Reviewing management of venous thromboembolism in elderly lymphoma patients Free

Background:

Older patients with lymphoma have an increased risk of venous thromboembolism (VTE), due to age-related physiologic changes, cancer-related prothrombotic factors, and treatment toxicity. Venous thromboembolism (VTE) in this population is associated with greater morbidity, hospitalizations, and mortality. Managing VTE in older patients with lymphoma is particularly challenging due to their comorbidities, including renal impairment and frailty. The American Society of Hematology (ASH) guidelines on cancer associated thrombosis acknowledge the complexity of anticoagulation in older cancer patients, recommending individualize risk-benefit discussion. Geriatric focused anticoagulation guidance from the American Geriatric Society emphasizes cautious use of anticoagulation, considering fall risk, drug interactions, and impaired renal clearance. Although these risks are well recognized, there is a lack of specific clinical guidance related to this population. Our review evaluates current evidence on VTE incidence, treatment considerations, and outcomes in elderly lymphoma patients.

Methods:

This scoping review included studies published between 2010 and 2025 evaluating VTE outcomes in adult lymphoma patients. We performed searches of databases including PubMed, EMBASE, Scopus, Taylor and Francis, and Medline according to PRISMA guidelines. Eligible studies included original cohort studies, randomized trials, registry anlayses, and conference abstracts reporting on the following outcomes: VTE incidence, timing, anticoagulation strategy, bleeding, recurrence, or survival. Two reviewers independently screened and extracted data. Due to heterogeneity in study design and outcomes definitions, quantitative meta-analysis was not performed, instead data was synthesized naratively. Risk of bias was assessed using ROBINS-I framework.

Results:

Out of 1,059 records, 11 studies met inclusion criteria, encompassing 9,800 patients, including 8,766 with confirmed lymphoma. Among the 11 included studies, several reported data on elderly lymphoma patients with VTE. One large cohort showed that age over 60 was independently associated with increased risk of thrombosis and worse survival, regardless of lymphoma subtype. Another study found that patients with VTE were older, with a median age of 70 compared to 60 in those without VTE. Additionally, one identified that patients aged 50-59 had over twice the risk of VTE compared to those under 50. Increasing age was independently associated with a higher risk of mortality in patients with hematologic malignancy and cancer associated VTE. Specifically, a VA study found that each 1-year increase in age was associated with a 3% higher hazard of death. Additionally, experiencing any clinically relevant bleeding event was associated with an increase in mortality risk. This study of VA patients also assessed frailty using the VA Frailty Index, finding that pre-frailty and frailty were common in this population. Frailty status was associated with both bleeding and mortality risk. Although, there were some studies in our review that found no association between age and VTE risk. Age findings related to thrombocytopenia varied. In one study, patients with platelet counts >50,000 had a significantly higher mean age compared to those with platelet counts <50,000. In another group, there was no statistically significant difference in age between those who received anticoagulation during severe thrombocytopenia and those who did not. In the cohorts studied, relatively few patients were aged 80 or older, with one study including ages 22-82, which overall limited conclusions about VTE risk or outcomes in this group.

Discussion:

The ASH 2021 guidelines describe the importance of individualizing anticoagulation decisions for older cancer patients, taking into account bleeding risk, comorbidities, and treatment goals. Our review found that these principles are generally reflected in lymphoma care. However, only a few studies specifically addressed geriatric considerations such as frailty scoring, none addressed cognitive status, renal impairment, or fall risk in this population. Further research focused specifically on the geriatric population is needed to improve management guidelines and reduce thrombotic complications.