Originally published as JCO Early Release 10.1200/JCO.2009.23.5788 on September 8 2009

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Diagnosis and Initial Treatment of Venous Thromboembolism in Patients With Cancer

From the Johns Hopkins Anticoagulation Service and Outpatient Clinics, Special Coagulation Laboratory, Johns Hopkins Medical Institutions, Baltimore, MD.

Corresponding author: Michael B. Streiff, MD, Johns Hopkins Medical Institutions, 1830 E Monument St, Suite 7300, Baltimore, MD 21205; e-mail: mstreif{at}jhmi.edu.

Purpose Venous thromboembolism (VTE) is a common complication of cancer and its therapy. The purpose of this article is to review the diagnosis and initial treatment of VTE in the patient with cancer.

Methods I conducted a survey of the English-language literature on topics relevant to the diagnosis and initial treatment of VTE in patients with cancer.

Results Patients with cancer are at increased risk for VTE because of the presence of multiple risk factors for thrombotic disease. The most common signs and symptoms of VTE as well as the utility of clinical prediction rules and D-dimer testing in the diagnosis of VTE in the patient with cancer are reviewed. Duplex ultrasound and computer tomography angiography are the primary objective diagnostic modalities for VTE. Low molecular weight heparin is the preferred initial therapy for VTE. Until further data emerge, thrombolysis and vena cava filters should be reserved for patients in whom anticoagulation is insufficient or contraindicated. Outpatient management is feasible for carefully selected patients with cancer with deep vein thrombosis (DVT) and low-risk pulmonary embolism. Anticoagulation is the preferred initial therapy for cancer patients with central venous catheter–associated DVT, calf DVT, and unsuspected VTE.

Conclusion Optimal initial management of VTE in patients with cancer entails maintaining a high index of suspicion for thrombotic disease, confirming diagnostic suspicions with objective testing and evidence-based use of anticoagulation, and adjunctive therapeutic modalities (thrombolysis, vena cava interruption, venous stenting). Further investigation of initial diagnostic and treatment strategies for VTE focusing on patients with cancer are warranted.

Author's disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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