Use of a DOAC if deep vein thrombosis (DVT) and cancer

Direct oral anticoagulants (DOACs) have a similar efficacy profile compared to subcutaneous injected low-molecular-weight-heparin (LMWH) in patients treated for cancer-associated thrombosis (CAT) (1)

• subanalysis of the Caravaggio study compared the sites of major and clinically relevant non-major bleeding (CRNMB) events, associated cancer sites, clinical presentation, and course of major bleeding in patients with CAT receiving either the DOAC apixaban or the LMWH dalteparin (2)
• major bleeding was present in 3.8% of patients with apixaban and in 4.0% in those treated with dalteparin (HR 0.82, 95%CI: 0.40-1.69) (3)

The study authors concluded that the number of bleedings as well as the clinical presentation and course of major bleeding events in patients treated for CAT were similar in the apixaban and dalteparin treatment groups. These findings were consistent across various cancers, including different gastrointestinal tumor types.

A living, interactive systematic review and network meta-analysis which includes randomized controlled trials (RCTs) evaluated the efficacy and safety of direct DOACs compared with low-molecular-weight heparin (LMWH) in patients with CAT

• DOACs decreased recurrent VTE events compared with dalteparin in patients with CAT (3)
  • was no difference between DOACs and dalteparin with regard to major bleedings
  • DOACs were associated with increased rates of clinically relevant non-major bleeding compared to dalteparin
  • "...DOACs should be considered a standard of care for the treatment of CAT except in patients with a high risk of bleeding. Current evidence favors the use of apixaban for the treatment of CAT among other DOACs..."

RCT (n=604) found that edoxaban treatment for 12 months was superior to 3 months in this population with respect to the composite outcome of a symptomatic recurrent VTE or VTE-related death (1% vs 7.2% in the 12 vs 3-month groups, (OR 0.13; 95% CI, 95% CI 0.03-0.44) (4).

A meta-analysis aimed to compare the efficacy and safety of direct oral anticoagulants (DOACs) and low-molecular-weight heparin (LMWH) for CAT (cancer associated thrombosis) treatment (5)

• analysis (n=4713 from 10 RCTs) found, compared to LMWH, DOAC treatment significantly reduced VTE incidence (incidence risk ratio 0.66, 95% CI 0.56 to 0.79)
  • however, total bleeding (1.10, 0.80 to 1.50) and mortality (1.00, 0.89 to 1.12) did not differ significantly between groups

Reference:

1. Konstantinides SV, Meyer G, Becattini C, et al; ESC Scientific Document Group. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41(04):543–603
2. Ageno W, Vedovati MC, Cohen A, et al. Bleeding with Apixaban and Dalteparin in Patients with Cancer-Associated Venous Thromboembolism: Results from the Caravaggio Study. Thromb Haemost. 2020 Nov 17. doi: 10.1055/s-0040-1720975.
3. Riaz I, Fuentes HE, Arsalan Ahmed Naqviet S et al. Direct Oral Anticoagulants Compared With Dalteparin for Treatment of Cancer-Associated Thrombosis: A Living, Interactive Systematic Review and Network Meta-analysis Mayo Clin Proc. 2022 Feb;97(2):308-324. doi: 10.1016/j.mayocp.2020.10.041.
4. Yamashita Y et al. Edoxaban for 12 Months Versus 3 Months in Cancer Patients With Isolated Distal Deep Vein Thrombosis (ONCO DVT study): An Open-label, Multicenter, Randomized Clinical Trial. Circulation August 28th 2023 https://doi.org/10.1161/CIRCULATIONAHA.123.066360
5. Mousavi A et al. Direct Oral Anticoagulants Versus Low-Molecular-Weight Heparin in Patients With Cancer-Associated Thrombosis: A Meta-Analysis of Randomized Controlled Trials. Am J Cardiol. 2025 Jun 25;254:32-41.