Assessment of bleeding risk in cancer patients treated with anticoagulants for venous thromboembolic events

Géraldine Poénou; Emmanuel Tolédano; Hélène Helfer; Ludovic Plaisance; Florent Happe; Edouard Versini; Nevine Diab; Sadji Djennaoui; Isabelle Mahé

doi:10.3389/fcvm.2023.1132156

Assessment of bleeding risk in cancer patients treated with anticoagulants for venous thromboembolic events

Front Cardiovasc Med. 2023 Aug 21:10:1132156. doi: 10.3389/fcvm.2023.1132156. eCollection 2023.

Authors

Géraldine Poénou¹, Emmanuel Tolédano^{1

2}, Hélène Helfer¹, Ludovic Plaisance¹, Florent Happe¹, Edouard Versini^{1

2}, Nevine Diab^{1

2}, Sadji Djennaoui¹, Isabelle Mahé^{1

2

3

4}

Affiliations

¹ Médecine Interne, Hôpital Louis Mourier, Assistance Publique Hôpitaux de Paris, Colombes, France.
² Université de Paris Cité, Paris, France.
³ Unité Inserm UMR-S1140 Innovation Thérapeutique en Hémostase, Paris, France.
⁴ INNOVTE-FCRIN, CEDEX 2, Saint-Etienne, France.

Abstract

Introduction: Anticoagulant is the cornerstone of the management of VTE at the cost of a non-negligible risk of bleeding. Reliable and validated clinical tools to predict thromboembolic and hemorrhagic events are crucial for individualized decision-making for the type and duration of anticoagulant treatment. We evaluate the available risk models in real life cancer patients with VTE. The objectives of the study were to describe the bleeding of cancer patients with VTE and to evaluate the performance of the different bleeding models to predict the risk of bleeding during a 6-month follow-up.

Materials and methods: VTE-diagnosed patient's demographic and clinical characteristics, treatment regimens and outcomes for up to 6 months were collected. The primary endpoint was the occurrence of a major bleeding (MB) or a clinically relevant non major bleeding (CRNMB) event, categorized according to the ISTH criteria.

Results: During the 6-months follow-up period, 26 out of 110 included patients (26.7%) experienced a bleeding event, with 3 recurrences of bleeding. Out of the 29 bleeding events, 19 events were CRNMB and 10 MB. One patient died because of a MB. Bleeding occurred in 27 % of the patients treated with DOACs and 22% of the patients treated with LMWH. Most of the bleedings were gastrointestinal (9 events, 31%); 26.9% of the bleedings occurred in patient with colorectal cancer and 19.6% in patients with lung cancer. In our cohort, none of the 10 RAMs used in our study were able to distinguish cancer patients with a low risk of bleeding, from all bleeding or non-bleeding patients. The Nieto et al. RAM had the best overall performance (C-statistic = 0.730, 95% CI (0.619-0.840)). However, it classified 1 out of 5 patients with major bleeding in the low risk of bleeding group. The rest of the RAMs showed a suboptimal result, with a range of C-statistic between 0.489, 95%CI (0.360-0.617)) and 0.532, 95%CI (0.406-0.658)).

Conclusions: The management of CAT patients is challenging due to a higher risk of both recurrent VTE and bleeding events, as compared with non-cancer patients with VTE. None of the existing RAMs was able to consistently identify patients with risk of anticoagulant associated bleeding events.

Keywords: anticoagulant; bleeding; cancer; risk assessment model (RAM); venous thromboembolism.