Bleeding can be distressing for patients, especially for those who are also dealing with a cancer diagnosis.  

Cancer patients have an increased risk of venous thromboembolism (VTE), therefore, anticoagulant treatment may be required to reduce the risk of a potentially fatal thrombotic event. However, in those who are also at risk of bleeding it is important to find the right treatment for your patient to mitigate these risks.  

It is important to choose an anticoagulant for the patient based on their individual risk.  

1. Fatal bleeding, and/or 
2. Symptomatic bleeding in a critical area or organ, such as intracranial, intraspinal, intraocular, retroperitoneal, intraarticular or pericardial, or intramuscular with compartment syndrome, and/or 
3. Bleeding causing a fall in haemoglobin level of 20 g/L (1.24 mmol/L) or more or leading to transfusion of two or more units of whole blood or red cells.

Any sign or symptom of haemorrhage (e.g., more bleeding than would be expected for a clinical circumstance, including bleeding found by imaging alone) that does not fit the criteria for the ISTH definition of major bleeding but does meet at least one of the following criteria: 

• Requiring medical intervention by a healthcare professional 

• Leading to hospitalisation or increased level of care 

• Prompting a face-to-face evaluation (i.e., not just a telephone or electronic communication) 

'Minor’ bleeding events are important as patient-centric outcomes as they may influence quality of life or may not be ‘minor’ to the patient.  

• Age >65 years or age > 75 years (study-dependent)  
• Diabetes 
• Anaemia and low haemoglobin 
• Previous bleeding 
• Antiplatelet therapy 
• Cancer  

• Poor anticoagulation control 
• Metastatic cancer  
• Comorbidity and reduced functional capacity 
• Renal failure  
• Liver failure  
• Thrombocytopenia

• Frequent falls 

• Previous stroke  

• Alcohol abuse 

• Recent trauma or surgery 

• History of hypertension or cardiovascular disease 

A 2013 study (figure 1) showed that patients with cancer are at higher risk of all-cause, major and minor bleeding than those without cancer.⁴ 
 

Cancer alone increases the risk of bleeding events even before anticoagulation treatment for VTE.¹ 

In the same study, they assessed predictors of all-cause bleeding in ambulatory patients with solid tumours receiving chemotherapy.⁴  

Bladder, gastric, pancreatic, lung, colorectal and ovarian cancers are high risk of VTE. Here, Khorana et al. show that these same cancers are accompanied by a high risk of bleeding.  

So, if you have patients with cancer, who are high risk for VTE, and high risk of bleeding, how do you manage this while they are receiving treatment for their cancer and/or surgery?  

Which risk is higher, VTE or bleeding?  

According to Khorana et al. pancreatic and lung cancer have the higest risk for VTE, while bladder and gastric cancer have the highest risk of  bleeding.⁴ 

As clinicians, you have the ability to choose the right anticoagulant for your patients to mitigate this risk.  

Methodology⁴ 
 

A retrospective observational cohort of 17,284 cancer patients was compared to a matched control cohort of non-cancer patients. Data were extracted from the IMS/PharMetrics database of commercially insured patients in the United States (2004-2009).  

Patients aged ≥18 years with prescription drug coverage who had an inpatient diagnosis of malignant neoplasm of the lung, pancreas, gastrointestinal system, colon/rectum, bladder, or ovary and who received cytotoxic chemotherapy between January 2005 and December 2008 were selected from the database. 

Patients were excluded if they received biologic agents alone, had a diagnosis of VTE, severe renal impairment, haemorrhagic stroke, or thrombocytopenia during the previous 12 months, had major bleeding during the previous 3 months, or who received antithrombotic/thrombolytic treatment <2 weeks previously. 

Major bleeding is significantly increased in patients with cancer receiving anticoagulation for VTE compared to patients without cancer.⁵  

The risk of bleeding during anticoagulation treatment was approximately twice as high in patients with cancer than those without cancer (figure 2). Bleeding risk increased approximately 2-fold with ‘less extensive cancer’ but was over 5-fold higher in patients with ‘extensive cancer’.⁵

Regardless of cancer type, or the anticoagulant used, cancer patients with established venous thrombosis have an increased risk of major bleeding complications.⁵

Individual patient treatment strategies should be developed. 

Methodology ⁵
In a prospective follow-up study of 842 patients (181 with known cancer) undergoing anticoagulation therapy for VTE, the 12-month cumulative incidence of major bleeding was 12.4% and 4.9% in patients with and without cancer, respectively (HR, 2.2; 95% Cl, 1 .2-4. 1). 
CI = Confidence Interval