Anticoagulants for Cancer-Related VTE: What Works Best?

Liam Davenport

July 28, 2023


Direct oral anticoagulants (DOACs) are associated with a reduced risk of venous thromboembolism (VTE), major bleeding, and mortality for cancer patients with VTE in comparison with low-molecular-weight heparin (LMWH), according to a recent analysis of US claims data.


  • This retrospective cohort study of electronic records claims data from OptumLabs included adults with an active primary cancer and acute VTE.

  • Patients had filled an anticoagulation prescription within 30 days of VTE onset and were categorized on the basis of the anticoagulant prescribed: DOAC, LMWH, or warfarin.

  • Patients were followed until the end of treatment. VTE recurrence and all-cause mortality were the main efficacy endpoints, and major bleeding episodes and bleeding sites were the main safety endpoints.

  • Overall, 5100 patients were included (mean age, 66.3 years); a majority (69.8%) were White, 15.7% were Black, and 7.6% were Hispanic. The patients had a range of cancer types, including lung, colorectal, gynecologic, and urologic.

  • Nearly half of patients (49.3%) filled prescriptions for DOACs, 29.2% for LMWH, and 28.6% for warfarin.


  • Compared with DOACs, LMWH and warfarin were associated with an increased risk of VTE recurrence (hazard ratio [HR], 1.47 and 1.46, respectively).

  • LMWH use was associated with an increased risk of major bleeding (HR, 2.27) and all-cause mortality (HR, 1.61) compared with DOAC use; mortality rates did not differ significantly between warfarin and DOACs (HR, 1.19; 95% CI, 0.85 – 1.68).

  • Patients who received LMWH were at increased risk of hospitalization for major bleeding, GI bleeding, and intracranial bleeding compared with those who received DOACs (HR, 2.27, 1.72, 2.72, respectively).

  • The risks of hospitalization for major bleeding, GI bleeding, and intracranial bleeding among patients who received warfarin and DOACs were similar (HR, 1.12, 1.03, 1.04, respectively).


Consistent with recent trials, "these data reinforce the general efficacy and safety of DOACs in this patient population" and reveal an association between DOACs and reduced all-cause mortality, the study authors wrote. These data may "help facilitate shared decision-marking and inform clinical guidelines for the treatment of such patients."


The study, led Irbaz Bin Riaz, MD, PhD, of Mayo Clinic, Phoenix, was published online in JAMA Network Open on July 24.


  • The study is limited by the potential for information bias in the database, the use of ICD codes to identify VTE patients, and the lack of radiologic evidence for VTE, as well as the lack of assessment for clinically relevant nonmajor bleeding.

  • The use of US claims data limits the applicability of the results to other populations, including the uninsured.


  • No funding was declared. The authors have disclosed no relevant financial relationships.

For more from Medscape Oncology, join us on Twitter and Facebook.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.