Venous thromboembolism (VTE) is a common and serious complication among cancer patients. Mitochondrial DNA (mtDNA) copy number is known to influence various cellular pathways involved in cancer development. While an association between reduced mtDNA and VTE risk in non-cancer patients was previously reported, its relationship with VTE in cancer patients remains unclear. Therefore, we aimed to investigate the association between mtDNA copy number and VTE risk in a nested-case control study of 48 patients from the Vienna Cancer and Thrombosis Study (CATS), a prospective observational cohort study. The mtDNA copy number was measured in equally distributed age, sex, cancer type, and stage matched patients with and without VTE using a qPCR-based method. Of the 48 patients, 24 were diagnosed with VTE (median age [IQR] 62 [57-60] years, 54.2 % female) and 24 had no VTE event (median age [IQR] 63 [58-71] years, 54.2 % female). We found that patients who developed VTE had lower mtDNA copy numbers compared to those without VTE (216.73 [167.99-401.39] vs 301.47 [210.66-526.84]). Multivariable analysis adjusting for chronological age, D-dimer, sex, cancer stage and BMI revealed that each 10-unit increase in mtDNA copy number decreased the odds of VTE occurrence by 5.9 % (p = 0.021). Patients with distant metastatic cancer (M1) had lower mtDNA copy numbers than those without distant metastasis at study inclusion (220.34 [172.67-323.70] vs 328.48 [213.89-556.68
p = 0.052). Overall, our findings suggest a potential link between reduced mtDNA copy number and increased VTE risk in cancer patients.