Screening for Occult Cancer in Unprovoked Venous Thromboembolism — SOME trial Ovarian Cancer and Us OVARIAN CANCER and US Ovarian Cancer and Us

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Sunday, June 28, 2015

Screening for Occult Cancer in Unprovoked Venous Thromboembolism — SOME trial



open access + Commentary

Venous thromboembolism, which comprises deep-vein thrombosis and pulmonary embolism, is the third most common cardiovascular disorder.1-3 It is classified as provoked when it is associated with a transient risk factor (e.g., trauma, surgery, prolonged immobility, or pregnancy or the puerperium) and as unprovoked when it is associated with neither a strong transient risk factor nor overt cancer.
Unprovoked venous thromboembolism may be the earliest sign of cancer4,5; up to 10% of patients with unprovoked venous thromboembolism receive a diagnosis of cancer in the year after their diagnosis of venous thromboembolism.6 More than 60% of occult cancers are diagnosed shortly after the diagnosis of unprovoked venous thromboembolism.6 Thereafter, the incidence rate of cancer diagnosis gradually declines and returns to the rate in the general population after 1 year.5-7
Faced with these troubling statistics, clinicians, patients, and policymakers struggle with how aggressive to be in screening for occult cancers in patients who present with unprovoked venous thromboembolism.
The rationale for screening is to allow early detection and intervention and ultimately reduce cancer-related mortality. However, owing to the paucity of data in this context, there is great variation in practice. Whereas some studies have suggested that a limited screening strategy for occult cancer — including history taking, physical examination, routine blood testing, and chest radiography — is adequate to detect most occult cancers, other studies have suggested that a more extensive screening strategy (e.g., incorporating ultrasonography or computed tomography [CT] of the abdomen and pelvis, measurement of tumor markers, or a combination of these) can substantially increase the rate of detection of occult cancer.8-11 We conducted a randomized clinical trial to assess the efficacy and safety of adding CT of the abdomen and pelvis to a limited screening strategy for occult cancer.

Methods

Study Design and Oversight

The Screening for Occult Malignancy in Patients with Idiopathic Venous Thromboembolism (SOME) trial was a multicenter, open-label, randomized clinical trial comparing comprehensive CT of the abdomen and pelvis in addition to limited occult-cancer screening with limited occult-cancer screening alone in patients with unprovoked venous thromboembolism. The members of the steering committee (see the Supplementary Appendix, available with the full text of this article at NEJM.org).....



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