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BACKGROUND Cancer increases the risk of developing dangerous and sometimes deadly blood clots, which are known as cancer-associated thrombosis (CAT). While direct oral anticoagulants (DOACs) can be considered for CAT, evidence is limited regarding their use in comparison to low molecular weight heparin (LMWH). AIM To compare the efficacy, bleeding risks, reoccurrence rate, and patient-reported outcomes of DOACs compared to LMWH in CAT of different cancer types. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 checklist was followed during the search and screening of publications. Articles were searched systematically through biomedical databases such as PubMed, Scopus, and Cochrane covering studies published from January 1, 2003 to December 31, 2024. Articles were carefully chosen and studied according to the set Population Intervention Comparator Outcomes criteria. The research we analyzed examined the use of anticoagulants in cancer patients with venous thromboembolism (VTE) in comparison LMWH. The outcomes were cases of bleeding, VTE recurrence in patients, and their level of satisfaction with the treatment results. RESULTS The 21371 cancer patients were included in 29 studies (15 randomized clinical trials and 14 observational studies). Rates of VTE recurrence between DOAC (5.6%-11%) and LMWH (7.9%-11%) in major trials were similar. There was a lot of difference to bleeding risks based on subtypes of cancers. In upper gastrointestinal (6.2%) and genitourinary (4.5%) cancers, the rate of significant bleeding was greater with DOACs, and the risk ratio compared to LMWH was 1.5 or 3-fold. Conversely, the rate of bleeding was lower in remitting patients (2.1% DOACs vs 3.0% LMWH). DOACs consistently outperformed LMWH in terms of patient satisfaction (75%-83% vs 45%-65%), as well as quality of life indicators (48%-57% vs 29-39%), and medication adherence (15%-25% improvement). CONCLUSION Doctors use both LMWH and DOACs for CAT, the decision of which patient to use DOACs depends on bleeding risk, with a specific focus on the risk by cancer subtypes. CAT management needs to be tailored to the specific cancer sub-type (especially upper vs lower gastrointestinal cancers), the risk of bleeding, and the patient's preferences or abilities.
Asad et al. (2026) studied this question.