DVT and cancer

and cancer? Deep vein thrombosis and pulmonary emboli which can make up venous thromboembolic disease are much commoner in patients who have an underlying malignancy. They can be the first signs and symptoms of the cancer may actually be the presentation of the deep vein thrombosis, the pulmonary embolus or sometimes a superficial vein thrombosis in the lower limbs which go on to give a deep vein thrombosis and subsequent embolic disease. We know that if you have cancer you probably have a four to five fold increased risk of developing a deep vein thrombosis. If you develop a deep vein thrombosis and you have underlying active malignancy, there is obviously a recommendation for long-term treatment with anticoagulation. The standard teaching at present is that you should use low molecular weight heparin rather than warfarin or a direct oral anticoagulant. However, in the last six months to a year, there is increasing evidence to suggest that the oral heparin such as rivoxaban or a Pixaban, which make up part of the DOAC group, the direct oral anticoagulants, are actually safe to use during a episode of active cancer and reduce the risk of VTE to the same extent as low molecular weight heparin. Do all individuals who develop a DVT undergo cancer screening? The role of screening for patients who present with a deep vein thrombosis is an area of controversy. Often, when somebody presents with a deep vein thrombosis and that is the harbinger of them having an underlying malignancy, it means that the malignancy is usually fairly florid. There are some studies that have suggested that actually even if you screen people who present with a deep vein thrombosis who have cancer, that you may not actually improve their long-term survival. However, these views are all relatively controversial. The overall recommendations from the NICE guidance, which are followed fairly well around most of the world are that if you have somebody who has got what we call an unprovoked deep vein thrombosis that there is no obvious cause such as a long-haul flight, surgery or maybe a compression in the upper limb between the collarbone and the clavicle giving rise to a thoracic outlet syndrome then you should perform some screening. This screening would probably take the role of taking routine blood tests such as a full blood count, use and ease, some liver function tests looking at a film, a chest x-ray and an abdominal and pelvic ultrasound. There are some people who would advocate that a formal CT scan is done of the whole torso. Again the recommendations for screening for malignancy will be different in different countries and different healthcare systems, however if you have an unprovoked deep vein thrombosis it is important that a very full and comprehensive history is taken to try and rule out any underlying malignancy. It's very important if you have a female patient that their breasts are examined and that you rule out any evidence of breast carcinoma. And finally, do individuals who've received a diagnosis of cancer receive DVT prophylaxis? The answer is that the majority of patients who have a diagnosis of cancer do not receive DVT prophylaxis. There are exceptions to this with some of the very aggressive tumors or blood disorders who are going under forms of chemotherapy where there will be a discussion with the oncologists and the hematologists as to whether pharmacological prophylaxis should be used. There are occasional patients who will have infiltration of their malignancy into a blood vessel such as the inferior vena cava which puts them at a greater risk of developing a VTE and again in this cohort you may consider giving them chemoprophylaxis. However, this is very much on an individual patient basis. However, globally, for the majority of patients with active cancer, we do not put them on two prophylactic measures. Thank you.