Recommendations
32.

Offer all patients diagnosed with unprovoked DVT or PE who are not already known to have cancer the following investigations for cancer:

  • a physical examination (guided by the patient’s full history) and
  • a chest X-ray and
  • blood tests (full blood count, serum calcium and liver function tests) and
  • urinalysis.
Relative values of different outcomesNumber of cancers detected (incidence) was considered the most important outcome because early detection of cancer and treatment may improve survival rates and reduce morbidity in patients. It can also enable patients to make better decisions about based on the availability of information on their underlying diagnosis.
Therefore, the sensitivity and specificity of investigations were important outcomes.
Trade off between clinical benefits and harmsThe potential benefit of detecting cancer early and initiating treatment (reducing potential mortality and morbidity), and of instituting the optimal form and duration of anticoagulation (reducing potential morbidity for complication of anticoagulation treatment or recurrence) was considered against the potential harm from using these tests.
These tests apart from chest x-rays and serum Calcium, form part of the routine assessment of all patients with VTE to determine severity, and safety of anticoagulation. Therefore, there is little additional harm associated with their use for clarifying the cause of the VTE, where this may be an underlying cancer. The radiation dose associated with chest x-ray is also minimal, and is done in all patients with a suspected PE, and a proportion with a DVT where there is an associated suspicion of PE. Clinicians have to be aware that VTE can be the presenting symptom of cancer and they should consider cancer while conducting the examination and tests.
These combinations of tests have been shown to detect cancer in about 10% of patients with a first episode of unprovoked VTE with no prior cancer diagnosis. Therefore the GDG recommend that these tests should be offered to all patients with unprovoked VTE. Patients who have a suspected cancer based on these tests should be directed to the appropriate local cancer diagnosis and care pathways.
Economic considerationsOffering baseline tests such as physical examination, history, chest X-ray and blood tests is associated with some costs. However, given the high prevalence of cancer in the screened population, offering these tests have been shown to detect about half of all cancers.
Quality of evidenceThere was no evidence comparing performing the baseline tests vs no tests. However one RCT showed that this combination of tests detect cancer in about 10% of patients with first episode unprovoked VTE. Please see the “Quality of Evidence” section in the recommendation for intensive investigations for further details.
Other considerationsPhysical examination, medical history documentation and baselines tests should be conducted and interpreted with a focus on the possibility that a patient with unprovoked VTE (no obvious risk factor identified) may have an underlying cancer. This should be performed in all patients, as there are few disadvantages and cancer can be effectively detected in up to half of all patients presenting with VTE and having an underlying cancer.

From: 13, Investigations for cancer in VTE patients

Cover of Venous Thromboembolic Diseases
Venous Thromboembolic Diseases: The Management of Venous Thromboembolic Diseases and the Role of Thrombophilia Testing [Internet].
NICE Clinical Guidelines, No. 144.
National Clinical Guideline Centre (UK).
Copyright © 2012, National Clinical Guideline Centre.

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