Treatment of Cancer-Associated Venous Thromboembolism in the Age of Direct Oral Anticoagulants

C. Ay; J. Beyer-Westendorf; I. Pabinger


Ann Oncol. 2019;30(6):897-907. 

In This Article

DOACs for Treatment of Cancer-associated VTE

Due to insufficient data at the time they were drafted, clinical guidelines published before 2018 include few recommendations on DOACs for treatment of cancer-associated VTE.[12,16,17,19] Until recently, there was only mid-level evidence available to inform the use of DOACs in patients with cancer-associated VTE, derived primarily from secondary analyses of pivotal phase III clinical trial data for each of the DOACs (Table 1).[29–32] These studies enrolled limited numbers of patients with cancer, and some excluded patients with active cancer for whom long-term LMWH treatment was planned,[31,32] as well as patients with intracranial neoplasia[29] or life expectancy <6 months.[29,31] Approximately 6% of patients in phase III trials of DOACs versus VKA for VTE treatment had active cancer, although definitions of active cancer differed substantially among the studies (Table 1).[29–33] Nevertheless, all four studies found comparable rates of VTE recurrence and similar or lower rates of bleeding events in patients with active cancer treated with DOACs versus VKAs (Table 1).[29–32] Where cause of major bleeding events was reported, the majority among all patients were considered cancer related.[29,30] A 2015 network meta-analysis of randomized, controlled trials of LMWH, VKAs, and DOACs for treatment of cancer-associated VTE—including these four studies as well six studies comparing LMWH versus VKAs—suggested the efficacy and safety of DOACs were noninferior to VKAs and possibly comparable with LMWH.[34]