Systematic Review: The Trousseau Syndrome Revisited: Should We Screen Extensively for Cancer in Patients with Venous Thromboembolism?

2 September 2008 | Volume 149 Issue 5 | Pages 323-333

Background: Identifying previously undiagnosed cancer in patients with newly diagnosed venous thromboembolism (VTE) is important. Screening for malignant conditions can potentially diagnose more cases of cancer and at earlier stages, thereby preventing cancer-associated morbidity and perhaps mortality.

Purpose: To summarize the period prevalence of previously undiagnosed cancer at baseline (within 1 month of VTE diagnosis), 6 months, and 12 months after VTE diagnosis and to quantify the additional value of an extensive cancer screening strategy (limited screening plus imaging techniques or tumor marker measurement) at baseline compared with more limited screening (history, physical examination, and simple widely available tests) at baseline.

Data Sources: MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and Evidence-Based Medicine Reviews.

Study Selection: A total of 36 studies that reported the prevalence of undiagnosed cancer at baseline, 6 months, and 12 months were selected. Fourteen articles and 1 abstract also met inclusion criteria for the assessment of extensive versus limited cancer screening.

Data Extraction: Two reviewers independently extracted data onto standardized forms.

Data Synthesis: The period prevalence of previously undiagnosed cancer in patients with unprovoked VTE was 6.1% (95% CI, 5.0% to 7.1%) at baseline and 10.0% (CI, 8.6% to 11.3%) from baseline to 12 months. An extensive screening strategy using computed tomography of the abdomen and pelvis statistically significantly increased the proportion of previously undiagnosed cancer detected from 49.4% (CI, 40.2% to 58.5%) (with limited screening alone) to 69.7% (CI, 61.1% to 77.8%) in patients with unprovoked VTE.

Limitation: The investigators could not determine complication rates, cost-effectiveness, and difference in morbidity and mortality associated with extensive screening strategies.

Conclusion: Previously undiagnosed cancer is frequent in patients with unprovoked VTE. Many cases of previously undiagnosed cancer are missed by screening. An extensive cancer screening strategy detects more malignant conditions than does a limited screening strategy.

Editors' Notes Context Screening and surveillance for occult cancer in patients with unprovoked venous thromboembolism (VTE) is poorly understood. Contribution The authors systematically reviewed studies of occult cancer in patients with newly diagnosed unprovoked VTE. In 36 studies, the combined prevalence of occult cancer was 6.1% at baseline and 10.0% at 12 months after VTE diagnosis. The proportion of occult cancer diagnosed at baseline was 49.4% with limited screening and 69.7% with extensive screening. Caution The report did not describe the outcomes of newly diagnosed cancer associated with VTE. Implication Because only two thirds of cases of occult cancer are diagnosed at baseline, patients with unprovoked VTE need ongoing surveillance. —The Editors

 

Author and Article Information

From the University of Ottawa and the Ottawa Health Research Institute, Ottawa, Ontario, Canada, and Brest University Hospital, Brest, France.

Grant Support: Dr. Carrier is a recipient of a Canadian Institutes of Health Research Fellowship. Dr. Fergusson is a recipient of a Canadian Institutes of Health Research New Investigator Research Award. Dr. Rodger is the recipient of a Career Scientist Award from the Heart and Stroke Foundation of Ontario. Dr. Wells is a recipient of a Canada Research Chair.

Potential Financial Conflicts of Interest: Honoraria: P.S. Wells (Dade Behring, bioMérieux, Sanofi-Aventis, Leo Pharma, Organon).

Requests for Single Reprints: Marc A. Rodger, MD, MSc, Clinical Epidemiology Program, Ottawa Health Research Institute, 501 Smyth Road, Room W6116, Eye Institute, Ottawa, Ontario K1H 8L6, Canada; e-mail, mrodger{at}ohri.ca.

Current Author Addresses: Drs. Carrier, Fergusson, and Ramsay: Eye Institute, 501 Smyth Road, Room W6109, Ottawa, Ontario K1H 8L6, Canada.

Dr. Le Gal: Centre Hospitalier Universitaire de la Cavale Blanche, EA 3878, 29609 Brest, France.

Dr. Wells: Ottawa Hospital, Civic Campus, Suite F6-49, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.