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Patient Evidence Summary
In patients with cancer-associated VTE who received anticoagulant therapy for a minimum of 3 months, case-fatality of recurrent VTE is higher than case-fatality of major bleeding
Question
In people who have cancer-associated VTE who are treated for a minimum of 3 months with anticoagulant therapy, what is the incidence and case-fatality of recurrent VTE versus incidence and case-fatality of major bleeding?
The research
A summary of 29 studies (randomized controlled 14, prospective cohort 15) published up to Jan 2019.
Who? The studies included 8,000 people who had active cancer with confirmed PE and/or DVT treated with anticoagulation for at least 3 months (4,786 patient-years of follow-up; range 3-36 months).
What? The studies compared incidence and case-fatality of recurrent VTE with incidence and case-fatality of major bleeding.
Recurrent VTE | vs | Major Bleeding |
|---|---|---|
Incidence (number of recurrent VTE per 100 patient-years) Case-fatality (proportion of total recurrent VTE resulting in death) Recurrent VTE were objectively confirmed with conventional imaging | Incidence (number of major bleeds per 100 patient-years) Case-fatality (proportion of total major bleeds resulting in death) Definition of major bleeding varied across the studies |
What the researchers found
The quality of the studies varied from low to high.
Incidence of recurrent VTE was 23.7 per 100 patient-years and incidence of major bleeding was 13.1 per 100 patient-years.
Case-fatality of recurrent VTE was 14.8% and case-fatality of major bleeding was 8.9%.
The bottom line
In people with cancer-associated VTE who received anticoagulant therapy for a minimum of 3 months, recurrent VTE is both more common and more likely to be fatal than major bleeding.
Summary of findings
Recurrent VTE vs major bleeding in patients with cancer-associated VTE who received a minimum of 3 months of anticoagulant therapy
Outcomes | Recurrent VTE | Major Bleeding | Number of studies and quality of the evidence |
|---|---|---|---|
Rate (95% CI) | 23.7 per 100 pt-yrs (20.1 to 27.8) | 13.1 per 100 pt-yrs (10.3 to 16.7) | 29 studies of low-high quality |
Case-fatality (95% CI) | 14.8% (6.6 to 30.1%) | 8.9% (3.5 to 21.1%) | 29 studies of low-high quality |
This Evidence Summary is based on the following article:
Abdulla A, Davis WM, Ratnaweera N, et al. A Meta-Analysis of Case Fatality Rates of Recurrent Venous Thromboembolism and Major Bleeding in Patients with Cancer. Thromb Haemost. 2020 Apr;120(4):702-713. doi: 10.1055/s-0040-1708481. Epub 2020 Apr 14. PubMed
Higher rate of case-fatality from recurrent VTE than major bleeding in patients with cancer-associated VTE
VTE is the second leading cause of death in people with cancer. Decisions about duration of treatment for VTE depend on weighing the risk of recurrent VTE against the risk of anticoagulant-associated major bleeding. This meta-analysis by Abdulla et al shows that in patients with cancer-associated VTE treated with anticoagulation for at least 3 months, the case-fatality of recurrent VTE is two-fold higher than the case-fatality of major bleeding.
There are limitations of this meta-analysis that should be considered. The reviewed studies were heterogenous with respect to outcome (PE only (4/29), DVT only (4/29), both (21/29)), definition of active cancer, and definition of VTE- or bleeding-associated death. Variation in anticoagulation type across the studies makes the pooled incidence rates more difficult to interpret. For instance,13 studies (45%) had a VKA arm, which is not currently considered first-line treatment for cancer-associated VTE due to a higher recurrence rate than with LMWH. Lastly, the incidence of bleeding was not reported according to cancer-specific site, which is one of the key factors that influences bleeding risk.
The bottom-line
In general, this meta-analysis supports anticoagulation for patients with cancer-associated VTE, given that the case-fatality for recurrent VTE is higher than for major bleeding. However, the risk of bleeding should be assessed on an individual basis.
Rachelle Blackman is currently a fourth-year Hematology resident at Dalhousie University. She completed her undergraduate medical education at Dalhousie Medicine New Brunswick and subsequently her Internal Medicine training at Dalhousie University.
Lori-Ann Linkins, MD, MSc (Clin Epi), FRCPC
Dr. Linkins is an Associate Professor of Medicine (thrombosis) at McMaster University in Hamilton, Canada. She holds a Masters Degree in Health Research Methodology and is a Deputy Editor with the Health Information Research Unit, McMaster. She is Co-Editor of the ACP Journal Club and Co-lead on the CanVECTOR Knowledge Translation Platform.
Published: Wednesday, July 29, 2020
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
, McMaster University