Among patients with cancer-associated thrombosis (CAT), rivaroxaban may be superior to low-molecular-weight heparin (LMWH) for reducing all-cause mortality, although additional study is necessary, according to a systematic review and meta-analysis published in Clinical and Applied Thrombosis/Hemostasis.

Patients with cancer have a far greater risk of thrombosis than that seen in the general population, potentially accounting for 20% of all community cases of venous thromboembolism. LMWH is, furthermore, seen as the current standard of care in CAT.

LMWH is, however, linked with a number of clinical and non-clinical complications, including high cost, low adherence to daily injection, and drug accumulation among those patients with a low glomerular filtration rate. Rivaroxaban, an oral anticoagulant, has shown promise in previous study, although it is unclear in the real-world setting whether it is superior to LMWH in the CAT setting.

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For this study, researchers aimed to synthesize existing real-world data to determine the safety and efficacy of rivaroxaban in comparison with LMWH. The primary outcome was net clinical benefit.

Of 1188 records screened, 17 studies were included in the present meta-analysis. These studies comprised data from 12,318 patients across intervention and control arms.

Overall, the net clinical benefit was higher with rivaroxaban than with LMWH (relative risk [RR], 0.82; 95% CI, 0.75-0.89), and rivaroxaban was associated with fewer venous thromboembolism events (RR, 0.73; 95% CI, 0.65-0.82) and lower all-cause mortality (RR, 0.72; 95% CI, 0.57-0.91).

Major bleeding events were, however, comparable between the 2 groups (RR with rivaroxaban vs LMWH, 1.07; 95% CI, 0.85-1.33), and clinically relevant non-major bleeding was more common with rivaroxaban (RR, 2.02; 95% CI, 1.46-2.80).

On further analysis, primary cancer site did not appear to affect these findings.

“The reviews’ findings support the use of rivaroxaban in this group of patients,” the authors wrote. “A sizable superiority [randomized controlled trial] is imperative to confirm our findings (especially the mortality and the bleeding data).”


Mohamed MFH, ElShafei MN, Ahmed MB, et al. The net clinical benefit of rivaroxaban compared to low-molecular-weight heparin in the treatment of cancer-associated thrombosis: systematic review and meta-analysis. Clin Appl Thromb Hemost. 2021;27:1076029620940046. doi:10.1177/1076029620940046