Anticoagulation management and related outcomes in patients with cancer-associated thrombosis and thrombocytopenia: A systematic review and meta-analysis

Tzu-Fei Wang; Marc Carrier; Brian J Carney; Miriam Kimpton; Aurélien Delluc

doi:10.1016/j.thromres.2023.05.012

Anticoagulation management and related outcomes in patients with cancer-associated thrombosis and thrombocytopenia: A systematic review and meta-analysis

Thromb Res. 2023 Jul:227:8-16. doi: 10.1016/j.thromres.2023.05.012. Epub 2023 May 11.

Authors

Tzu-Fei Wang¹, Marc Carrier¹, Brian J Carney², Miriam Kimpton³, Aurélien Delluc¹

Affiliations

¹ Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada.
² Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
³ Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, ON, Canada. Electronic address: mkimpton@toh.ca.

PMID: 37196605
DOI: 10.1016/j.thromres.2023.05.012

Abstract

Background: Patients with cancer have an increased risk of both venous thromboembolism (VTE) requiring anticoagulation and thrombocytopenia. The optimal management is unclear. We performed a systematic review and meta-analysis to evaluate the outcomes in these patients.

Methods: We searched MEDLINE, Embase, Scopus, and Cochrane Central Register of Controlled Trials from inception to February 5, 2022. Studies assessing adult patients with cancer-associated thrombosis and platelet count <100 × 10⁹/L were included. Three anticoagulation management strategies were reported: full dose, modified dose, or no anticoagulation. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding. The incidence rates of thrombotic and bleeding outcomes by anticoagulation management strategies were descriptive, and were pooled using random effects model and expressed as events per 100 patient-months with associated 95 % confidence intervals (CI).

Results: We included 19 observational cohort studies (N = 1728 patients) in the systematic review, with 10 included in the meta-analysis (N = 707 patients). Approximately 90 % of patients had hematological malignancies, with low-molecular-weight heparin being the main anticoagulant. The rates of recurrent VTE and bleeding complications were high regardless of management strategies - recurrent VTE on full dose: 2.65/100 patient-months (95 % CI 1.62-4.32), modified dose: 3.51/100 patient-months (95 % CI 1.00-12.39); major bleeding on full dose: 4.45/100 patient-months (95 % CI 2.80-7.06), modified dose: 4.16/100 patient-months (95 % CI 2.24-7.74). There was serious risk of bias in all studies.

Conclusions: Patients with cancer-associated thrombosis and thrombocytopenia have high risks of both recurrent VTE and major bleeding, but current literature is significantly limited to guide the best management.

Keywords: Anticoagulation; Malignancy; Systematic review; Thrombocytopenia; cancer-associated thrombosis; meta-analysis.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Adult
Anticoagulants / adverse effects
Hemorrhage / chemically induced
Heparin, Low-Molecular-Weight / adverse effects
Humans
Neoplasm Recurrence, Local / chemically induced
Neoplasm Recurrence, Local / complications
Thrombocytopenia* / chemically induced
Thrombocytopenia* / complications
Thrombocytopenia* / drug therapy
Thrombosis* / chemically induced
Thrombosis* / etiology
Venous Thromboembolism* / chemically induced
Venous Thromboembolism* / etiology

Substances

Anticoagulants
Heparin, Low-Molecular-Weight