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Abstract
Optimal management of venous thromboembolism (VTE) in cancer patients with thrombocytopenia is uncertain. We described current management and clinical outcomes of these patients. We retrospectively included a cohort of cancer patients with acute VTE and concomitant mild (platelet count 100,000–150,000/mm3), moderate (50,000–99,000/mm3), or severe thrombocytopenia (< 50,000/mm3). Univariate and multivariate logistic regression analyses explored the association between different therapeutic strategies and thrombocytopenia. The incidence of VTE and bleeding complications was collected at a 3-month follow-up. A total of 194 patients of whom 122 (62.89%) had mild, 51 (26.29%) moderate, and 22 (11.34%) severe thrombocytopenia were involved. At VTE diagnosis, a full therapeutic dose of LMWH was administered in 79.3, 62.8 and 4.6% of patients, respectively. Moderate (OR 0.30; 95% CI 0.12–0.75), severe thrombocytopenia (OR 0.01; 95% CI 0.00–0.08), and the presence of cerebral metastasis (OR 0.06; 95% CI 0.01–0.30) were independently associated with the prescription of subtherapeutic LMWH doses. Symptomatic VTE (OR 4.46; 95% CI 1.85–10.80) and pulmonary embolism (OR 2.76; 95% CI 1.09–6.94) were associated with the prescription of full therapeutic LMWH doses. Three-month incidence of VTE was 3.9% (95% CI 1.3–10.1), 8.5% (95% CI 2.8–21.3), 0% (95% CI 0.0–20.0) in patients with mild, moderate, and severe thrombocytopenia, respectively. The corresponding values for major bleeding and mortality were 1.9% (95% CI 0.3–7.4), 6.4% (95% CI 1.7–18.6), 0% (95% CI 0.0–20.0) and 9.6% (95% CI 5.0–17.4), 48.2% (95% CI 16.1–42.9), 20% (95% CI 6.6–44.3). In the absence of sound evidence, anticoagulation strategy of VTE in cancer patients with thrombocytopenia was tailored on an individual basis, taking into account not only the platelet count but also VTE presentation and the presence of cerebral metastasis.
Highlights
Venous thromboembolism (VTE) threatens the clinical course of cancer, representing a strong predictor of decreased survival for all cancer types [1]
Thrombocytopenia at venous thromboembolism (VTE) diagnosis was mild in 121 patients (121/194, 62.4%), moderate in 51 (51/194, 26.3%), and severe in 22 (22/194, 11.3%), including five with a platelet count lower than 20,000/mm3
When the multivariate analysis was repeated by including the dichotomous classification of thrombocytopenia around 50,000 and 75,000/mm3, we found that a platelet count lower than the pre-specified cut-off was associated with no anticoagulant therapy or treatment with a subtherapeutic low-molecular weight heparin (LMWH) dose (OR = 0.03; 95% CI 0.01–0.13 and OR = 0.09; 95% CI 0.04–0.23, respectively)
Summary
Venous thromboembolism (VTE) threatens the clinical course of cancer, representing a strong predictor of decreased survival for all cancer types [1]. Despite the recommended anticoagulant treatment, cancer-associated thrombosis (CAT) is linked to high risk of major bleeding and recurrent thrombosis [2]. Cancer-associated thrombocytopenia has a wide variable severity, ranging from mild Treatment with low-molecular weight heparin (LMWH) has been the standard of care for CAT for many years, but little is known about the optimal treatment in patients at higher risk of bleeding, such as those with thrombocytopenia. Since low platelet count is usually an exclusion criterion in studies of anticoagulant drugs, patients with a platelet count lower than 75,000/mm or 50,000/mm were excluded from all clinical trials on CAT management [2, 3]. The occurrence of thrombocytopenia has been associated with increased bleeding risk, and with a higher risk of recurrent VTE [3, 4]
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