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

Abstract

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.

Predicting serious complications in patients with cancer and pulmonary embolism using decision tree modelling: the EPIPHANY Index

“…Unlike other prognostic tools, the EPIPHANY index is applicable across the entire spectrum of PE severity, including both incidental and symptomatic events (Wicki et al , 2000; Aujesky et al , 2006; Uresandi et al , 2007; Jiménez et al , 2010; Kline et al , 2012; Den Exter et al , 2013). The model is a validation and extension of the CDR proposed in several clinical trials with the aim of pragmatically selecting low-risk patients eligible for outpatient care (Siragusa et al , 2005; Zondag et al , 2011; Font et al , 2014; Weeda et al , 2016). These decision-making rules are based on the combination of altered vital signs (e.g., hypotension, hypoxaemia, tachycardia, etc.)…”

“…The introduction of multidetector computed tomography (CT) has increased detection rates of incidental PE, present in 2–8% of the studies performed in cancer patients (Dentali et al , 2010). In some recent series, incidentally diagnosed PE accounted for a∼50% of embolic events (Font et al , 2014, 2016). On the other end of the spectrum of severity, PE is also a common cause of fatal events in daily practice, as well as in trials with new targeted therapies (Ranpura et al , 2011; Den Exter et al , 2013).…”

“…In contrast, subjects at higher risk should receive stepped up care or monitoring (Streiff et al , 2013). Different studies have identified several prognostic factors for cancer-associated symptomatic PE, most decisive among them being the presence of metastasis, immobilisation, low weight, or altered vital signs (Kline et al , 2012; Den Exter et al , 2013; Font et al , 2014, 2016). Several prospective, cohort studies have based selection of low-risk patients eligible for outpatient treatment on pragmatic clinical decision rules (CDR), such as the HESTIA study eligibility criteria, which are based prominently on altered vital signs and risk of bleeding (Siragusa et al , 2005; Zondag et al , 2011; Font et al , 2014; Weeda et al , 2016).…”

British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism (PE)

“…Three studies included only patients with cancer and concurrent VTE, two included DVT/PE 102 103 and one included only patients with cancer and diagnosed PE 100 …”

Symptoms, signs, suspicion and setting: a PESI score for cancer-associated pulmonary embolism?

“…Third, there is a gap in the available evidence for treatment of UPEs because this patient subgroup was excluded from even the most recent randomised controlled trial investigating the efficacy and safety of anticoagulant treatment with low molecular weight heparin versus warfarin for cancer-associated thrombosis [12]. Finally, guideline-endorsed risk assessment models that inform whether patients with PE should be hospitalised or may be treated as outpatients, such as the (simplified) Pulmonary Embolism Severity Index ((s)PESI) [13,14], have limited utility for cancer patients, because they innately classify cancer patients in the "not low-risk" categories [15] or even fail to predict short-term mortality at all [16]. Therefore, cancer-specific PE risk tools have been developed [7,8], but they do not account for UPE.…”