3Lessons from VTE registries: the RIETE experience
Section snippets
RIETE
Current guidelines from the American College of Chest Physicians (ACCP), based on evidence from clinical trials, recommend that patients with venous thromboembolism (VTE) should be treated initially with heparin, followed by long-term treatment with a vitamin K antagonist (VKA) [1]. However, patients with active cancer are often excluded from clinical trials of anticoagulant therapy because of short life expectancy, inability or unwillingness to attend for regular laboratory monitoring during
Prediction of fatal pulmonary embolism and fatal bleeding [2]
In cancer patients who develop VTE, the risk of death is more than three-fold higher than that in patients without cancer who have VTE *[3], [4], [5], and in patients with cancer but no VTE [6]. The high mortality rate in cancer patients with VTE is probably due to both VTE and the fact that malignancies associated with VTE are usually at later stages, and appear to follow a more aggressive course [6]. Identifying clinical characteristics that put cancer patients with VTE at increased risk of
Hidden cancer in patients with VTE [8]
Although usually developing in advanced stages of cancer, VTE may also appear before the cancer has become symptomatic and may lead to an earlier diagnosis of cancer. This association is greatest within the first few months after VTE, thus suggesting that these cancers are present at the time of diagnosis. In the last three decades, increasing attention has been given to this relationship, and some doubts have been clarified. First, in patients with clinically suspected VTE, the development of
Predicting VTE recurrence or major bleeding [23]
As discussed above, cancer patients with VTE have an increased incidence of VTE recurrence and anticoagulant-related bleeding complications compared with patients without cancer [24], *[25], [26], [27]. Reliable information on factors determining the risk of VTE recurrence or major bleeding complications may facilitate better use of therapy by improving the selection of patients in whom its benefit will likely outweigh the risk, and by identifying those who may benefit from careful management.
Elevated white blood cell count and outcome [29]
A significant association between elevated white blood cell (WBC) count and mortality in patients with cancer has been reported, but the predictive value of elevated WBC on mortality in cancer patients with acute VTE has not been explored [30], [31], [32], [33]. A study was undertaken to compare the 3-month outcome of cancer patients with acute VTE according to their WBC count at baseline.
As of May 2007, 3805 patients with active cancer and acute VTE had been enrolled in RIETE. Of them, 215
Long-term therapy with VKA [38]
As discussed above, international guidelines recommend the use of subtherapeutic doses of LMWH for the long-term prevention of recurrent VTE in all cancer patients. However, in clinical practice, many clinicians still administer VKA to their cancer patients, especially to those with limited disease and longer life expectancy.
The risk of recurrent VTE and major bleeding was determined in a large number of patients with and without cancer who were recruited in RIETE, had an initial treatment with
Summary
Analysis of data from RIETE reveal that: (1) cancer patients with VTE who had recently been immobilized had a higher rate of both fatal PE and fatal bleeding; (2) VTE patients with hidden cancer had an increased incidence of recurrence, major bleeding or death during the first 3 months of therapy, and early identification of occult malignancies by screening may be guided by easily obtainable variables at the diagnosis of VTE, with a direct effect on treatment; (3) cancer patients could be
Conflict of interest statement
The authors declare that they have no conflicts of interest.
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