From the Guidelines
The risk of recurrent bleeding per tumor site is highest in gastrointestinal tumors, particularly those in the upper GI tract, with rates of 25-50% without intervention. This is based on the most recent evidence from the 2022 NCCN clinical practice guidelines in oncology 1. The guidelines highlight that acute bleeding is common in patients with gastric cancer and may be tumor-related or a consequence of therapy.
Tumor Site and Rebleeding Risk
- Gastrointestinal tumors: 25-50% rebleeding rate without intervention
- Urogenital tumors: 15-30% rebleeding rate
- Respiratory tract tumors: 20-35% rebleeding rate
- Brain tumors: 10-25% rebleeding rate, depending on location and vascularity
Management of Rebleeding
- Local hemostatic measures: endoscopic interventions for GI bleeds, embolization for accessible vascular tumors, and surgical resection when feasible
- Systemic approaches: antifibrinolytic agents like tranexamic acid, correction of coagulopathies, and consideration of radiation therapy for radiosensitive tumors
- Regular monitoring of hemoglobin levels and prompt intervention at early signs of bleeding can significantly reduce morbidity and mortality in these patients, as suggested by the guidelines 1.
The risk of rebleeding correlates with tumor vascularity, invasion of major blood vessels, tumor size, and underlying coagulation status, emphasizing the need for a multidisciplinary approach to manage bleeding in patients with cancer, as recommended by the guidelines 1.
From the Research
Risk of Recurrent Bleeding per Tumour Site
- The risk of recurrent bleeding varies depending on the tumour site, with certain sites having a higher risk of bleeding than others 2, 3.
- Patients with gastrointestinal cancer have a higher incidence of bleeding compared to other tumours, across all anticoagulants 3.
- Independent risk factors for major bleeding in patients with cancer-associated venous thromboembolism include genitourinary cancer site, upper gastrointestinal cancer site, and non-resected luminal gastrointestinal cancer 2.
- The risk of bleeding is also increased in patients with metastatic disease, chronic kidney disease, and thrombocytopenia 3.
Tumour Sites with High Risk of Bleeding
- Genitourinary cancer site: associated with a higher risk of major bleeding (HR 2.72,95% CI 1.28-5.77) 2.
- Upper gastrointestinal cancer site: associated with a higher risk of major bleeding (HR 3.17,95% CI 1.22-8.23) 2.
- Non-resected luminal gastrointestinal cancer: associated with a higher risk of major bleeding (HR 2.77,95% CI 1.38-5.56) 2.
- Gastrointestinal cancer: associated with a higher incidence of bleeding compared to other tumours, across all anticoagulants 3.
Anticoagulant Treatment and Bleeding Risk
- The risk of bleeding is higher in cancer patients treated with anticoagulation, regardless of the anticoagulant used 3.
- Direct oral anticoagulants (DOACs) have a heterogeneous safety profile in patients with cancer-associated venous thromboembolism, but may be considered as anticoagulant options in selected patients 4.