Validation of a prognostic score for hidden cancer in unprovoked venous thromboembolism

Abstract

The usefulness of a diagnostic workup for occult cancer in patients with venous thromboembolism (VTE) is controversial. We used the RIETE (Registro Informatizado Enfermedad Trombo Embólica) database to perform a nested case-control study to validate a prognostic score that identifies patients with unprovoked VTE at increased risk for cancer. We dichotomized patients as having low- (≤2 points) or high (≥3 points) risk for cancer, and tried to validate the score at 12 and 24 months. From January 2014 to October 2016, 11,695 VTE patients were recruited. Of these, 1,360 with unprovoked VTE (11.6%) were eligible for the study. At 12 months, 52 patients (3.8%; 95%CI: 2.9–5%) were diagnosed with cancer. Among 905 patients (67%) scoring ≤2 points, 22 (2.4%) had cancer. Among 455 scoring ≥3 points, 30 (6.6%) had cancer (hazard ratio 2.8; 95%CI 1.6–5; p<0.01). C-statistic was 0.63 (95%CI 0.55–0.71). At 24 months, 58 patients (4.3%; 95%CI: 3.3–5.5%) were diagnosed with cancer. Among 905 patients scoring ≤2 points, 26 (2.9%) had cancer. Among 455 patients scoring ≥3 points, 32 (7%) had cancer (hazard ratio 2.6; 95%CI 1.5–4.3; p<0.01). C-statistic was 0.61 (95%CI, 0.54–0.69). We validated our prognostic score at 12 and 24 months, although prospective cohort validation is needed. This may help to identify patients for whom more extensive screening workup may be required.

A clinical practice-based evaluation of the RIETE score in predicting occult cancer in patients with venous thromboembolism

“…The RIETE score was not able to identify a subgroup of patients with a high risk of occult cancer, contrary to prior validations [ 10 – 12 ]. When applied only to men, the score was able to identify a subgroup of patients with a high risk of occult cancer, but the performance was poor in the whole group.…”

“…The study included patients with unprovoked and provoked VTE, but only 12% of patients with no cancer at VTE presentation were included in the study [ 9 ]. Three validations of the RIETE score have been published [ 10 – 12 ]. These validations are, however, hampered by several limitations.…”

“…These validations are, however, hampered by several limitations. The first validation was performed in a cohort of unprovoked VTE patients from the same registry that was used to develop the score and thus had a similar rate of missing data [ 10 ]. Post hoc analyses have also been performed on VTE patients included in two clinical trials, the MVTEP study (unprovoked VTE) [ 11 ] and the Hokusai-VTE trial (unprovoked and provoked VTE) [ 12 ].…”

Cancer Screening in Patients with Unprovoked Thromboembolism: How to do it and Who Benefits?

“…When calculating the RIETE score for the population with uVTE, we concluded that 69.5% (N=41) had a score equal or above 3 and, therefore, a risk of occult cancer superior to 10%. According to the score validation trials, this may be the subgroup that benefits the most from ES [18]. In these trials, one-third of the population was at high risk, which leads to the conclusion that our population would have a higher risk.…”

“…Several clinical and analytical factors have revealed a predictive value for the identification of patients with uVTE at increased risk of cancer [14][15][16][17]. The Computerized Registry of Patients with Venous Thromboembolism (RIETE) score was validated for this purpose, with the highest risk being present in patients who meet three or more of the following criteria: male gender, age equal or superior to 70 years, chronic lung disease, anemia, thrombocytosis, previous VTE and recent surgery [18]. However, it remains unclear which patients should undergo more extensive screening and whether the earlier detection of cancer improves patients' morbidity, mortality, and quality of life.…”