Oncological and Hematological Neoplasms: Concomitant Oral Anticoagulation Therapy

The oral anticoagulant therapy (OAT) in oncologic patient is often problematic because both the haemorragic risk and the thrombotic risk, i.e. the recurrence of venous thromboembolism, are increased. Many studies have been conducted in patient with solid neoplasms; it remains still unclear whether these results could be entirely extrapolated to patients with haematological malignancies. Our aim was to analyse the clinical outcomes and the control of anticoagulation, measured as % time in target INR range, in the patients with cancer compared to patients without cancer; moreover we focused on patients with haematological neoplasms. A total of 500 patients were recruited in 6 years, regardless of the indication for OAT; 146 (29%) of them were affected by cancer (47 haematological and 99 solid neoplasms); those being treated with warfarin for less than 1 month were excluded from this analysis. It resulted that patients affected with cancer had a worse anticoagulation control, compared to those without cancer (55% vs 60%; p<0.001). The rate of thrombosis was similar (6/146=4.1% vs 14/354=3.9%; OR 1.1); moreover the former had a tendency toward a higher rate of major bleeding complications (3/146=2.1% and 5/354=1.4% respectively; OR 1.5). As regarding hematologic patients we noted that the quality of anticoagulation control did not differ compared with solid malignancies (54% vs 55%, p = ns); no significant differences were found in the major bleeding (1/47=2.1% and 2/99=2.0% respectively; OR 1.05) and thrombotic complications (2/47=4.3% and 4/99=4.1% respectively; OR 1.05). The cancer patients discontinued warfarin primarily for surgical, endoscopic diagnostic or therapeutic procedures (32% vs 19%; p<0.001); in particular the surgical procedures more frequently were the reason for discontinuation (27% vs 4% of the haematological patients, p<0.001). The 47 haematological patients showed a younger median age compared to those with solid neoplasms (67 vs 72 years, p<0.001), and discontinued OAT often because of invasive procedures (45% vs 26% of cancer patients, p<0.02). In this experience the haematological patients seem not to have an increased risk of thrombosis recurrence and bleeding during OAT. Such a result probably reflects a good management of OAT even in presence of risk factors like central vein catheter or thrombocytopenia. Moreover, an appropriate initial decision of employing low-molecular-weight heparins (LMWH) rather than OAT in particular subsets of haematological patients (for example those with life-expectancy less than 2–3 months or undergoing high-dose chemotherapy for stem cell transplantation) can reduce the hemorragic risk.