Low‐molecular‐weight heparin (LMWH), when compared with warfarin, has been shown to reduce the risk of recurrent VTE in patients with cancer‐associated thrombosis (CAT),4 and is therefore the standard treatment for acute CAT for the past 15 years. However, the high cost and significant lifestyle burden associated with LMWH have led many clinicians and investigators to wonder whether the direct oral anticoagulants (DOACs) might be a better choice for primary and/or secondary VTE prevention in patients with cancer.
Based on the aggregate of available evidence, warfarin and other VKA should be a “third choice” for cancer patients, used only in situations where neither a DOAC nor LMWH is feasible.
direct oral anticoagulants :
Direct oral anticoagulants (DOAC)
Four DOACs have been approved for the treatment of DVT and/or PE, including dabigatran, rivaroxaban, apixaban, and edoxaban. All have demonstrated a comparable efficacy and safety to VKA in the cancer subpopulation.37 However, the cancer subpopulation enrolled in these large studies was small and generally had lower risks of both recurrent VTE and hemorrhage when compared with patients enrolled in earlier studies specific to cancer patients (such as CLOT study).38Meta‐analyses have suggested that DOACs and LMWH may have similar efficacy and safety in cancer patients, but these were based on indirect comparisons.38, 39 A few single‐center cohort studies of rivaroxaban for CAT have yielded encouraging results, but all had significant methodologic limitations.40, 41, 42, 43 A recent study explored the use of rivaroxaban in cancer patients with catheter‐related thrombosis also had promising results.44 Overall, these preliminary results are encouraging, but not definitive.