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PO-45 Do all patients with venous thrombosis require screening for malignancy? A predictive model to identify patients with VTE at minimal risk of malignancy
Abstracts / Thrombosis Research 120 Suppl. 2 (2007) S145–S178 patients (0.6%) and other causes included septicaemia and acute myocardial infarction. Conclusions: Pulmonary embolism is an uncommon complication patients in patients undergoing chest surgery for lung or pleural malignant disease. Antithrombotic prophylaxis with unfractionated heparin at a dose of 5,000 U bid or with low molecular heparin appears to be effective in these patients.
PO-45 Do all patients with venous thrombosis require screening for malignancy? A predictive model to identify patients with VTE at minimal risk of malignancy S. Paneesha1 *, W. Zhang2 , N. Parsons2 , P. Kesteven3 , H. Marr3 , A. Borg4 , P. Rose4 . 1 Department of Haematology, Heart of England NHS Foundation Trust, Birmingham; 2 Department of Statistics, University of Warwick, Coventry, 3 Department of Haematology, The Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne; 4 Department of Haematology, Warwick Hospital, Warwick, UK Association between VTE and cancer has been recognised for over a century. The incidence of occult or overt malignancy in patients with thrombosis is 7 26%. VTE has been shown to impart poor prognosis in patients with cancer and cancer also adversely impacts on the survival of patients with VTE. It is desirable to identify patients with thrombosis at an increased risk of malignancy or those with minimal risk, thus avoiding unnecessary investigations. We propose here a predictive model using age, quantitative D-dimer level at presentation along with site of thrombosis. Materials and Methods: This study included 696 (M: 358; F: 338) consecutive patients from the prospectively maintained database of patients with venous thrombosis at a University Teaching Hospital, between February 2001 and December 2005. All patients underwent a Doppler ultrasound examination to confirm the diagnosis and determine the extent of venous thrombosis. At presentation, D-dimer assays were done using bioM´ erieux kit containing mouse monoclonal antibody. The database was regularly updated (6-monthly) using hospital information systems, questionnaires and clinical review. Thrombosis recurrence was always confirmed by Doppler ultrasound examination. All patients with thrombosis received standard treatment with low molecular weight heparin and warfarin. Statistical analysis was carried out using SPSS 13.0 for Windows software. A logistic multivariate regression model was fitted using complete data records from 621 patients with an indicator variable for a subsequent cancer as the response and age, the natural logarithm of the quantitative D-dimer level and the site of the thrombosis as explanatory variables. The fitted model was validated using an additional set of independent data. Results: The model correctly identified the VTE patients without malignancy in 473 out of 480 cases (98.5% accuracy). But the model was ineffective in identifying VTE patients with malignancy (13 out of 141; 9% accuracy). The area under the receiver operating characteristic (ROC) curve was 0.72, indicating that the test developed for predicting cancer for the model data was reasonably good. Our model shows that below a predicted probability of 0.10 less than 5% of the patients actually developed cancer (9/190) whereas for a predicted probability of 0.19 less than 10% of patients actually developed cancer (27/276). In the validation dataset of 93 patients with VTE, the model correctly identified the number of patients without malignancy in 72 out of 73 cases (98.6% accuracy). There were no significant difference in the number VTE patients with cancer between the model and the validation dataset for the predicted probabilities of 0.10 and 0.19 (One-sample binomial tests; p-values of 0.650 and 0.246 respectively). Conclusions: Our model is useful for identifying patients at minimal risk of having malignancy with VTE. This predictive model is reproducible as it has been validated by an independent dataset.
S159
This model will enable a focused and a cost-effective strategy of screening for a malignancy in patients with VTE.
PO-46 Venous thrombosis (VTE) shortens the survival in patients with malignancy S. Paneesha1 *, A. Lokare2 , Z. Lester3 , T. Nokes3 , R. Arya4 , T. Farren5 , A. McManus6 , F. Pressley7 , N. Scriven8 , D. O’Shaughnessy9 , P. Rose2 . 1 Department of Haematology, Heart of England NHS Foundation Trust, Birmingham; 2 Department of Haematology, Warwick Hospital, Warwick; 3 Department of Haematology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth; 4 Haematology, King’s College Hospital, London; 5 Department of Haematology, Barts and The London Hospitals, London; 6 Thrombosis Research Institute, London; 7 Royal Gwent Hospital, Gwent; 8 The Calderdale Royal Hospital, Halifax; 9 Department of Health, London, UK Association between VTE and cancer has been recognised for over a century. The incidence of occult or overt malignancy in patients with thrombosis is 7 26%. Malignancy adversely impacts on the survival of patients with VTE. Data on adverse impact of venous thrombosis on survival in patients with malignancy is conflicting. This study included 902 (M: 463; F: 439) patients from the prospectively maintained database of patients from UK venous thromboembolism registry (VERITY) between February 2001 and December 2006. Counterpart group included 2,263 (F: 1518; M: 745) consecutive patients without venous thrombosis from one site, between February 2001 and December 2005. All patients underwent a Doppler ultrasound examination to confirm the diagnosis and determine the extent of venous thrombosis. At presentation, D-dimer assays were done using bioM´ erieux kit containing mouse monoclonal antibody. The database was regularly updated (6-monthly) using hospital information systems, questionnaires and clinical review. Thrombosis recurrence was always confirmed by Doppler ultrasound examination. All patients with thrombosis received standard treatment with low molecular weight heparin and warfarin. Statistical analysis was carried out using SPSS 13.0 for Windows software. Median age at presentation was 66 yrs (16 96). Median D-dimer level was 2,500 ug FEU/ml (range: 100 40,000 ug FEU/ml). 17.3% had D-dimer >8,000ug FEU/ml. 61% had above-knee VTE while 34% had below-knee VTE. 522 patients had no malignancy, 89 had bowel, 61 prostate, 56 breast, 41 gynaecological, 29 lung and 102 had miscellaneous carcinoma. Median follow-up was 21 months (range: 0 74). Mean overall survival (OS) in non-VTE patients without malignancy was 56 months as compared to 54 months in VTE patients with malignancy. Mean OS in VTE patients with carcinoma breast was 34 months (counterpart group: 47 mo). Median OS in VTE patients with carcinoma bowel was 9 months (counterpart group: 36 mo). Median OS in VTE patients with carcinoma prostate was 31 months (counterpart group: 33 m). Median OS in VTE patients with gynaecological carcinoma was 17 months (counterpart group: 50 mo). Median OS in VTE patients with miscellaneous carcinoma was 9 months (counterpart group: 30 mo). Median OS in VTE patients with carcinoma lung was 5 months (counterpart group: 4 mo). Median D-dimer levels in VTE patients without malignancy, Ca Breast, Ca bowel, Ca Prostate, Gynaecological Ca, Miscellaneous Ca and Ca Lung respectively were 2,200, 3,650, 4,100, 2,850, 3,140, 3,230 and 3,400 ug FEU/ml. D-dimer >8,000ug FEU/ml was associated with shorter survival (Log rank test; p value <0.001). Conclusions: Our study shows occurrence of VTE shortens the survival in patients with malignancies. Our study also shows D-dimer >8000ug FEU/ml is associated with significant shorter survival. More studies are warranted to determine whether this adverse impact correlates with the thrombogenicity of underlying malignancy rather than recurrence and also can it be negated by optimum anticoagulant therapy.
PO-45 Do all patients with venous thrombosis require screening for malignancy? A predictive model to identify patients with VTE at minimal risk of malignancy S. Paneesha1 *, W. Zhang2 , N. Parsons2 , P. Kesteven3 , H. Marr3 , A. Borg4 , P. Rose4 . 1 Department of Haematology, Heart of England NHS Foundation Trust, Birmingham; 2 Department of Statistics, University of Warwick, Coventry, 3 Department of Haematology, The Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne; 4 Department of Haematology, Warwick Hospital, Warwick, UK Association between VTE and cancer has been recognised for over a century. The incidence of occult or overt malignancy in patients with thrombosis is 7 26%. VTE has been shown to impart poor prognosis in patients with cancer and cancer also adversely impacts on the survival of patients with VTE. It is desirable to identify patients with thrombosis at an increased risk of malignancy or those with minimal risk, thus avoiding unnecessary investigations. We propose here a predictive model using age, quantitative D-dimer level at presentation along with site of thrombosis. Materials and Methods: This study included 696 (M: 358; F: 338) consecutive patients from the prospectively maintained database of patients with venous thrombosis at a University Teaching Hospital, between February 2001 and December 2005. All patients underwent a Doppler ultrasound examination to confirm the diagnosis and determine the extent of venous thrombosis. At presentation, D-dimer assays were done using bioM´ erieux kit containing mouse monoclonal antibody. The database was regularly updated (6-monthly) using hospital information systems, questionnaires and clinical review. Thrombosis recurrence was always confirmed by Doppler ultrasound examination. All patients with thrombosis received standard treatment with low molecular weight heparin and warfarin. Statistical analysis was carried out using SPSS 13.0 for Windows software. A logistic multivariate regression model was fitted using complete data records from 621 patients with an indicator variable for a subsequent cancer as the response and age, the natural logarithm of the quantitative D-dimer level and the site of the thrombosis as explanatory variables. The fitted model was validated using an additional set of independent data. Results: The model correctly identified the VTE patients without malignancy in 473 out of 480 cases (98.5% accuracy). But the model was ineffective in identifying VTE patients with malignancy (13 out of 141; 9% accuracy). The area under the receiver operating characteristic (ROC) curve was 0.72, indicating that the test developed for predicting cancer for the model data was reasonably good. Our model shows that below a predicted probability of 0.10 less than 5% of the patients actually developed cancer (9/190) whereas for a predicted probability of 0.19 less than 10% of patients actually developed cancer (27/276). In the validation dataset of 93 patients with VTE, the model correctly identified the number of patients without malignancy in 72 out of 73 cases (98.6% accuracy). There were no significant difference in the number VTE patients with cancer between the model and the validation dataset for the predicted probabilities of 0.10 and 0.19 (One-sample binomial tests; p-values of 0.650 and 0.246 respectively). Conclusions: Our model is useful for identifying patients at minimal risk of having malignancy with VTE. This predictive model is reproducible as it has been validated by an independent dataset.
S159
This model will enable a focused and a cost-effective strategy of screening for a malignancy in patients with VTE.
PO-46 Venous thrombosis (VTE) shortens the survival in patients with malignancy S. Paneesha1 *, A. Lokare2 , Z. Lester3 , T. Nokes3 , R. Arya4 , T. Farren5 , A. McManus6 , F. Pressley7 , N. Scriven8 , D. O’Shaughnessy9 , P. Rose2 . 1 Department of Haematology, Heart of England NHS Foundation Trust, Birmingham; 2 Department of Haematology, Warwick Hospital, Warwick; 3 Department of Haematology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth; 4 Haematology, King’s College Hospital, London; 5 Department of Haematology, Barts and The London Hospitals, London; 6 Thrombosis Research Institute, London; 7 Royal Gwent Hospital, Gwent; 8 The Calderdale Royal Hospital, Halifax; 9 Department of Health, London, UK Association between VTE and cancer has been recognised for over a century. The incidence of occult or overt malignancy in patients with thrombosis is 7 26%. Malignancy adversely impacts on the survival of patients with VTE. Data on adverse impact of venous thrombosis on survival in patients with malignancy is conflicting. This study included 902 (M: 463; F: 439) patients from the prospectively maintained database of patients from UK venous thromboembolism registry (VERITY) between February 2001 and December 2006. Counterpart group included 2,263 (F: 1518; M: 745) consecutive patients without venous thrombosis from one site, between February 2001 and December 2005. All patients underwent a Doppler ultrasound examination to confirm the diagnosis and determine the extent of venous thrombosis. At presentation, D-dimer assays were done using bioM´ erieux kit containing mouse monoclonal antibody. The database was regularly updated (6-monthly) using hospital information systems, questionnaires and clinical review. Thrombosis recurrence was always confirmed by Doppler ultrasound examination. All patients with thrombosis received standard treatment with low molecular weight heparin and warfarin. Statistical analysis was carried out using SPSS 13.0 for Windows software. Median age at presentation was 66 yrs (16 96). Median D-dimer level was 2,500 ug FEU/ml (range: 100 40,000 ug FEU/ml). 17.3% had D-dimer >8,000ug FEU/ml. 61% had above-knee VTE while 34% had below-knee VTE. 522 patients had no malignancy, 89 had bowel, 61 prostate, 56 breast, 41 gynaecological, 29 lung and 102 had miscellaneous carcinoma. Median follow-up was 21 months (range: 0 74). Mean overall survival (OS) in non-VTE patients without malignancy was 56 months as compared to 54 months in VTE patients with malignancy. Mean OS in VTE patients with carcinoma breast was 34 months (counterpart group: 47 mo). Median OS in VTE patients with carcinoma bowel was 9 months (counterpart group: 36 mo). Median OS in VTE patients with carcinoma prostate was 31 months (counterpart group: 33 m). Median OS in VTE patients with gynaecological carcinoma was 17 months (counterpart group: 50 mo). Median OS in VTE patients with miscellaneous carcinoma was 9 months (counterpart group: 30 mo). Median OS in VTE patients with carcinoma lung was 5 months (counterpart group: 4 mo). Median D-dimer levels in VTE patients without malignancy, Ca Breast, Ca bowel, Ca Prostate, Gynaecological Ca, Miscellaneous Ca and Ca Lung respectively were 2,200, 3,650, 4,100, 2,850, 3,140, 3,230 and 3,400 ug FEU/ml. D-dimer >8,000ug FEU/ml was associated with shorter survival (Log rank test; p value <0.001). Conclusions: Our study shows occurrence of VTE shortens the survival in patients with malignancies. Our study also shows D-dimer >8000ug FEU/ml is associated with significant shorter survival. More studies are warranted to determine whether this adverse impact correlates with the thrombogenicity of underlying malignancy rather than recurrence and also can it be negated by optimum anticoagulant therapy.