Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

Maria A. de Winter; Jannick A. N. Dorresteijn; Walter Ageno; Cihan Ay; Jan Beyer-Westendorf; Michiel Coppens; Frederikus A. Klok; Farès Moustafa; Nicoletta Riva; Pedro C. Ruiz Artacho; Thomas Vanassche; Mathilde Nijkeuter

doi:10.1055/s-0041-1735251

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2022; 122(05): 818-829
DOI: 10.1055/s-0041-1735251

Stroke, Systemic or Venous Thromboembolism

Estimating Bleeding Risk in Patients with Cancer-Associated Thrombosis: Evaluation of Existing Risk Scores and Development of a New Risk Score

Maria A. de Winter

¹Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

,

Jannick A. N. Dorresteijn

²Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

,

Walter Ageno

³Department of Medicine and Surgery, University of Insubria, Varese, Italy

,

Cihan Ay

⁴Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria

⁵I. M. Sechenov First Moscow State Medical University, Moscow, Russia

,

Jan Beyer-Westendorf

⁶Department of Hematology/Hemostasis, Dresden University Hospital “Carl-Gustav Carus,” Dresden, Germany

,

Michiel Coppens

⁷Department of Vascular Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands

,

Frederikus A. Klok

⁸Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands

,

Farès Moustafa

⁹Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France

,

Nicoletta Riva

¹⁰Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta

,

Pedro C. Ruiz Artacho

¹¹Department of Internal Medicine, Clínica Universidad de Navarra, Madrid, Spain

¹²CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain

¹³Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Universidad de Navarra, Madrid, Spain

,

Thomas Vanassche

¹⁴Department of Cardiology, Leuven University Hospital, Leuven, Belgium

,

Mathilde Nijkeuter

¹Department of Acute Internal Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

› Author Affiliations

Abstract

Background Bleeding risk is highly relevant for treatment decisions in cancer-associated thrombosis (CAT). Several risk scores exist, but have never been validated in patients with CAT and are not recommended for practice.

Objectives To compare methods of estimating clinically relevant (major and clinically relevant nonmajor) bleeding risk in patients with CAT: (1) existing risk scores for bleeding in venous thromboembolism, (2) pragmatic classification based on cancer type, and (3) new prediction model.

Methods In a posthoc analysis of the Hokusai VTE Cancer study, a randomized trial comparing edoxaban with dalteparin for treatment of CAT, seven bleeding risk scores were externally validated (ACCP-VTE, HAS-BLED, Hokusai, Kuijer, Martinez, RIETE, and VTE-BLEED). The predictive performance of these scores was compared with a pragmatic classification based on cancer type (gastrointestinal; genitourinary; other) and a newly derived competing risk-adjusted prediction model based on clinical predictors for clinically relevant bleeding within 6 months after CAT diagnosis with nonbleeding-related mortality as the competing event (“CAT-BLEED”).

Results Data of 1,046 patients (149 events) were analyzed. Predictive performance of existing risk scores was poor to moderate (C-statistics: 0.50–0.57; poor calibration). Internal validation of the pragmatic classification and “CAT-BLEED” showed moderate performance (respective C-statistics: 0.61; 95% confidence interval [CI]: 0.56–0.66, and 0.63; 95% CI 0.58–0.68; good calibration).

Conclusion Existing risk scores for bleeding perform poorly after CAT. Pragmatic classification based on cancer type provides marginally better estimates of clinically relevant bleeding risk. Further improvement may be achieved with “CAT-BLEED,” but this requires external validation in practice-based settings and with other DOACs and its clinical usefulness is yet to be demonstrated.

Keywords

anticoagulants - bleeding - cancer - venous thromboembolism

Full Text

References

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