Direct oral anticoagulants significantly decreased cancer-associated venous thrombosis recurrence without significantly increasing bleeding, found an ongoing Mayo Clinic study.
Thrombotic outcomes increase mortality in cancer patients and are the second most common cause of death after disease progression.
The study, published in Mayo Clinic Proceedings, examined the results of four randomised clinical trials involving 2,894 patients. It found that direct oral anticoagulants significantly decreased cancer-associated venous thrombosis recurrence without significantly increasing bleeding, compared with parenteral dalteparin.
“Our meta-analysis finds that cancer patients who experience acute venous thrombosis events and were treated with direct oral anticoagulants experienced a 41% decrease in the rate of thrombosis recurrence, compared with dalteparin, without significantly increasing major bleeding,” said Mayo Clinic haematologist and oncologist Dr Irbaz Riaz.
Riaz and Dr Harry Fuentes Bayne, also a Mayo Clinic medical oncologist, are co-first authors of the study.
Direct oral anticoagulants have been considered the standard of care to treat venous thrombosis in patients without cancer. “This analysis indicates the same is true for cancer patients,” said Dr Robert McBane, a Mayo Clinic cardiologist and the study’s senior author.
The systematic review led by Mayo Clinic, which also involved researchers from five other institutions, did not find differences in mortality based on the use of oral anticoagulants versus dalteparin. The authors recommend caution in using anticoagulants when treating patients at high risk of bleeding.
The researchers used a novel framework for a “living” interactive review of randomised controlled trials, beginning in September 2019. Results will be updated as more information becomes available.
“We have created interactive evidence summaries of multiple treatment options that present the benefits and harms, and evidence certainty for outcomes, and this evidence is updated as soon as new studies are published,” said Dr M. Hassan Murad, a Mayo Clinic clinical epidemiologist who leads the clinic’s Evidence-Based Practice Research Program and is the study’s corresponding author.
“We will continue to add randomised controlled trials to this ‘living’ research, leading to more discoveries that produce improved outcomes for patients.”
This approach was developed by a Mayo Clinic team consisting of Murad and Riaz, as well as Mayo Clinic artificial intelligence experts Huan He, PhD, and Hongfang Liu, PhD.
Study details
Direct Oral Anticoagulants Compared With Dalteparin for Treatment of Cancer-Associated Thrombosis: A Living, Interactive Systematic Review and Network Meta-analysis
Irbaz Bin Riaz, Harry E. Fuentes, Syed Arsalan Ahmed Naqvi, Huan He, Qurat-ul-Ain Riaz Sipra, Alfonso J. Tafur, Leslie Padranos, Waldemar E. Wysokinski, Ariela L. Marshall, Per Olav Vandvik, Victor Montori, Alan H. Bryce, Hongfang Liu, Robert G. Badgett, Mohammad Hassan Murad, and Robert D. McBane.
Published in Mayo Clinic Proceedings on 17 January 2022
Abstract
Objective
To maintain living, interactive evidence (LIvE) on the benefits and harms of different treatment options in adults with cancer-associated thrombosis (CAT).
Methods
We have used a novel LIvE synthesis framework to maintain this living, interactive systematic review since September 19, 2018. Randomised controlled trials evaluating the efficacy and safety of direct oral anticoagulants (DOACs) compared with low-molecular-weight heparin for CAT are included in this analysis.
Results
The results are constantly updated as new information becomes available (https://cat. network-meta-analysis.com/CAT.html). The living, interactive systematic review currently includes 4 randomised controlled trials (N¼2894). Direct comparisons show that DOACs significantly decrease recurrent venous thromboembolism (VTE) events compared with dalteparin (odds ratio [OR], 0.59; 95% CI, 0.41 to 0.86; I 2 , 25%) without significantly increasing major bleeding (OR, 1.34; 95% CI, 0.83 to 2.18; I 2 , 28%). Mixed treatment comparisons show that apixaban (OR, 0.41; 95% credible interval [CrI], 0.16 to 0.95) and rivaroxaban (OR, 0.58; 95% CrI, 0.37 to 0.90) significantly decrease VTE recurrent events compared with dalteparin. Edoxaban significantly increases major bleeding compared with dalteparin (OR, 1.73; 95% CrI, 1.04 to 3.16), and rivaroxaban significantly increases clinically relevant nonmajor bleeding compared with dalteparin and other DOACs. There are no significant differences between DOACs in terms of VTE recurrences and major bleeding. Conclusion: DOACs should be considered a standard of care for the treatment of CAT except in patients with a high risk of bleeding. Current evidence favours the use of apixaban for the treatment of CAT among other DOACs.
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