What is the risk of death in a 74-year-old woman with treated breast cancer and malignant melanoma, and a Wells score of 4, without anticoagulation (anti-coagulant therapy)?

From the Guidelines

A 74-year-old woman with treated breast cancer, malignant melanoma, and a Wells score of 4 is at a high risk of death without anticoagulation, and therefore, anticoagulation therapy is strongly recommended to reduce her mortality risk. The patient's Wells score indicates a "likely" probability of deep vein thrombosis (DVT) or pulmonary embolism (PE), with an approximately 28-30% risk of having a DVT or PE 1. Without anticoagulation, she has roughly a 15-25% risk of mortality if a PE develops, with this risk potentially higher given her age and cancer history 1. Cancer patients have 4-7 times higher risk of venous thromboembolism compared to the general population, and both breast cancer and melanoma increase thrombotic risk 1. Her advanced age further elevates this risk. Some key points to consider in this patient's care include:

• The risk of recurrent VTE and early death is higher in cancer patients who develop VTE 1
• The occurrence of VTE for patients with cancer may interfere with planned chemotherapy regimens, worsen patient quality of life, increase the risk of cancer recurrence and mortality, and result in increased costs compared with patients without cancer who experience VTE 1
• Pharmacologic options for VTE treatment and prevention include unfractionated heparin (UFH), low-molecular-weight heparins (LMWHs), fondaparinux, vitamin K antagonists (VKAs), and direct oral anticoagulants (DOACs) 1
• Treatment or prophylaxis of VTE for patients with cancer must always balance the risk of recurrent VTE events with the increased risk of anticoagulant-related bleeding and take into consideration the consequences of these outcomes (including mortality, financial cost, quality of life), as well as patient values and preferences 1 Given these factors, anticoagulation therapy would be strongly recommended, typically with low molecular weight heparin (such as enoxaparin 1mg/kg twice daily) as first-line treatment for cancer-associated thrombosis, or direct oral anticoagulants like apixaban (10mg twice daily for 7 days, then 5mg twice daily) or rivaroxaban (15mg twice daily for 21 days, then 20mg daily) as alternatives 1. Regular monitoring of bleeding risk and reassessment of anticoagulation needs would be essential components of her care plan.

From the Research

Risk of Death in a 74-Year-Old Woman with Treated Breast Cancer and Malignant Melanoma

The risk of death in a 74-year-old woman with treated breast cancer and malignant melanoma, and a Wells score of 4 without anticoagulation, is a complex issue that involves considering the patient's cancer history, age, and the presence of venous thromboembolism (VTE) risk factors.

• The Wells score is a clinical prediction rule used to estimate the probability of deep vein thrombosis (DVT) in patients. A score of 4 or higher indicates a high probability of DVT 2.
• Cancer patients, especially those with a history of breast cancer and malignant melanoma, are at an increased risk of developing VTE due to their hypercoagulable state 3, 4.
• The use of anticoagulation therapy in cancer patients with VTE can reduce the risk of recurrent VTE and mortality, but it also increases the risk of bleeding 5, 6, 4.
• Low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are commonly used anticoagulants in cancer patients with VTE. LMWH may be preferred in certain cancers, while DOACs offer convenience and ease of administration 5, 3, 4.
• The decision to initiate anticoagulation therapy in a cancer patient should balance the benefits and harms, considering the patient's values and preferences, as well as their individual risk factors for VTE and bleeding 6.

Bleeding Risk and Anticoagulation

The bleeding risk in cancer patients without anticoagulation is not directly addressed in the provided studies. However, the studies suggest that cancer patients are at an increased risk of bleeding when receiving anticoagulant therapy, and that a bleeding risk assessment should be performed before initiating anticoagulation 5, 3, 4.

• The risk of major bleeding in cancer patients receiving anticoagulation therapy is a concern, and the choice of anticoagulant should take into account the patient's individual risk factors for bleeding 5, 6, 4.
• Reversal agents or antidotes to bleeding may be required in cases of persistent or life-threatening bleeding, and inferior vena cava (IVC) filter insertion can be considered in patients with major bleeding 5.

Mortality Risk

The mortality risk in a 74-year-old woman with treated breast cancer and malignant melanoma, and a Wells score of 4 without anticoagulation, is not directly addressed in the provided studies. However, the studies suggest that cancer patients with VTE are at an increased risk of mortality, and that anticoagulation therapy can reduce this risk 3, 6, 4.

• The use of LMWH in cancer patients with VTE may reduce mortality compared to unfractionated heparin (UFH) 6.
• The use of DOACs in cancer patients with VTE may be effective in reducing the risk of recurrent VTE, but caution is needed in patients at high risk of bleeding 4.