Venous thromboembolism (VTE) which includes deep vein thrombosis (DVT) and pulmonary embolism (PE) is a key cause of morbidity and mortality in patients with cancer.

The link between cancer and a hypercoagulable state has been established for around 200 years. It was acknowledged in the 19th century by French physician Armand Trousseau, who was one of the first to highlight the clinical features of this combination of disorders, through self-diagnosis.

Ahead of his time Trousseau perceptively observed:

“a particular condition in the blood, speculated to be excess of fibrin and an increase of white globules was the primary cause of thrombosis that the change [hypercoagulable state] was also evident in many other disorders”.

Thromboembolism in people with cancer may also affect other systems in the body – the splanchnic veins which involve blood flow to the stomach, liver, spleen, pancreas and intestines; visceral veins are mainly associated with the heart and lungs; and cerebral veins relate to the brain. The arteries might also be affected which are associated with arterial thrombosis, stroke and myocardial infarction.

Cancer-associated thrombosis (CAT) is extremely significant for patients with cancer. It is connected with higher rates of hospitalisation, the possible interruption of cancer treatments, and worsened survival.

Image source – Khorana, A.A., Mackman, N., Falanga, A. et al. (2022) Cancer-associated venous thromboembolism. Nat Rev Dis Primers 8(11)

Advancements in cancer treatments have resulted in improved patient outcomes, however the risk of venous thromboembolism has not lessened. There is research literature which has found that the incidence of CAT has actually risen over the past 20 years.

People with cancer have an increased risk of developing venous thromboembolism and having both conditions present additional challenges in their management. Approximately 15% of cancer patients will experience venous thromboembolism. Data from 2007 determined cancer patients had a 5 to 7-fold increased risk of developing VTE. This has elevated to a 9-fold risk in 2021.

Research from September 2023 investigated the five-year mortality of cancer patients with venous thromboembolism (VTE). The study period was 1995 to 2020 and comprised of 886,536 cancer patients. Here are some of the results.

From this group, 25,248 (25.1%) had VTE and the comparison cohort without VTE made up 74.9% (n=75,284). Venous thromboembolism was detected in 92.5% after the cancer diagnosis and in 7.5% at the same time. In the patients where VTE was diagnosed after the cancer, the average time between each diagnosis was 2.6 years.

When VTE and cancer were concurrent, the cumulative mortality incidence was:

• 27.7% after one month compared 7.5% in the cohort without VTE.
• 48.7% after three months compared to 17%.
• 68.2% after one year compared to 38.5%.
• 84.1% after five years compared to 66.6%.

When VTE was diagnosed after the cancer, mortality was:

• 13.8% after one month compared to 2.2% in the cohort without VTE.
• 25.4% after three months compared to 5.7%.
• 44.8% after one year compared to 16.8%.
• 68.6% after five years compared to 42.3%.

This study has demonstrated that despite the vast advancements in cancer treatment, when cancer-associated VTE occurs, survival rates are considerably reduced.

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References

• Khorana, A.A., Mackman, N., Falanga, A. et al. (2022) Cancer-associated venous thromboembolism. Nat Rev Dis Primers 8(11).
• Metharom, P., Falasca, M., & Berndt, M. C. (2019). The history of Armand Trousseau and cancer-associated thrombosis. Cancers, 11(2), 158. https://doi.org/10.3390/cancers11020158.
• Mulder, F.I. et al. (2021). Venous thromboembolism in cancer patients: a population-based cohort study. Blood. 137(14):1959-1969. doi: 10.1182/blood.2020007338.
• Naess, I., Christiansen, S., Romundstad, P., et al. Incidence and mortality of venous thrombosis: a population-based study. J Thromb Haemost 2007;5(4):692-699. DOI:10.1111/j.1538-7836.2007.02450.x
• Sørensen, H. T., Pedersen, L., van Es, N., Büller, H. R., & Horváth-Puhó, E. (2023). Impact of venous thromboembolism on the mortality in patients with cancer: a population-based cohort study. The Lancet Regional Health. Europe, 34, 100739–100739. https://doi.org/10.1016/j.lanepe.2023.100739