause of death and three times more common than bleeding, whereas in patients with DVT alone at baseline, bleeding was as common as infection as a cause of death and over three times more common than PE . The lower risk of dying from PE in patients initially presenting with DVT can be attributed to the fact that DVT patients most likely recurred as DVT.…”

“…These frequencies were much higher than in VTE patients without cancer (1.4% and 0.3%, respectively). Some years later we assessed the time‐course and clinical characteristics of cancer patients with VTE who died of PE or bleeding . There were 10 962 patients (5740 with PE, 5222 with DVT alone), and during the 12‐month follow‐up, 239 (2.17%) died of PE and 170 (1.55%) had fatal bleeding.…”

Atrial Fibrillation and Malignancy: The Clinical Performance of Non–Vitamin K Oral Anticoagulants—A Systematic Review

“…20 On the other hand, cancer patients show an increased risk of major bleeding during anticoagulant treatment as shown in the Computerized Registry of Patients with Venous Thromboembolism (RIETE) registry. 21 Moreover, some malignancies, such as primary or metastatic intracranial tumors and hematological malignancies, pose on their own an increased risk of hemorrhage and may therefore constitute contraindications to anticoagulant therapy or may require a thorough clinical surveillance, even in patients at high thromboembolic risk. 21 NOACs significantly reduce mortality and intracranial hemorrhage; 22 so, the current guidelines recommend preference for NOACs to VKAs, when oral anticoagulation is initiated in patients with AF who are eligible for NOAC therapy.…”