Coagulation

Clinical backing for cancer screening after spontaneous VTE


Limited screening for cancer in patients with spontaneous VTE, as recommended by ISTH and NICE guidelines, is also supported by real world evidence, new research shows.

A New Zealand study has backed screening advice based on observations that spontaneous VTE may be the first sign of previously undiagnosed malignancy.

Clinicians reviewed all 328 adult patients who presented to the Auckland City Hospital Thrombosis Unit with spontaneous DVT or PE during 2010 – 2013.

Spontaneous VTE was defined as occurring in the absence of potential provoking factors such as known active cancer (excluding simple skin cancers), recent surgery or trauma, recent hospitalisation >72 hr, pregnancy or significant immobilisation.

The study, published in the Internal Medicine Journal, found 17 patients were subsequently diagnosed with malignancy including upper and lower GI, lung, prostate and ovarian cancers.

Four cancers were detected incidentally at imaging for the VTE while 13 were detected following limited screening as per guidelines – a focussed clinical history, physical exam, basic lab tests including a FBC, coag screen, serum calcium and creatinine, LFTs, urinalysis, and age and gender-specific cancer screening tests where appropriate.

Some of the suspicious findings promoting further investigation and diagnosis were abdominal pain, weight loss, shortness of breath, pelvic mass and abnormal LFTs.

“In all of the 17 cases there was sufficient basis for a high index of clinical suspicion within the history, physical examination, limited age and gender-appropriate cancer screening investigations as per the NICE and ISTH guidelines or the initial imaging performed to diagnose the associated VTE (i.e. CTPA or limb ultrasound).”

The study found malignancies were mostly advanced stage at the time of identification, with 11 of the 17 patients having at least local nodal involvement and eight having evidence of distal metastases.

“Overall, the observation that all 17 malignancies would have been safely diagnosed based on the ‘limited’ screening approach endorsed by ISTH and NICE guidance provides a level of comfort for using these guidelines in routine clinical practice,” the study said.

“In particular, there was no evidence that abdominal imaging as part of an initial malignancy screen would have yielded additional diagnoses that would have been otherwise missed. This supports the recent removal of this recommendation from NICE guidance in contrast to earlier published guidelines.”

Haematologist Dr Scott Dunkley, from the Royal Prince Alfred Hospital, told the limbic that most clinicians adopted a commonsense approach to cancer screening in older patients with an idiopathic DVT or PE.

“So we just think about that and … make sure there is no suggestion clinically. And then we would just do simple blood tests as much as anything, to assess for coagulation, a FBC, kidneys and liver and then we would do what we think is appropriate for the patients.”

“It is very common to ask someone if they are up to date with mammograms etc. In the men, often we will do a PSA.”

“Generally with the age and appropriate screening, we will write back to the GP for that. Sometimes I will give them a form or the number for BreastScreen, etc.”

Dr Dunkley said RCTs had shown “full-on screening” such as CT scans, special pelvic ultrasounds, colonoscopies and “every blood test you can think of” were not warranted routinely.

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