Recurrent venous thromboembolism in anticoagulated patients with cancer: management and short-term prognosis

S Schulman, M Zondag, L Linkins, S Pasca, Yuk Cheung, M de Sancho, Alexander Gallus, R Lecumberri, S Molnar, W Ageno, G Le Gal, A Falanga, E Hulegardh, S Ranta, P Kamphuisen, P Debourdeau, V Rigamonti, T Ortel, Agnes Lee

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55 Citations (Scopus)

Abstract

Recommendations for management of cancer-related venous thromboembolism (VTE) in patients already receiving anticoagulant therapy are based on low-quality evidence. This international registry sought to provide more information on outcomes after a breakthrough VTE in relation to anticoagulation strategies. Methods: Patients with cancer and VTE despite anticoagulant therapy were reported to the registry. Data on treatments, VTE events, major bleeding, residual thrombosis symptoms and death were collected for the following 3 months. Breakthrough VTE and subsequent recurrences were objectively verified. Outcomes with different treatment strategies were compared with Cox proportional hazards regression. Results: We registered 212 patients with breakthrough VTE. Of those, 59% had adenocarcinoma and 73% had known metastases. At the time of the breakthrough event, 70% were on low-molecular-weight heparin (LMWH) and 27% on a vitamin K antagonist (VKA); 70% had a therapeutic or supratherapeutic dose. After breakthrough the regimen was: unchanged therapeutic dose in 33%, dose increased in 31%, switched to another drug in 24%; and other management in 11%. During the following 3 months 11% had another VTE, 8% had major bleeding and 27% died. Of the survivors, 74% had residual thrombosis symptoms. Additional VTE recurrence was less common with LMWH than with a VKA (hazard ratio [HR], 0.28; 95% confidence interval [CI], 0.11-0.70) but similar with unchanged or increased anticoagulant intensity (HR, 1.09; 95% CI, 0.45-2.63). The bleeding rate did not increase significantly with dose escalation. Conclusion: Morbidity and mortality are high after recurrence of cancer-related VTE despite anticoagulation. Further treatment appears to be more effective with LMWH than with a VKA.

Original languageEnglish
Pages (from-to)1010-1018
Number of pages9
JournalJournal of Thrombosis and Haemostasis
Volume13
Issue number6
DOIs
Publication statusPublished - 2015

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