A simple test that involves answering several clinical questions and completing a blood test can accurately predict if cancer patients have a blockage in one of the arteries leading to the lungs.
The YEARS algorithm was non-inferior to doing a computed tomography pulmonary angiography (CTPA) scan, which is current common practice for cancer patients with a suspected pulmonary embolism.
As reported in JAMA, 22% of patients in the study did not need to have CT scanning at all, avoiding a more invasive form of screening that also exposes patients to radiation.
Patients with active cancer have an estimated 11-fold increase in risk for blood clotting events such as venous thromboembolism or pulmonary embolism compared with people without cancer. Until now, guidelines specifically cautioned against using clinical decision rules like YEARS in cancer patients, leaving clinicians with no validated alternative to CT scanning.
While CTPA is an accurate way to diagnose a pulmonary embolism, it requires patients be injected with contrast dye and scanned in a hospital setting, which is a relatively invasive an expensive option for patients who already have cancer.
The YEARS algorithm requires answers to three questions: does the patient have signs of deep vein thrombosis, are they coughing up blood, and does the clinician think pulmonary embolism is the most likely diagnosis? A blood test measuring D-dimer, a measure of recent clot formation in the body, is also required.
If the answers to the questions are all no, the D-dimer test must be below 1000 ng/ml, whereas if one or more questions are answered in the affirmative then the D-dimer level has to be below 500 ng/ml. If it is above these levels then patients are referred for CTPA scanning.
In this study, Menno Huisman, MD, PhD, a clinician researcher at Leiden University Medical Center, and colleagues tested whether the YEARS algorithm could safely replace CTPA for cancer patients. Researchers randomized 698 cancer patients with suspected pulmonary embolism across 21 hospitals in six European countries. Half were assigned to YEARS-guided management and half to immediate CTPA.
The researchers measured diagnostic failure, defined as a missed pulmonary embolism or death from this cause within 90 days of testing, and reported a rate of 1.8% in the YEARS group versus 5.5% in the CTPA-only group. Almost a quarter of the YEARS group managed to avoid having CTPA altogether.
“Even though the majority of patients with cancer and suspected pulmonary embolism still have to undergo CTPA, the use of the YEARS algorithm in this setting will result in a substantial annual reduction in the total number of CTPAs performed,” write the authors. If widely adopted, they estimate use of YEARS could eliminate 70,000–80,000 unnecessary CT scans annually in the U.S. alone.
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