Among some patients with cancer-associated thrombosis (CAT), rivaroxaban may be a viable alternative to low-molecular-weight heparin (LMWH), according to research published in Blood Advances; however, these suggestions do not apply to patients with gastrointestinal or genitourinary cancers.

Patients with active cancer are about 5 times more likely than individuals without cancer to develop venous thromboembolism, and after thromboembolism occurrence, are at a much higher risk of recurrence. Therefore, treatment of CAT requires anticoagulants to minimize bleeding in this patient population.

While LMWH is frequently used in this setting, guidelines also include direct-acting oral anticoagulants (DOACs), though no particular DOAC has been shown to be superior to others. Evidence suggests that while DOACs may reduce thrombosis risk compared with LMWH, they may also increase bleeding risk, particularly among patients with gastrointestinal or genitourinary cancers.

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Given a lack of strong clinical trial data supporting specific DOAC use in this setting, researchers accessed patient data using the Surveillance, Epidemiology, and End Results-Medicare database to determine whether rivaroxaban, a DOAC, is safe and effective compared with LMWH among patients with CAT. Data from patients with luminal gastrointestinal or genitourinary cancers were excluded.

Overall, data from 1058 patients were used: 529 (50%) of whom had received rivaroxaban and 529 (50%) had received LMWH. In the rivaroxaban group, the median age was 73 years, 74.7% of patients were women, 80.2% were White, 73% were on active anticancer therapy, and the most common primary cancer sites were the lung (43.5%), breast (36.9%), pancreas (10.2%), and ovary (6.2%).

In the LMWH group, the median age was 72 years, 71.3% of patients were women, 80.7% were White, 72.4% were on active anticancer therapy, and the most common primary cancer sites were the lung (46.3%), breast (35%), pancreas (8.7%), and ovary (6.8%).

Compared with LMWH, use of rivaroxaban was not linked with major bleeding (hazard ratio [HR], 1.01), mortality (HR, 0.87), or risk of the composite outcome (HR, 0.71). However, rivaroxaban was linked to a lower risk of recurrent thrombosis (HR, 0.37).

“Our study of select patients with CAT, without luminal gastrointestinal or genitourinary malignancies because of the higher risk of bleeding, found rivaroxaban to be associated with a reduced risk of recurrent [venous thromboembolism] vs LMWH without a significant impact on the composite outcome, major bleeding, or all-cause mortality,” the authors wrote.

Disclosures: Some authors have declared affiliations with or received funding from the pharmaceutical industry. Please refer to the original study for a full list of disclosures.


Costa OS, Kohn CG, Kuderer NM, Lyman GH, Bunz TJ, Coleman CI. Effectiveness and safety of rivaroxaban compared with low-molecular-weight heparin in cancer-associated thromboembolism. Blood Adv. 2020;4(17):4045-4051. doi:10.1182/bloodadvances.2020002242