ABSTRACT
Since several trials have demonstrated that low-molecular-weight-heparin (LMWH) is superior to vitamin K antagonist (VKA) in preventing recurrent venous thromboembolism (VTE) in patients with cancer-associated VTE, guidelines now recommend LMWH monotherapy in this setting. We evaluated whether this shift resulted in improved outcomes in routine clinical practice. We performed a cohort study of consecutive patients with cancer-associated VTE during 2001 and 2010. We compared the risks for recurrent VTE, major bleeding and mortality between patients diagnosed before and after 2008 during a 6-month routine follow-up. A total of 381 patients were included, of which 234 (61.4%) were diagnosed before 2008. Before 2008, 23% of the patients were treated with LMWH; thereafter, this percentage was higher: 67%. The 6-month incidence for recurrent VTE was 8.6% in patients diagnosed before 2008 versus 7.5% for patients diagnosed after 2008 (risk difference [RD]: -1.1%; 95% confidence interval [CI]: -6.3, 5.3). The respective risks for major bleeding were 6.4 versus 4.8% (RD: -1.6%; 95% CI: -3.8 to 5.8), and 39.7 versus 41.5% (RD: 1.8%; 95% CI: -8.8, 12) for overall mortality. The mean time in therapeutic range (TTR) of patients treated with VKA was 61%. Despite a clear shift toward LMWH as agent of choice for cancer-associated VTE, we did not observe a clear improvement in terms of recurrent VTE and bleeding complications.
Subject(s)
Anticoagulants/administration & dosage , Blood Coagulation/drug effects , Heparin, Low-Molecular-Weight/administration & dosage , Neoplasms/drug therapy , Venous Thromboembolism/prevention & control , Vitamin K/antagonists & inhibitors , Adult , Aged , Anticoagulants/adverse effects , Clinical Decision-Making , Female , Hemorrhage/chemically induced , Heparin, Low-Molecular-Weight/adverse effects , Humans , Kaplan-Meier Estimate , Male , Middle Aged , Neoplasms/blood , Neoplasms/complications , Neoplasms/mortality , Netherlands , Recurrence , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Venous Thromboembolism/blood , Venous Thromboembolism/etiology , Venous Thromboembolism/mortalityABSTRACT
PURPOSE: The routine use of modern computed tomography scanners has led to an increased detection of incidental pulmonary embolism (PE), in particular in patients with cancer. The clinical relevance of these incidental findings is unknown. PATIENTS AND METHODS: In this retrospective cohort study, oncology patients in whom PE was objectively proven between 2004 and 2010 and anticoagulant treatment was started, were included. Fifty-one patients with incidental PE and 144 with symptomatic PE were observed for 1 year to compare the risks of recurrent venous thromboembolism (VTE), bleeding complications, and mortality. Kaplan-Meier and Cox survival analyses were performed. RESULTS: Incidental and symptomatic patients did not differ with respect to mean age, sex, cancer type and stage, and risk factors for VTE. As a result from evolving treatment guidelines, approximately half of the patients in both groups received long-term treatment with vitamin K antagonists in stead of currently recommended low-molecular-weight heparin. The 12-month cumulative incidence of recurrent VTE was 13.3% in the incidental group versus 16.9% in the symptomatic group (P = .77). Notably, 20% VTE events recurred after premature termination of anticoagulant therapy. The risk of major bleeding complications was also comparable in the two groups (12.5% for incidental patients and 8.6% for symptomatic patients; P = .5). The respective 12-month mortality risks were 52.9% and 53.3% (P = .7). CONCLUSION: Our findings suggest that oncology patients diagnosed with and treated for incidental PE, have similar high rates of recurrent VTE, bleeding complications, and mortality, as compared with oncology patients who develop symptomatic PE.
