During the ICTHIC webinar, “What is the profile of the real-world CAT patient?”, Dr. Laurent Bertoletti gave a lecture on the real-world cancer-associated thrombosis (CAT) patient profile from the RIETE registry. Here, we summarize the key messages of his speech. You can also watch Laurent Bertoletti’s lecture in the video below and the full webinar recording here.
The RIETE registry is a prospective, international, ongoing registry of consecutive patients with venous thromboembolism (VTE). One of the primary goals of the registry is to learn about the natural history of patients with VTE, particularly those not included in randomized controlled trials (RCTs).
It was launched in March 2001 in 25 Spanish hospitals, and in 2006 it was translated into English and expanded to other countries. Up to now, more than 100,000 patients with acute VTE have been included in the database, making it the world’s largest database on patients with acute VTE.
Only two exclusion criteria for the RIETE registry exist: participating in a double-blind trial (because it does not allow to know which drug was taken by the patient) and the inability of the patient to follow up at 3 months. Generally, almost all the patients with acute VTE managed in a center may participate in the RIETE registry .
CAT may affect any patient with any type of cancer.
Based on the data collected, colorectal, lung, breast, and prostate are the most common cancers in the registry and are responsible for about 50% of all CAT events. Thus, one in two patients with CAT has an unusual type of cancer, such as melanoma, biliary system, or liver cancer .
In addition, the frequency of cancer types varies depending on gender. For example, the most frequent cancer associated with VTE in men is lung cancer, followed by prostate and colorectal cancer. While in women, breast cancer is the most common cancer associated with VTE, followed by colorectal and lung .
Treatment of CAT varies depending on the site of the cancer
Death, major bleeding, recurrent VTE, post-thrombotic syndrome, and post-pulmonary embolism syndrome are some of the parameters collected at the follow-up in the RIETE registry.
Data collected show that the risk of VTE recurrence, major bleeding, and mortality while on anticoagulant treatment differs according to the cancer site .
Lung cancer is associated with the highest risk for venous thromboembolism recurrence (hazard ratio [HR]: 3.8) and death (HR: 3.1) and with an increased risk of bleeding (HR: 1.8) .
On the other hand, prostate and colorectal cancer are associated with a similar higher risk of major bleeding (HR: 2.1) than the risk of VTE recurrences (HR: 1.7) .
Differences exist in the time course of VTE-related complications according to the cancer site. For example, breast, prostate or colorectal cancer patients have half of the VTE recurrence rate compared with major bleeding during the first month of therapy. On the contrary, patients with lung cancer have a twofold higher rate of VTE recurrences than major bleeding, both during and beyond the first 30 days of therapy .
Ineligible patients for RCTs have the worst VTE prognosis.
A study assessed the real-life use of direct oral anticoagulants in patients with VTE and exclusion criteria for RCT using the RIETE registry .
It was found that patients with VTE excluded from RCT (for meeting at least one exclusion criterion) have a higher rate of VTE recurrences or major bleeding than those without exclusion criteria .
Patients with exclusion criteria had a fourfold higher rate of major bleeding (and a sixfold higher rate of fatal bleeding) than those without exclusion criteria. In patients with cancer, an increased rate of major bleeding and recurrent VTE was found in those with metastatic cancer .
RCTs on appropriate anticoagulant therapy for VTE patients excluded from previous studies are needed.
Fatal arterial events are an issue in patients with CAT
A study analyzed clinical characteristics, time course, risk factors, incidence and severity of VTE recurrences, arterial ischemic events, and major bleeding in 5717 patients with active cancer and VTE recruited into the RIETE registry .
Results showed that arterial ischemic events and major bleeding were among the most frequent causes of death in patients with active cancer .
Pulmonary embolism and CAT temporal trend
Another study investigated the trends in the management and outcomes of acute symptomatic pulmonary embolism using data from the RIETE registry .
Results suggest that the increased use of more effective therapies and interventions (such as low-molecular-weight heparins, direct oral anticoagulants, thrombolysis, and surgical embolectomy) was accompanied by a reduction in short-term all-cause and PE-specific mortality .
However, another study indicates an increase in the incidence of CAT in the past two decades. The 12-month cumulative VTE incidence increased threefold for cancer patients and sixfold for those receiving chemotherapy or targeted therapy. Increased VTE incidence in cancer patients may result from improved survival and more frequent chemotherapy and targeted therapies .
The cancer site may vary according to gender. Still, CAT may affect any patient with any type of cancer, and its evolution under anticoagulant therapy varies according to the cancer site. In addition, patients ineligible for RCT have a worse VTE prognosis than those eligible, and fatal arterial events are another important issue in patients with CAT.
Watch Laurent Bertoletti’s lecture:
- Mahé I, Chidiac J, Bertoletti L, et al. The Clinical Course of Venous Thromboembolism May Differ According to Cancer Site. Am J Med. 2017;130(3):337-347. doi:10.1016/j.amjmed.2016.10.017
- Moustafa F, Pesavento R, di Micco P, et al. Real-life use of anticoagulants in venous thromboembolism with a focus on patients with exclusion criteria for direct oral anticoagulants. Clin Pharmacol Ther. 2018;103(4):684-691. doi:10.1002/cpt.781
- Brenner B, Bikdeli B, Tzoran I, et al. Arterial ischemic events are a major complication in cancer patients with venous thromboembolism. Am J Med. 2018;131(9):1095-1103. doi:10.1016/j.amjmed.2018.04.037
- Jiménez D, de Miguel-Díez J, Guijarro R, et al. Trends in the management and outcomes of acute pulmonary embolism: analysis from the RIETE registry. J Am Coll Cardiol. 2016;67(2):162-170. doi:10.1016/j.jacc.2015.10.060
- Mulder FI, Horváth-Puhó E, van Es N, et al. Venous thromboembolism in cancer patients: a population-based cohort study. Blood. 2021;137(14):1959-1969. doi:10.1182/blood.2020007338