Chapter 3. Treatment of recurrence of VTE in cancer patients under anticoagulation


Menu
3.1. Bibliographic strategy results
3.2. Data extraction
3.3. Data analysis
3.4. Discussion
3.5. Recommendations – recurrent VTE in cancer patients


 

3.1. Bibliographic strategy results

The results of the bibliographic search for vena cava filters (VCF) are also shown in a previous chapter. In these studies, the main indications of insertion of vena cava filter (IVCF) were recurrence of VTE and contraindication to anticoagulation. In some cases, VCF were inserted as a primary treatment of VTE.

 

HTA Questions

Studies included

HTA 1: Recurrence in patients treated with LMWH or VKA

1 specific retrospective study

[CARRIER2009]

HTA 2: Vena cava filters

14 retrospective studies

[COHEN1991] [CALLIGARO1991] [COHEN1992] [LEVIN1993] [HUBBARD1994] [SCHIFF1994] [SCHWARZ1996] [GREENFIELD1997] [IHNAT1998] [SCHLEICH2001] [JARRETT2002] [WALLACE2004] [ZERATI2005] [SCHUNN2006]

Menu


 

3.2. Data extraction

Table 15 Retrospective study - Treatment of VTE recurrence

Table 15 Retrospective study – Treatment of VTE recurrence

The results of studies on vena cava filters are shown in Chapter-1 “Initial treatment of established VTE”

Menu


 

3.3 Data Analysis

Patients treated with LMWH or VKA

Studies

1 specific retrospective study

[CARRIER2009]

Agreement

Not applicable

Quality of evidence

Very low (observational study + very serious indirectness)

Results

In the case of recurrence of VTE, there is only one specific study with two therapeutic options:

  • in patients treated with VKA: switch from VKA to LMWH
  • in patients treated with LMWH: increase LMWH

The results appear to be similar to those obtained in cancer patients without VTE recurrence.

Vena cava filters

Studies

14 retrospective studies

[COHEN1991] [CALLIGARO1991] [COHEN1992] [LEVIN1993] [HUBBARD1994] [SCHIFF1994] [SCHWARZ1996] [GREENFIELD1997] [IHNAT1998] [SCHLEICH2001] [JARRETT2002] [WALLACE2004] [ZERATI2005] [SCHUNN2006]

Agreement

Impossible to determine heterogeneity

Quality of evidence

Very low (observational, serious limitations, serious imprecision)

Results

The efficacy of vena cava filters is not proven in cancer patients. Cancer is neither a specific indication nor a special contraindication to vena cava filters.

Conclusion
In the case of recurrence of VTE or PE in cancer patients, three therapeutic options have been studied:
1. Switch from VKA to LMWH in patients treated with VKA,
2. Increased dose of LMWH in patients treated with LMWH,
3. Vena cava filter insertion.
There is insufficient evidence to determine if one option is superior to the others.
Menu


 

3.4. Discussion

Data are lacking to determine the best management of cancer patients with a recurrent VTE.
The main indications of VCF insertion are recurrence of VTE and contraindication
to anticoagulation, but no separate results are available for cancer patients with recurrent VTE.
Furthermore, these studies are retrospective and among the 14 studies selected, 9 included
fewer than 100 patients.
The sole study on recurrent VTE specifically in cancer patients was retrospective with a small number of patients (n=70). In this study, the therapeutic options were switch from VKA to LMWH in patients treated with VKA or increase in the weight-adjusted dose of LMWH by 20 to 25% in patients treated with LMWH [CARRIER2009].The results from these three therapeutic options appear similar in terms of efficacy and it is impossible to know if one option is superior to others.

Menu


 

3.5. Recommendations – recurrent VTE in cancer patients

Quality of evidence

Very low

Balance between desirable and undesirable effects

Unknown

Values and preferences

Individual decision

Costs (resource allocation)

Not considered

Level of recommendation

Best practice

Menu