Cancer-associated thromboembolism: could direct-acting oral anticoagulants be a promising therapeutic option? Literature review

Abstract Background Cancer-associated thromboembolism (CAT) is usually managed with low-molecular-weight heparins (LMWHs) or vitamin K antagonists (VKAs). The recent data suggest that direct-acting oral anticoagulants (DOACs) might have a role in the management of CAT both in terms of prevention and treatment. The aim of this article is to review the current literature regarding the use of DOACs in patients with cancer. Methods PUBMED and ClinicalTrials.gov were searched to identify prospective trials on patients with cancer managed with DOACs as either primary prophylaxis or treatment of venous thromboembolic events. Results In terms of primary prophylaxis, five studies (CASSINI, ADVOCATE, MYELAXAT, NCT02958969, and AVERT) have been identified. When considered together, CASSINI and AVERT showed a significant benefit of rivaroxaban and apixaban, respectively, versus placebo for the prevention of venous thromboembolism (VTE), with a low incidence of major bleeding and no significant difference in mortality. ADVOCATE, MYELAXAT, and NCT02958969 showed that apixaban was well tolerated in patients with metastases receiving chemotherapy or those with multiple myeloma receiving immunomodulatory imide drugs. With respect to VTE treatment, 3 studies (HOKUSAI-VTE, SELECT-D, and ADAM-VTE) were identified. These studies demonstrated significantly lower rates of VTE recurrences in patients treated with edoxaban, rivaroxaban, or apixaban, without compromise on safety. Conclusions DOACs seem a promising therapeutic option in CAT. As cancer is a heterogeneous disease, future research will clarify the role of these newer anticoagulant agents in both prevention and treatment of cancer-related VTE.