Bleeding risk, which is elevated among patients with cancer receiving anticoagulant therapy, may correlate with metastatic disease, chronic kidney disease, and thrombocytopenia, among other risk factors, according to a study published in the American Journal of Hematology.

Using the Explorys database, researchers examined patient records from the United States spanning 1999 to 2018 to compare bleeding incidences between patients with or without cancer, grouped by anticoagulant therapy and by possible bleeding risk factors. The dataset comprised 3,283,140 patients with cancer, 135,140 (13.3%) of whom had been treated with anticoagulation in the first 6 months after cancer diagnosis.

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Bleeding risk factors that were considered included thrombocytopenia, body mass index (BMI) of 40 or higher, stage III or higher chronic kidney disease (CKD), type of cancer, and existence of metastasis.

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Overall, patients with cancer showed significantly higher bleeding incidence than did those without cancer, and this held true for every anticoagulant examined (P <.001 for each).

For patients on warfarin, bleeding incidence was 20.2% among those with cancer and 12.6% among those without cancer. With rivaroxaban, bleeding incidence was 16.7% in patients with cancer and 12.1% in patients without cancer. With apixaban, these rates were 14.5% in patients with cancer and 9.3% in patients without cancer, and with low-molecular-weight heparin, bleeding incidence was 13.2% in patients with cancer and 9.7% in patients without cancer.

Platelet counts of 100 x 109/L or lower and stage III or higher CKD were associated with greater bleeding risk for patients with cancer for each anticoagulant (P <.001 for each). Metastatic disease was associated with greater bleeding risk for all anticoagulants except warfarin.

Primary gastrointestinal cancer showed a significantly greater association with bleeding risk compared with other cancer types, and this was true across anticoagulants. Among gastrointestinal cancers, luminal malignancies typically showed the greatest association with bleeding risk (P <.001 for each anticoagulant).

The study authors concluded that anticoagulation strategies need to be tailored to a patient’s overall condition in order to minimize bleeding risk.

Disclosures: Some authors have declared affiliations with the pharmaceutical industry. Please refer to the original study for a full list of disclosures.


  1. Angelini DE, Radivoyevitch T, McCrae KR, Khorana AA. Bleeding incidence and risk factors among cancer patients treated with anticoagulation [published online April 21, 2019]. Am J Hematol. doi:10.1002/ajh.25494