Outpatient Management of Pulmonary Embolism in Cancer: Data on a Prospective Cohort of 138 Consecutive Patients

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The purpose of this prospective cohort study was to assess the feasibility of outpatient treatment in patients with cancer and objectively confirmed pulmonary embolism (PE), and to compare the performance of the different prognostic scales available in this setting. Patients were selected for outpatient management according to a set of exclusion criteria. Outcomes at 30 and 90 days of follow-up included thromboembolic recurrences, major bleeding, and all-cause death. The performance of 4 prognostic scales (Pulmonary Embolism Severity Index, Geneva Prognostic Score, POMPE-C, and Registro Informatizado de Enfermedad Tromboembólica [RIETE registry]) was evaluated. Of 138 patients, 62 (45%) were managed as outpatients. Incidental PE constituted 47% of the sample. Most patients treated at home had an incidentally detected PE (89%). The rate of recurrence and major bleeding events was similar in both groups. Mortality rates were higher for patients admitted to the hospital compared with outpatients at 30 days (18% vs 3%; P=.06) and 90 days (34% vs 10%; P=.001) of follow-up. None of the patients selected for home treatment required further admission because of PE complications. None of the prognostic models developed for symptomatic PE was significantly associated with 30-day mortality. Improved survival outcomes were observed in incidentally detected PEs compared with acute symptomatic events (overall mortality rates, 3.2% vs 18.4%; P=.006). A large proportion of patients with cancer and PE may be safely treated as outpatients, especially those with incidental PE. Cancer-specific prognostic scales including incidental PE should be developed for the optimal management of PE in this setting.

Correspondence: Carme Font, MD, PhD, Hospital Clinic Provincial, Villarroel 170, 08036-Barcelona Spain. E-mail: cfont@clinic.ub.es

Authors contributed equally to the preparation of this article.

  • 1.

    PrandoniPFalangaAPiccioliP. Cancer and venous thromboembolism. Lancet Oncol2005;6:401410.

  • 2.

    TapsonVF. Acute pulmonary embolism. N Engl J Med2008;358:10371052.

  • 3.

    StreiffMB. Diagnosis and initial treatment of venous thromboembolism in patients with cancer. J Clin Oncol2009;27:48894894.

  • 4.

    CarsonJLKelleyMADuffA. The clinical course of pulmonary embolism. N Engl J Med1992;326:12401245.

  • 5.

    LaporteSMismettiPDecoususH. Clinical predictors for fatal pulmonary embolism in 15,520 patients with venous thromboembolism: findings from the Registro Informatizado de la Enfermedad Tromboembolica Venosa (RIETE) registry. Circulation2008;11:17111716.

    • Search Google Scholar
    • Export Citation
  • 6.

    HuttenBPrinsMGentM. Incidence of recurrent thromboembolic and bleeding complications among patients with venous thromboembolism in relation to both malignancy and achieved international normalized ratio: a retrospective analysis. J Clin Oncol2000;18:30783083.

    • Search Google Scholar
    • Export Citation
  • 7.

    KearonCAklEAComerotaAJ. Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest2012;141(Suppl):e419S494S.

    • Search Google Scholar
    • Export Citation
  • 8.

    SquizzatoAGalliMDentaliF. Outpatient treatment and early discharge of symptomatic pulmonary embolism: a systematic review. Eur Respir J2009;33:11481155.

    • Search Google Scholar
    • Export Citation
  • 9.

    ErkensPGandaraEWellsP. Safety of outpatient treatment in acute pulmonary embolism. J Thromb Haemost2010;8:24122417.

  • 10.

    KovacsMJHawelJDRekmanJF. Ambulatory management of pulmonary embolism: a pragmatic evaluation. J Thromb Haemost2010;8:24062411.

  • 11.

    OteroRUresandiFJiménezD. Home treatment in pulmonary embolism. Thromb Res2010;126:e15.

  • 12.

    AujeskyDRoyPMVerschurenF. Outpatient versus inpatient treatment for patients with acute pulmonary embolism: an international, open-label, randomized, non-inferiority trial. Lancet2011;378:4148.

    • Search Google Scholar
    • Export Citation
  • 13.

    DonzéJLe GalGFineMJ. Prospective validation of the Pulmonary Embolism Severity Index: a clinical prognostic model for pulmonary embolism. Thromb Haemost2008;100:943948.

    • Search Google Scholar
    • Export Citation
  • 14.

    WickiJPerrierAPernegerTV. Predicting adverse outcome in patients with acute pulmonary embolism: a risk score. Thromb Haemost2000;84:548552.

    • Search Google Scholar
    • Export Citation
  • 15.

    JimenezDAujeskyDMooresL. Simplification of the pulmonary embolism severity index for prognostication in patients with acute symptomatic pulmonary embolism. Arch Intern Med2010;170:13831389.

    • Search Google Scholar
    • Export Citation
  • 16.

    JakobssonCJimenezDGomezV. Validation of a clinical algorithm to identify low-risk patients with pulmonary embolism. J Thromb Haemost2010;8:12421247.

    • Search Google Scholar
    • Export Citation
  • 17.

    KlineJARoyPMThanMP. Derivation and validation of a multivariate model to predict mortality from pulmonary embolism with cancer: the POMPE-C tool. Thromb Res2012;129:e194199.

    • Search Google Scholar
    • Export Citation
  • 18.

    Den ExterPLGomezVJimenezD. A clinical prognostic model for the identification of low-risk patients with acute symptomatic pulmonary embolism and active cancer. Chest2013;143:138145.

    • Search Google Scholar
    • Export Citation
  • 19.

    Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA1990;263:27532759.

    • Search Google Scholar
    • Export Citation
  • 20.

    BüllerHRAgnelliGHullRD. Antithrombotic therapy for venous thromboembolic disease: the Seventh ACCP Conference on antithrombotic and thrombolytic therapy. Chest2001;126:401428.

    • Search Google Scholar
    • Export Citation
  • 21.

    KearonCKhanSRAgnelliG. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines (8th Edition). Chest2008;133:454545.

    • Search Google Scholar
    • Export Citation
  • 22.

    SchulmanSKearonC. Definition of major bleeding in clinical investigations of antihemostatic medicinal products in non-surgical patients. J Thromb Haemost2005;3:692694.

    • Search Google Scholar
    • Export Citation
  • 23.

    DeLongERDeLongDMClark-PearsonDL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics1998;44:837845.

    • Search Google Scholar
    • Export Citation
  • 24.

    SiragusaSArcaraCMalatoA. Home therapy for deep vein thrombosis and pulmonary embolism in cancer patients. Ann Oncol2005;16:136139.

  • 25.

    AgenoWSteidlLMarchesiC. Selecting patients for home treatment of deep vein thrombosis: the problem of cancer. Haematologica2002;87:286291.

    • Search Google Scholar
    • Export Citation
  • 26.

    ZondagWMosICCreemers-SchildD. Outpatient treatment in patients with acute pulmonary embolism: the Hestia Study. J Thromb Haemost2011;9:15001507.

    • Search Google Scholar
    • Export Citation
  • 27.

    SorensenHTMellemkjaerLOlsenJH. Prognosis of cancers associated with venous thromboembolism. N Engl J Med2000;343:18461850.

  • 28.

    PaneeshaSMcManusAAryaR. Frequency, demographics and risk (according to tumour type or site) of cancer-associated thrombosis among patients seen at outpatient DVT clinics. Thromb Haemost2010;103:338343.

    • Search Google Scholar
    • Export Citation
  • 29.

    SinghRSousouTMohileS. High rates of symptomatic and incidental thromboembolic events in gastrointestinal cancer patients. J Thromb Haemost2010;8:18791881.

    • Search Google Scholar
    • Export Citation
  • 30.

    SunJMKimTSLeeJ. Unsuspected pulmonary emboli in lung cancer patients: the impact on survival and the significance of anticoagulation therapy. Lung cancer2010;69:330336.

    • Search Google Scholar
    • Export Citation
  • 31.

    Di NisioMFerranteNDe TursiM. Incidental venous thromboembolism in ambulatory cancer patients receiving chemotherapy. Thromb Haemost2010;104:10491054.

    • Search Google Scholar
    • Export Citation
  • 32.

    FontCFarrúsBVidalL. Incidental versus symptomatic venous thrombosis in cancer patients: a prospective observational study of 340 consecutive patients. Ann Oncol2011;22:21012106.

    • Search Google Scholar
    • Export Citation
  • 33.

    O’ConnellCIBoswellWDDuddalwarV. Unsuspected pulmonary emboli in cancer patients: clinical correlates and relevance. J Clin Oncol2006;24:49284932.

    • Search Google Scholar
    • Export Citation
  • 34.

    Den ExterPLHoojerJDekkersOM. Risk of recurrent venous thromboembolism and mortality in patients with cancer incidentally diagnosed with pulmonary embolism: a comparison with symptomatic patients. J Clin Oncol2011;29:24052409.

    • Search Google Scholar
    • Export Citation
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