Is it safe to use the YEARS algorithm in patients with active cancer?
Bottom line up top: Based on limited high-quality evidence, it appears safe to use the YEARS algorithm when evaluating patients with active cancer for pulmonary embolism.
Clinical scenario
A 56-year-old man with colon cancer currently on chemotherapy presents with pleuritic chest pain. Vitals are unremarkable: HR 72, BP 120/80, SpO₂ 99% on room air, RR 14, T 98.7 °F. His exam is unremarkable except for mild left-sided chest wall tenderness, in the same area where he has pain with deep breathing. Your concern for PE is low, and because he is PERC positive you order a D-dimer. You are unsure whether you can use the YEARS algorithm to raise the D-dimer cutoff.
What your gut says: Use the standard cutoff. Patients with active cancer cannot be entered into the YEARS algorithm.
What the evidence says
The problem YEARS tries to solve
PE is hard to diagnose clinically because its presentation varies, so we depend on objective testing.
Decision instruments such as PERC and the Wells score sort patients into low or high probability to focus the use of CT pulmonary angiography (CTPA).
Despite these tools, CTPA use is increasing while the diagnostic yield is falling (< 10%). The result is overdiagnosis of subsegmental PE, unnecessary radiation, false positives, unnecessary anticoagulation, and longer ED stays.
YEARS aimed to improve the diagnostic performance of the D-dimer without increasing missed PE.
How YEARS works
If the clinician answers "no" to all three YEARS items:
clinical signs of DVT
hemoptysis
PE is the most likely diagnosis
then the D-dimer threshold is doubled (500 → 1,000 ng/mL FEU, or 250 → 500 ng/mL DDU).
The original study found no significant increase in missed PE and a significant reduction in CTPA (van der Hulle 2017). Later studies validated these findings (Kabrhel 2018; Eddy 2020). Current guidelines support YEARS but stop short of endorsing it for patients with active cancer, because of limited data.
New data in active cancer
A recent JAMA trial randomized nearly 700 patients with suspected PE and active cancer and found the YEARS approach non-inferior to standard evaluation for 90-day VTE/PE-related outcomes (failure rate: YEARS 1.5% vs standard approach 5.5%) (Akerboom 2026).
YEARS could have avoided CTPA in 22% of patients, a significant reduction, without more missed PE.
Clinical bottom line
Using the YEARS algorithm to assess for PE in patients with active cancer appears safe and effective at reducing imaging. More studies are needed, but it is reasonable to use YEARS in this subgroup.
Clinical pearls
YEARS: no DVT signs, no hemoptysis, and PE not the most likely diagnosis means a D-dimer cutoff of 1,000 ng/mL FEU.
Active cancer was historically a reason to avoid YEARS. New randomized data suggest it is safe in this group.
Know your lab's D-dimer units (FEU vs DDU) before applying any threshold.
Resources
References
van der Hulle T, et al. Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study. Lancet. 2017;390:289–297. PMID: 28549662
Kabrhel C, et al. Multicenter evaluation of the YEARS criteria in emergency department patients evaluated for pulmonary embolism. Acad Emerg Med. 2018;25(9):987–994. PMID: 29603819
Eddy M, et al. External validation of the YEARS diagnostic algorithm for suspected pulmonary embolism. J Thromb Haemost. 2020;18(12):3289–3295. PMID: 32869501
Akerboom B, et al. YEARS algorithm for diagnosis of suspected pulmonary embolism in patients with cancer. JAMA. 2026. PMID: 42437322
