VTE occurs in 20% of cancer patients and is the second leading cause of morbidity and mortality in cancer. Common thromboembolic complications in cancer patients include DVT, PE, and Trousseau's syndrome. Screening cancer patients who present with VTE finds an undiagnosed cancer rate of 10% for those with no prior risk factors and 1.9-2.9% for those with prior risk factors. High risk cancer patients presenting with VTE should undergo extensive screening testing including CT scans and tumor markers to detect cancer early and improve outcomes. While screening increases cancer detection, no clear survival benefit has been proven.

1. Screening for Cancer in
Thromboembolic Disease

2. Epidemiology
• 20% of VTE occur in cancer patient
• 2nd most frequent cause of morbidity, mortality in cancer patients

3. Manifestations
• DVT and PE are the two most common thromboembolic
complications
• Trousseau's syndrome
• Pancreatic and Lung cancer
• Hepatic vein thrombosis (Budd-Chiari syndrome)
• Hematologic and Hepatocellular malignancies
• Marantic endocarditis (NBTE)
• lung cancer and mucin-producing adenocarcinoma
• Arterial thrombus

4. Estimated Prevalence of VTE during the
Course of Common Types of Cancer

5. Pathogenesis of DVTs in Malignancy
Procoagulant activity •Tissue Factor
•Cancer Procoagulant
•FV receptor
Fibrinolytic activity •u-PAR
•u-PA
•t-PA
•PAI-1
•PAI-2
Cytokine release •IL-1β
•TNF-α
•VEGF
Cell-cell interactions •Interaction with Endothelial cells
•Monocytes-macrophages
•Platelet

6. Factors determining screening
• Incidence of the particular cancer
• Cost
• Accuracy, and acceptability of the screening tests
• Early detection of such cancers would improve patient outcome

7. Screening for Cancer
• Large prospective studies of patients presenting with VTE find an
incidence of previously undiagnosed cancer on average of 10%
• No prior risk: higher incidences of cancer, of 7.3% to 12%
• Prior risk: 1.9% to 2.9%
• 44% was found to have metastases at the time of diagnosis
compared with 35% of controls
• One-year survival was only 12% compared with 36% in the controls

8. High Risk Patients
• Recurrent DVT is twice as likely in patients with cancer
• DVT while on anticoagulation therapy
• Arterial thrombus
• Embolism to the digits, brain, or solid organs
• NBTE
• Hepatic vein thrombosis

9. Testing
• Limited
• H&P
• Basic Labs (CBC, CMP)
• Routine cancer screening
• Chest radiograph
• Extensive
• Everything in limited
• A chest, abdominal, and pelvic CT scan
• Tumor markers (carcinoembryonic antigen, alpha-fetoprotein, CA 19-9, CA 125,
PSA)
• Mammography and a Papanicolaou smear in women
• Upper and lower gastrointestinal tract evaluation

10. Conclusion
• Although testing leads to the increased identification of cancer, no
convincing survival advantage seen
• First episode of uncomplicated unprovoked VTE should undergo
Limited testing
• High risk patients should undergo Extensive testing
• Test within first 6 months after diagnosis of VTE

11. Sources
• Evaluating patients with established venous thromboembolism for
acquired and inherited risk factors ;Kenneth A Bauer, MD; Gregory
YH Lip, MD, FRCPE, FESC, FACC, UpToDate
• Caine GJ, Stonelake PS, Lip GY, Kehoe ST. The Hypercoagulable
State of Malignancy: Pathogenesis and Current Debate. Neoplasia
(New York, NY). 2002;4(6):465-473.