Anemia and hypertension were the two modifiable risk factors most closely related to anticoagulant-associated bleeding risk in patients with cancer, according to findings from a large database analysis presented at the 66th American Society of Hematology Annual Meeting and Exposition.
The study suggests that eliminating these and other risk factors that are within the patient’s control could substantially lower the chance of bleeding events, said presenter Kristen Sanfilippo, MD, MPHS, associate professor of hematology at Washington University in St. Louis.
Patients with cancer are at increased risk for bleeding due to the malignancy itself, therapies, and comorbidities, and it’s made worse with anticoagulant therapies for the treatment or prevention of venous thromboembolism (VTE). Researchers set out to try to find modifiable risk factors that could allow patients to reduce the bleeding risk and remain on anticoagulants.
Researchers examined the U.S. Veterans Administration database and included 11,151 patients with a newly diagnosed cancer-associated VTE and a new prescription for anticoagulant therapy between 2012 and 2020, excluding those with an outpatient anticoagulant prescription within six months prior to the cancer diagnosis.
The gastrointestinal (GI) tract (57.2%), genitourinary tract (20.2%), and intracranial hemorrhage (10.4%) were the most common sites of clinically significant bleeding. Most of the patients received low-molecular-weight heparin, followed by direct oral anticoagulant (DOAC) or vitamin K antagonists, with more recent treatment dominated by DOACs, Dr. Sanfilippo said.
Anemia had the highest population attributable fraction at 12.2%, indicating it was the factor to which anticoagulant-related bleeding was most commonly attributed. Next was hypertension at 7.9%.
Eliminating anemia and hypertension together were associated with a 19% reduction in the probability of bleeding at one year after the start of anticoagulant therapy, researchers found. Eliminating those plus two other risk factors — alcohol abuse and antiplatelet prescriptions — resulted in a 23% reduction in this probability, they found, decreasing to 6.7% compared with 8.5%.
GI bleeding events were attributed to anemia in 16.3% of cases, and the four risk factors overall accounted for 28.6%.
“Elimination of multiple modifiable factors has the potential to decrease bleeding incidence,” Dr. Sanfilippo said. “If we were perfectly able to eliminate everything, it would be up to one in five for overall bleeds and one in three for GI bleeds.”
She said an interesting avenue for future work would be to explore the effects of modifying some of these risk factors before starting anticoagulant therapy.
Any conflicts of interest declared by the authors can be found in the original abstract.
Reference
Sanfilippo KM, Yan Y, Luo S, et al. Elimination of modifiable risk factors for anticoagulant-related bleeding in patients with cancer reduces the probability of bleeding. Abstract 814. Presented at the 66th American Society of Hematology Annual Meeting and Exposition; December 9, 2024; San Diego, California.
