Screening for occult cancer in patients with idiopathic venous thromboembolism: yes

[Thromboembolic disease and cancer: Attitude and practice of general practitioners. A qualitative study]

INTRODUCTION

Cancer is a major public health problem in France. Idiopathic venous thromboembolic disease may be one of the modes of discovery. Few studies have been performed on this subject in primary care. The general practitioner plays a key role in the diagnosis for which a more codified approach seems desirable. The aim was to study how general practitioners conceive the search for cancer in patients with idiopathic venous thromboembolic disease in primary care.

METHOD

A qualitative study, inspired by the grounded theory approach, was carried out using semi-structured interviews with 12 established general practitioners. It was conducted from May to July 2022. The interview guide was developed based on data from the literature.

RESULTS

Idiopathic venous thromboembolic disease as a mode of cancer discovery in primary care was a well-known topic among general practitioners but remained a difficult exercise in practice. Our study revealed similarities in their practices: a complete anamnesis, clinical examination, verification of screening tests, and finally a TAP scan. They emphasized the importance of collaboration with angiologists and asked for a more codified management.

DISCUSSION

The question of etiology of cancer remains unanswered. General practioners would like to be made aware of a common, codified attitude. This raises the question of the applicability of the recommendations. The aim is to avoid misdiagnosing a cancer or delaying a diagnosis, while at the same time, not unnecessarily exposing certain patients to excessive investigations when these are not needed. So, it is time to think about better dissemination of recommendations, tools to help GPs easily finding what they need among the multitude of existing recommendations and tools, to establish better collaboration between general practice and hospital medicine, and between general practice and specialist medicine in order to improve cancer diagnosis as early as possible.

Screening for occult cancer: where are we in 2020?

The relationship between venous thromboembolism (VTE) and cancer has become an area of intense debate due to the importance and the potential benefits of the identification of occult cancer following the diagnosis of unprovoked VTE. At present, extended screening is not recommended in patients with unprovoked VTE. However, if we were able to identify a group at greater risk of presenting cancer during follow-up, these patients would benefit from extended screening. The creation of a trans-organ screening model enables the unification of metrics of quality in the screening of cancer in different localizations. Likewise, it can incorporate cancer screening for other localizations or other specific situations of risk such as unprovoked VTE. This study summarizes the contribution of the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) initiative aimed at improving the cancer screening process. Likewise, we have carried out an updated review of unprovoked VTE and occult cancer. Finally, we discuss the studies currently ongoing aimed at identifying the population at greatest risk of presenting cancer during follow-up. The identification of this population at high risk could help to determine the following steps to undertake in order to implement screening in this population.

Screening cancer after venous thromboembolism: How many abnormal tests before diagnosing cancer? An analysis of practice

INTRODUCTION

Since Trousseau, we knows that venous thrombemboembolism (VTE) can reveal occult cancer. Different strategies of cancer screening have been evaluated: they are often time-consuming, cause stress and anxiety, and frequently require second-look examinations (due to the risk of false positives), with ultimately a very low yield (about 5%). We evaluated the number of suspect cancer tests before reporting them to the number of cancers finally diagnosed, after a VTE, in the setting of practice's analysis.

METHODS

We studied retrospectively patients hospitalized for a VTE and with a cancer screening, between 2011 and 2012. Screening cancer was defined by performing at least one of the following tests: PSA, fecal occult blood test, mammography, abdominopelvic iconography (abdominal ultrasound and/or abdominal CT scan). We recorded the suspected cancer tests, the cancers diagnosed, their stage and the survival. These results were expressed as a percentage with a 95% confidence interval.

RESULTS

Out of the 491 patients treated for a VTE, screening cancer was performed on 295 patients (median age 66.2 years). Nineteen PSA (16.7%, 95% CI [10.3-25]) were abnormal, with 2 localized prostate cancers. Nineteen fecal occult blood tests (15.3%, 95% CI [9.5-23]) were positive, with 2 local cancers. Five mammograms suspected cancer (4.7% 95% CI [1.6-10.8]) for one confirmed. Thirty-eight abdomino-pelvic iconographies (14.4% 95% CI [10.4-19.2]) were suspect, with 7 confirmed cancers, 6 being metastatic at times of diagnostic.

CONCLUSION

Among the 607 tests performed, 81 were suspected of cancer (13.3%) for only 12 cancers confirmed (2.0%). Screening cancer exposes patients to several false positive tests.

Occult cancer detection in patients with hemostatic disorder and venous thromboembolism

There are physiologic ties between Von Willebrand Factor (VWF) and circulating tumor cells. VWF appears to play a role in tumor biology, but it is unclear whether cancer behavior differs in Von Willebrand Disease. In patients presenting with venous thromboembolism (VTE), occult cancer is frequently considered as an underlying cause. The prevalence of occult cancer after provoked VTE is low (3%); therefore, cancer screening in these patients is not routinely recommended. In those with unprovoked VTE, occult cancer is more prevalent, estimated between 4 and 10%. Due to this elevated risk, occult cancer screening is recommended in this population. Multiple studies have investigated whether a "limited" approach (including history and physical exam, basic labs, and chest X-ray) versus "extensive" approach (addition of advanced imaging, such as computer tomography) is more effective. Current data fails to demonstrate extensive screening strategies diagnose more occult cancer, miss fewer cancers during follow up, or improve cancer-related mortality. Furthermore, many patients may be needlessly exposed to unnecessary diagnostic procedures with their associated complications and costs, as well as significant anxiety. Therefore, the decision to perform additional testing should be made on a case-by-case basis. Additional studies are needed to identify subgroups of patients with unprovoked VTE at highest risk for occult cancer.

Low incidence of cancer after venous thromboembolism: An update from the French OPTIMEV Cohort

BACKGROUND

Recent studies have shown lower rates of cancer following venous thromboembolism (VTE) than previously described.

OBJECTIVES

To reassess the risk of cancer in patients with clinical symptoms of VTE with or without confirmed VTE.

PATIENTS

We used data from OPTIMEV, a French prospective multicenter observational study of patients presenting to hospital and community vascular medicine specialists with suspected VTE. Patients with confirmed VTE (1565) and matched controls without VTE (1847) were followed for 3 years (2006-2009). The main outcome was occurrence of cancer at 3 years, and death was a censoring event.

RESULTS

A total of 5.0% [4.0-6.3] of patients with VTE and 3.8% [3.0-4.9] without VTE developed cancer during follow-up. The adjusted hazard ratio (HR) was 1.2 [0.9-1.8] for patients with confirmed VTE (P=0.22). The overall standardized incidence ratio (SIR) was 1.4 [1.1-1.6] for our population, VTE+ and VTE-, compared with the general population, statistically significant (P<0.05).

CONCLUSIONS

We found a lower occurrence of cancer after VTE than previously described, with no significant difference between patients whether VTE was confirmed or not. Our results (low incidence and no difference between patients VTE+ or VTE-) provide no argument in favor of an extensive screening for cancer in case of VTE.

Impact of anatomical location of lower limb venous thrombus on the risk of subsequent cancer

After a proximal deep-vein thrombosis (P-DVT), the risk of diagnosis of a previously unsuspected cancer is high. Isolated distal DVT (iD-DVT; i.e. infra-popliteal DVT without pulmonary embolism [PE]) and isolated superficial-vein thrombosis (iSVT; i.e. without concomitant DVT and PE) are at least as frequent as P-DVT but their association with subsequent cancer is uncertain. We exploited data from the OPTIMEV prospective, observational, multicentre study to i) compare the risk of subsequent cancer three years after a first objectively confirmed iSVT, iD-DVT and iP-DVT in patients without a prior history of cancer or of venous thromboembolism, ii) assess predictors of subsequent cancer in cases of iD-DVT. The overall cumulative rates of cancer among the 304 patients with iSVT, 536 patients with iD-DVT, and 327 patients with iP-DVT were similar (3.4% 95% confidence interval [1.8-6.2], 3.9% [2.5-5.9] and 3.9% [2.3-6.8], respectively), regardless of whether the index venous thromboembolic event was unprovoked or associated with a major transient risk factor. Neither anatomical (muscular vs deep-calf DVT) nor ultrasound scan characteristics (number of thrombosed veins, clot diameter under compression) seemed strongly associated with the risk of cancer in cases of iD-DVT. In patients managed in routine practice, all the different clinical expressions of lower limb venous thromboembolism are associated with a similar risk of subsequent cancer. From a clinical practice point of view, this suggests that cancer screening, without discussing the necessity, or not, of such screening, should not differ between a deep-proximal, deep-distal or superficial location of thrombosis.

Epidemiology of cancer-associated venous thrombosis

Cancer-associated venous thrombosis is a common condition, although the reported incidence varies widely between studies depending on patient population, start and duration of follow-up, and the method of detecting and reporting thrombotic events. Furthermore, as cancer is a heterogeneous disease, the risk of venous thrombosis depends on cancer types and stages, treatment measures, and patient-related factors. In general, cancer patients with venous thrombosis do not fare well and have an increased mortality compared with cancer patients without. This may be explained by the more aggressive type of malignancies associated with this condition. It is hypothesized that thromboprophylaxis in cancer patients might improve prognosis and quality of life by preventing thrombotic events. However, anticoagulant treatment leads to increased bleeding, particularly in this patient group, so in case of proven benefit of thromboprophylaxis, only patients with a high risk of venous thrombosis should be considered. This review describes the literature on incidence of and risk factors for cancer-associated venous thrombosis, with the aim to provide a basis for identification of high-risk patients and for further development and refinement of prediction models. Furthermore, knowledge on risk factors for cancer-related venous thrombosis may enhance the understanding of the pathophysiology of thrombosis in these patients.

[Incidence and distribution of 1026 lower limb venous thrombi diagnosed by ultrasonography in 3263 patients with cancer]

The study objective was to evaluate the incidence, characteristics and distribution of lower limb deep venous thrombi diagnosed by ultrasound among known cancer patients, in order to determine additional criteria that could be used to help select patients with unprovoked deep venous thrombosis caused by occult cancer.

PATIENTS AND METHODS

From January 2001 to May 2012, standardized report forms (n=38,424) were entered into a database. A total of 3263 report forms corresponding to cancer patients with suspected venous thrombo-embolic disease were selected from which 1026 cases of deep venous thrombosis were diagnosed by ultrasonography. Baseline characteristics, incidence, and anatomic distribution of venous thrombi were analyzed.

RESULTS

For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients with thrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins.

CONCLUSION

Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

The effect of cadmium on the coagulation and fibrinolytic system in women with uterine endometrial cancer and myoma

OBJECTIVES

Cadmium (Cd) is a persistent and widespread environmental pollutant, which may constitute a potential risk factor for hormone-dependent tumors such as endometrial cancer. The vascular endothelium is an important target of cadmium toxicity, which may interfere with the coagulation cascade and fibrinolytic system. The aim of this research was to investigate whether in female patients with uterine endometrial cancer or myoma in comparison to healthy women, the concentration of cadmium in blood affects the process of coagulation and fibrinolysis.

MATERIALS AND METHODS

The study group comprised 91 women: 35 healthy (A-control), 39 with uterine myoma (B) and 17 with endometrial cancer (C), in which blood cadmium concentrations (BCd), coagulation and selected fibrinolysis parameters in plasma were assayed.

RESULTS

In the women with myoma and especially in those with endometrial cancer disturbances in coagulation and fibrinolysis were detected when compared to the healthy women. In the group of women with endometrial cancer significant changes in prothrombin index, levels of fibrinogen, fibrin D-dimer and t-PA were observed. Whereas, in the patients with myoma significant changes in prothrombin time, index of vWillebrand Factor and fibrin D-dimer level were noted. Mean BCd concentrations in subsequent groups were as follows: B - 0.91±0.81; C - 0.78±0.45 μg Cd/l and did not differ significantly in comparison with the control group (0.86±0.35 μg Cd/l). However, in each study group smokers had approximately twice as high BCd as non-smokers. Studies also showed significant associations between BCd and fibrinogen level and thrombin time among the women with myoma and endometrial cancer, as well as in healthy women. Moreover, thrombin time significantly correlated with fibrinogen level in the women studied.

CONCLUSIONS

In the patients with myoma and especially in these with endometrial cancer disturbances in coagulation and fibrinolysis parameters leading to hypercoagulability were detected. Exposure to cadmium can be one of the factors inducing these changes.

Systematic screening for occult cancer in elderly patients with venous thromboembolism: a prospective study

BACKGROUND

Cancer is an established risk factor for venous thromboembolism (VTE) and the incidence of cancer increases in the elderly. The benefit of screening for occult cancers in this population is still not clear.

AIM

To evaluate a systematic screening programme for cancer in elderly patients with VTE.

METHODS

This was a prospective study with a 12-month follow-up period. It was conducted in a single centre in consecutive patients over the age of 70 years who had a confirmed diagnosis of VTE. Predefined non-invasive screening techniques for cancer with clinical, laboratory (including tumour markers) and radiological investigations (abdominal ultrasound, chest X-ray and a thoraco-abdominopelvic computed tomography scan) were evaluated.

RESULTS

Fifty patients with a median age of 80 years (range: 70 to 94 years) were included. One patient was diagnosed with chronic lymphocytic leukaemia at inclusion and cancers were found in three other patients during the follow-up period (rectosigmoid adenocarcinoma with hepatic metastases, hepatocellular carcinoma and gastric adenocarcinoma). Only one of the four cancers could have been treated at an earlier stage. The mortality rate of the entire cohort after 12 months was 28%. Two patients died as a direct consequence of cancer.

DISCUSSION

  In this study of elderly patients, a non-invasive screening strategy did not detect several cancers that were subsequently overt clinically. A full history, clinical examination and routine laboratory investigations might be the optimal first-line strategy to detect cancer after the diagnosis of VTE in elderly patients, but regular clinical examinations during follow up are warranted.

Is extensive screening for cancer in idiopathic venous thromboembolism warranted?

BACKGROUND

Patients with a first episode of idiopathic venous thromboembolism (IVTE) have an estimated 10% incidence of cancer within 12 months after diagnosis. However, the utility of screening for cancer in this population is controversial.

METHODS

In this prospective concurrently controlled cohort study, limited and extensive cancer screening strategies were compared. All 630 patients underwent baseline screening consisting of history, physical examination, basic laboratory tests and chest X-ray. In the extensive screening group abdominal and chest CT scan and mammography were added. Outcomes were incidence and curability of cancer, and cancer-related and overall mortality.

RESULTS

In 12 of the 342 (3.5%) patients in the extensive screening group malignancy was diagnosed at baseline compared with 2.4% (seven of 288 patients) in the limited screening group. Extensive screening detected six additional cancers (2.0%; 95% CI, 0.74-4.3), of which three were potentially curable. During a median 2.5 years of follow-up, cancer was diagnosed in 3.7% and 5.0% in the extensive and limited screening groups, respectively. In the extensive screening group 26 patients (7.6%) died compared with 24 (8.3%) in the limited screening group; adjusted hazard ratio 1.22 (95% CI, 0.69-2.22). Of these deaths 17 (5.0%) in the extensive screening group and 8 (2.8%) in the limited screening group were cancer related; adjusted hazard ratio 1.79 (95% CI, 0.74-4.35).

CONCLUSIONS

The low yield of extensive screening and lack of survival benefit do not support routine screening for cancer with abdominal and chest CT scan and mammography in patients with a first episode of IVTE.

Venous thromboembolic events and organ-specific occult cancers: a review and meta-analysis

BACKGROUND

Despite a recognized association between venous thromboembolic events (VTE) and cancer, little is known about the strength and the features of this association. We performed a meta-analysis in order to clarify this issue.

METHODS

We retrieved data from 40 reports published between 1982 and 2007: 12 contained cancer risk estimates for patients with either idiopathic or secondary VTE vs. subjects without VTE and 17 for patients with idiopathic vs. secondary VTE. We also pooled risk estimates from four cohort studies to assess the association between VTE and specific forms of cancer and conducted a proportional incidence study, based on the remaining 28 reports, which did not provide risk estimates.

RESULTS

The pooled relative risk (RR) of cancer was 3.2 [95% confidence interval (95% CI) 2.4-4.5] for patients with any form of VTE vs. no VTE, 2.7 (95% CI 1.9-3.9) for patients with idiopathic vs. no VTE and 3.8 (95% CI 2.6-5.4) for patients with idiopathic vs. secondary VTE. In the pooled cohort studies, RRs for VTE vs. no VTE were significantly elevated for cancers of the ovary (RR 7.0), pancreas (RR 6.1), liver (RR 5.6), blood (4.2), brain (RR 3.8), kidney (RR 3.4), lung (3.1), colon (2.9), and esophagus (2.1). In the proportional incidence study, cancers of the pancreas, colon, and blood were significantly more frequently observed than in the general population.

CONCLUSIONS

Overall we found a 3-fold excess risk of occult cancer in patients with VTE. The risk varies according to tumor site and is highest for cancers of the ovary, pancreas, and liver.

Recent advances in cardiorespiratory medicine: management of pulmonary embolism and prevention of venous thromboembolism, recent treatment strategies in childhood asthma, and dermatological adverse reactions to cardiovascular drugs

This article is the fifth in a series of CPD articles aimed at reviewing the recent general medical literature relating to topics that may be of interest to dermatologists. This issue looks at advances in cardiorespiratory medicine, including the management of pulmonary embolism and prevention of venous thromboembolism (VT), recent treatment strategies in childhood asthma, and an update on dermatological adverse reactions to cardiovascular drugs.

Clinical outcome in patients with venous thromboembolism and hidden cancer: findings from the RIETE Registry

INTRODUCTION

Although extensive screening in patients with venous thromboembolism (VTE) may result in early identification of hidden cancer, it is unknown whether the prognosis of these patients may be favorably influenced.

PATIENTS AND METHODS

RIETE is an ongoing, prospective registry of consecutive patients with objectively confirmed, symptomatic, acute VTE. We compared the 3-month outcome of patients with hidden cancer with that in patients in whom no symptoms of cancer were noted.

RESULTS

Of 17,475 patients with acute VTE, 2852 (16%) had cancer diagnosed before VTE or during admission. Hidden cancer was detected in 178 (1.2%) of the remaining 14,623 patients. The most common sites were lung, prostate, colorectum, or hematologic, and 51% had metastases. As compared with patients in whom no symptoms of cancer were noted, those with hidden cancer had an increased incidence of recurrent VTE (11.4% vs. 2.1%; P < 0.001), major bleeding (5.1% vs. 2.1%; P = 0.007), and mortality (20% vs. 5.4%; P < 0.001). In the multivariate analysis, patients aged 60-75 years [odds ratio 1.8; 95% CI 1.2-2.7], with idiopathic VTE (odds ratio 3.0; 95% CI 2.2-4.2), with bilateral thrombosis (odds ratio 2.3; 95% CI 1.3-4.1) or with anemia (odds ratio 1.9; 95% CI 1.4-2.6) were at an increased risk for hidden cancer.

CONCLUSIONS

VTE patients with hidden cancer have an increased incidence of recurrences, major bleeding or death during the first 3 months of therapy. With four simple, easily obtainable variables, it is possible to identify a subgroup of VTE patients with a higher risk for hidden cancer.

Thrombosis as a harbinger of cancer

PURPOSE OF REVIEW

The aim of this review is to explore the state of the art knowledge on the possible association between venous thromboembolism, especially idiopathic venous thromboembolism, and occult cancer, and to speculate on its implications.

RECENT FINDINGS

Venous thromboembolism, especially idiopathic venous thromboembolism, is sometimes associated with a subsequent increased risk of newly discovered cancers during the follow-up period. Its incidence approximates 10%. The performance of extensive screening procedures for cancer identification when venous thromboembolism is diagnosed appears advisable if it provides an impact on cancer-related mortality. Recent prospective trials have observed that, thanks to extensive screening procedures, most hidden cancers are detected at baseline or at an earlier stage. Data from these studies do not conclusively demonstrate that earlier diagnosis ultimately prolongs life, but the collective observation makes such a beneficial effect likely.

SUMMARY

Venous thromboembolism, especially in its idiopathic presentation, may sometimes be a marker for a hidden cancer. With extensive screening procedures, the earlier discovery of cancer, which might mean identification of the disease at an attachable stage, may be crucial, because innovations in treatment protocols provide increasing chances of success and the eradication of cancer.