Predicting recurrences or major bleeding in cancer patients with venous thromboembolism

Summary

Cancer patients with acute venous thromboembolism (VTE) have an increased incidence of recurrences and bleeding complications while on anticoagulant therapy. Methods RIETE is an ongoing registry of consecutive patients with acute VTE. We tried to identify which cancer patients are at a higher risk for recurrent pulmonary embolism (PE), deep vein thrombosis (DVT) or major bleeding. Up to May 2007, 3, 805 cancer patients had been enrolled in RIETE. During the first three months of follow-up after the acute, index VTE event, 90 (2.4%) patients developed recurrent PE, 100 (2.6%) recurrent DVT, 156 (4.1%) had major bleeding. Forty patients (44%) died of the recurrent PE,46 (29%) of bleeding. On multivariate analysis, patients aged <65 years (odds ratio [OR]: 3.0; 95% confidence interval [CI]: 1.9–4.9), with PE at entry (OR: 1.9; 95% CI: 1.2–3.1), or with <3 months from cancer diagnosis to VTE (OR: 2.0; 95% CI: 1.2–3.2) had an increased incidence of recurrent PE. Those aged <65 years (OR: 1.6; 95% CI: 1.0–2.4) or with <3 months from cancer diagnosis (OR: 2.4; 95% CI: 1.5–3.6) had an increased incidence of recurrent DVT. Finally, patients with immobility (OR: 1.8; 95% CI: 1.2–2.7), metastases (OR: 1.6; 95% CI: 1.1–2.3), recent bleeding (OR: 2.4; 95% CI: 1.1–5.1), or with creatinine clearance <30 ml/ min (OR: 2.2; 95% CI: 1.5–3.4), had an increased incidence of major bleeding. With some variables available at entry we may identify those cancer patients withVTE at a higher risk for recurrences or major bleeding.

Keywords

Cancer - venous thromboembolism - bleeding - recurrences

• References

• 1 Hutten BA, Prins MH, Gent M. et al. Incidence of recurrent thromboembolic and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio:A retrospective analysis. J Clin Oncol 2000; 18: 3078-3083.
• 2 Prandoni P, Lensing AW, Piccioli A. et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002; 100: 3484-3488.
• 3 Kearon C. Long-term management of patients after venous thromboembolism. Circulation. 2004; 110 (Suppl. 01) I-10-I-18
• 4 Kuijer PM, Hutten BA, Prins MH. et al. Prediction of the risk of bleeding during anticoagulant treatment for venous thromboembolism. Arch Intern Med 1999; 159: 457-460.
• 5 Monreal M, Falgá C, Valdés M. et al. for the RIETE Investigators. Fatal pulmonary embolism and fatal bleeding in cancer patients with venous thromboembolism: Findings from the RIETE Registry. J Thromb Haemost 2006; 04: 1950-1956.
• 6 Arcelus JI, Monreal M, Caprini JA. et al. and the RIETE investigators. Clinical presentation and timecourse of postoperative venous thromboembolism: Results from the RIETE Registry. Thromb Haemost 2008; 99: 546-551.
• 7 Blanco-Molina A, Trujillo-Santos J, Criado J. et al. and the RIETE Investigators. Venous Thrombo-embolism during pregnancy or postpartum:Findings from the RIETE Registry. Thromb Haemost 2007; 97: 186-190.
• 8 Trujillo-Santos J, Herrera S, Page MA. et al. for the RIETE Investigators. Predicting adverse outcome in outpatients with acute deep vein thrombosis. Findings from the RIETE Registry. J Vasc Surg 2006; 44: 789-793.
• 9 Nieto JA, Bruscas MJ, Ruiz-Ribo D. et al. for the RIETE Investigators. Acute venous thromboembolism in patients with recent major bleeding. The influence of the site of bleeding and the time elapsed on outcome. J Thromb Haemost 2006; 04: 2367-2372.
• 10 Cockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron 1976; 16: 31-41.
• 11 López-Jiménez L, Montero M, González-Fajardo JA. et al. for the RIETE investigators. Venous Thromboembolism in Very Elderly Patients: Findings from a Prospective Registry (RIETE). Haematologica 2006; 91: 1046-1051.
• 12 Falgà C, Capdevila JA, Soler S. et al. for the RIETE Investigators. Clinical Outcome of Patients with Venous Thromboembolism and Renal Insufficiency. Findings from the RIETE Registry. Thromb Haemost 2007; 98: 771-776.
• 13 Landefeld CS, Goldman L. Major bleeding in outpatients treated with warfarin: incidence and prediction by factors known at the start of outpatient therapy. Am J Med 1989; 87: 144-152.
• 14 Landefeld CS, Beyth RJ. Anticoagulant-related bleeding: Clinical epidemiology, prediction, and prevention. Am J Med 1993; 95: 315-328.
• 15 White RH, Beyth RJ, Zhou H, Romano PS. Major bleeding after hospitalization for deepvenous thrombosis. Am J Med 1999; 107: 414-424.
• 16 Heit JA, Mohr DN, Silverstein MD. et al. Predictors of survival after deep vein thrombosis and pulmonary embolism: a population-based, cohort study. Arch Intern Med 1999; 159: 445-453.
• 17 Ruiz-Giménez N, Suárez C, González R. et al. and the RIETE Investigators. Predictive variables for major bleeding in patients presenting with documented acute venous thromboembolism. Findings from the RIETE Registry. Thromb Haemost 2008; 100: 26-31.
• 18 Meyer G, Marjanovic Z, Valcke J. et al. Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer. Arch Intern Med 2002; 162: 1729-1735.
• 19 Lee AYY, Levine MN, Baker RI. et al. Low-molecular-weigh heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 34: 146-153.
• 20 Deitcher SR, Kessler CM, Merli G. et al. for the ONCENOX Investigators. Secondary prevention of venous thromboembolic events in patients with active cancer: Enoxaparin alone versus initial enoxaparin followed by warfarin for a 180-day period. Clin Appl Thromb Haemost 2006; 12: 389-396.
• 21 Hull RD, Pineo GF, Brant RF. et al. LITE Trial investigators. Self-managed long-term low-molecular-weight heparin therapy: the balance of benefits and harms. Am J Med 2007; 120: 72-82.
• 22 Büller HR, Agnelli G, Hull RD. et al. Antithrombotic therapy for venous thromboembolic disease. Chest 2004; 126: 401S-428S.