Cancer Patients with VTE Treated in ED Face Higher Mortality Risks

One in five cancer patients will develop a blood clot at some point during the course of their illness, increasing their risk of morbidity and mortality.

Cleveland Clinic researchers recently investigated venous thromboembolism (VTE ) — which includes deep vein thrombosis (DVT) and/or pulmonary embolism (PE) — prevalence in cancer patients in the emergency department (ED) setting, and the associated utilization of health care resources and costs.

“We’ve done a lot of research to show these clots are really important and consequential for cancer patients,” says Alok Khorana, MD, Vice Chair for Clinical Services at Cleveland Clinic Cancer Center, who recently presented data from the investigation at the American Society of Hematology’s annual meeting.

“VTE can lead to the delay or discontinuation of treatment,” he says,” and may lead to additional health care resource utilization including emergency room visits and hospital admissions.”

Higher rate of admission, costs, death

Dr. Khorana and his colleagues used the Agency for Healthcare Research and Quality sponsored Nationwide Emergency Department Sample (NEDS) database to identify cancer patients and ED utilizations between 2006 and 2012. The NEDS database captures 20 percent of US ED visits.

Using ICD-9 codes to identify cancer types and VTE, they found 6,330,322 ED visits by cancer patients during the study period, of which the overall VTE rate was 2.35 (95% CI: 2.34-2.37) per 100 ED visits.

The researchers found that cancer patients with VTE had a higher rate of death in the ED (6.5 vs 4 percent of those without VTE, P for trend < 0.0001) and a higher rate of admission (92 vs 61 percent of those without VTE, P for trend < 0.0001). The cost of their care was also higher. From 2006 to 2012, the total median hospital costs of cancer patients with VTE increased from $26,069 to $34,254 and were consistently higher than those without VTE.

Increased use of scans

Dr. Khorana and his colleagues also noted that 1.6 percent of patients received either computed tomography pulmonary angiography (CTPA), CT chest with contrast (CTC), duplex ultrasound of the veins (DUS) or ventilation-perfusion (VQ) scan during their ED visits and that use of these imaging studies increased over time from 0.92 to 2.35 per 100 ED visits.

“We found that there was increased use of certain types of scans to diagnose VTE, which is a good thing,” Dr. Khorana says. “This could mean ED providers are more aware of this diagnosis and they’re looking for it. On the other hand, it could also indicate the risk of this complication is going up because more people are being diagnosed with it, and that’s not such a good thing.”

The investigators also found that patients with pancreatic cancer had the highest rate (5.84 per 100 ED visits), followed by lung (3.51 per 100 ED visits) and stomach cancers (3.09 per 100 ED visits). Patients with thyroid, prostate and head and neck cancers had the lowest rates.

Prevention, early detection key

Dr. Khorana says prevention and early detection could lower the risks for cancer patients developing VTE. He and his colleagues also presented on a study they conducted showing that performing lower extremity ultrasounds on cancer patients who are at high risk for blood clots can help catch VTE early before a patient ends up in the ED.

Finally, he says there’s data that show the injectable drug low molecular weight heparin can reduce the risk of patients developing VTE. He also says there are ongoing clinical trials looking at oral agents to prevent blood clots in cancer patients.

Dr. Khorana and his colleagues, for instance, are participating in the CASSINI trial, which should be completed in late 2018 or early 2019. There is also Canadian-run trial AVERT with a similar timeline.

“I think this study emphasizes the need to continue those prevention-type approaches,” he says, “because once a patient is in the emergency room with a clot then the chances of a bad thing happening is pretty high. We don’t want it to get to that point.”

Photo Credit: Annie O’Neill