Safety and efficiency of D-dimer testing in combination with clinical decision rules to exclude pulmonary embolism in patients with cancer: individual patient data meta-analysis.

Background Failure rates of clinical decision rules (CDRs) combined with D-dimer to exclude pulmonary embolism (PE) are higher in patients with cancer compared to non-cancer patients, raising concerns about their use in this patient group.Objective To compare the failure rates of the Wells score, revised Geneva score and YEARS algorithm in patients with cancer who underwent standard imaging to those in whom the imaging was withheld and report the diagnostic yield of those algorithms.Methods We used data from an individual-patient level meta-analysis of prospective diagnostic management studies in patients with suspected PE. The primary outcome was the 3-month VTE incidence after excluding PE (failure) when using fixed and age adjusted (AA) D-dimer results across different patient management categories of all investigated CDRs. Secondary outcome included the proportion of patients in whom PE could be ruled out without further imaging (diagnostic yield).Results A total of 2,258 (7.6%) patients with cancer from 17 studies could be included in the analysis. The 3-month VTE incidence in patients in whom PE was excluded varied from 0.52% (95% CI 0.06 - 4.35) to 2.83% (95% CI 0.96 - 8.34) and was comparable across all management categories. The highest diagnostic yield of 26% was found for the revised Geneva score with AA D-dimer cut-off and the YEARS algorithm.Conclusions The failure rates in patients with cancer in whom PE is excluded using CDRs withholding imaging is similar to that observed after standard imaging. Current diagnostic algorithms for suspected PE are applicable to patients with cancer.