Predictors of venous thromboembolism recurrence and bleeding among active cancer patients: a population-based cohort study

Abstract

Key Points• VTE recurrence risk in patients with cancer can be stratified by cancer type, stage, stage progression, and presence of leg paresis.• Patients with cancer at high VTE recurrence risk should be considered for secondary prophylaxis.Active cancer is the major predictor of venous thromboembolism (VTE) recurrence, but further stratification of recurrence risk is uncertain. In a population-based cohort study of all Olmsted County, Minnesota, residents with active cancer-related incident VTE during the 35-year period from 1966 to 2000 who survived 1 day or longer, we estimated VTE recurrence, bleeding on anticoagulant therapy, and survival and tested cancer and noncancer characteristics and secondary prophylaxis as predictors of VTE recurrence and bleeding, using Cox proportional hazards modeling. Of 477 patients, 139 developed recurrent VTE over the course of 1533 person-years of follow-up. The adjusted 10-year cumulative VTE recurrence rate was 28.6%. The adjusted 90-day cumulative incidence of major bleeding on anticoagulation was 1.9%. Survival was significantly worse for patients with cancer who had recurrent VTE (particularly pulmonary embolism) and with bleeding on anticoagulation. In a multivariable model, brain, lung, and ovarian cancer; myeloproliferative or myelodysplastic disorders; stage IV pancreatic cancer; other stage IV cancer; cancer stage progression; and leg paresis were associated with an increased hazard, and warfarin therapy was associated with a reduced hazard, of recurrent VTE. Recurrence rates were significantly higher for cancer patients with 1 or more vs no predictors of recurrence, suggesting these predictors may be useful for stratifying recurrence risk. (Blood. 2014;123(25):3972-3978)

Effect of a near-universal hospitalization-based prophylaxis regimen on annual number of venous thromboembolism events in the US

“…1,2,5,[19][20][21] For this study, we restricted our analyses to residents with incident or recurrent leg DVT alone (including isolated anterior and posterior tibial and peroneal [calf] DVT but excluding isolated gastrocnemius or soleal vein thrombosis) or PE with or without DVT (excluding isolated subsegmental PE) over the 6-year period 2005-2010; 98% of events were objectively diagnosed, and the remainder were clinically diagnosed events treated with anticoagulants. Olmsted County residents with a first VTE while a nonresident and a recurrence while a resident were also included (see supplemental Data).…”

“…Recurrent VTE was defined as thrombosis of a venous site that was either previously uninvolved or had interval documentation of thrombus resolution. 5,20,21 For deceased patients, all death certificates and autopsy reports were reviewed regardless of the location at death. The study was approved by the Mayo Clinic and Olmsted Medical Center institutional review boards.…”

“…1,2,5,[19][20][21] Data were collected on dates and types of incident and recurrent VTE events, baseline characteristics (see supplemental Data), dates of heparin and warfarin initiation and completion and inferior vena cava filter placement, VTE risk factors, and vital status at last clinical contact, as described in detail elsewhere. 5,19,[21][22][23] Using data from the REP Cost Data Warehouse (see supplemental Data), hospital admission and discharge dates were compiled for all Olmsted County residents (2005)(2006)(2007)(2008)(2009)(2010), including ICD-9-CM discharge diagnosis codes. Individual level in-hospital VTE prophylaxis data were only available for Olmsted County residents admitted to a Mayo Clinic hospital and were captured from their Mayo electronic medical record, including pharmacy lists of medications dispensed in hospital (2005)(2006)(2007) and hospital order entry data (2008)(2009)(2010).…”

Clinical Challenges in Patients with Cancer-Associated Thrombosis: Canadian Expert Consensus Recommendations

“…Based on expert discussions and widespread clinical practice, anticoagulation treatment after a 6-month treatment period is usually guided by a thorough assessment of the factors contributing directly to the risk of recurrent cancer-associated thrombosis (including the risk of cancer recurrence). Risk stratification based on the tumour type or biology; stage of disease; and patient comorbidities (hospitalization or immobilization, surgery, chemotherapy or radiation therapy, central venous catheter insertion, or localized tumour compression) is important 10 .…”

Managing thrombosis in cancer patients

“…Other studies have identified additional risk factors for recurrent VTE. For example, in the Olmstead County population based cohort study, cancer type, stage, stage progression, and leg paresis were significant risk factors,21 while elevated tissue factor, venous compression, and hepatobiliary cancer were identified as risk factors in the CATCH study 22. More studies are needed to delineate the most useful risk assessment tool to help clinicians to identify patients with high risk of recurrent VTE.…”