Efficacy and safety of rivaroxaban compared with LMWH in patients with cancer-associated thrombosis: A systematic review and meta-analysis of randomized controlled trials.

e15136 Background: The optimal anticoagulation strategy for managing cancer-associated thrombosis (CAT) remains uncertain. The choice between low molecular weight heparin (LMWH), the traditional standard of care, and rivaroxaban, a newer oral direct factor Xa inhibitor, lacks clear guidance due to inconclusive evidence. To address this gap, we conducted a systematic review and meta-analysis to compare the safety and efficacy of rivaroxaban versus LMWH in patients with CAT. Methods: We did an extensive search using PubMed, Clinicaltrials.gov and Cochrane Library for studies published from inception to June 2025, evaluating the use of rivaroxaban and LMWH in patients with CAT. Data were extracted and analyzed on RevMan v.5.2. Pooled proportions with 95% confidence intervals (CI) were calculated using a random effects model. Risk ratios (RR) with 95% confidence intervals were used as effect measures for dichotomous variables. The I 2 and χ 2 were used to assess interstudy heterogeneity. A p-value of < 0.05 was considered statistically significant. Results: This meta-analysis included a total of five studies, involving 1,533 patients (622 patients were on rivaroxaban, and 639 patients were on LMWH. The inclusion criteria were patients aged > 18 years with active cancer sites experiencing VTE. Rivaroxaban showed a statistically significant association with a 48% lower risk of recurrent VTE compared to LMWH (RR 0.52, 95% CI 0.30-0.92, I2 = 0%, P = 0.02) and 90% higher risk of minor bleeding compared to LMWH (RR 1.90, 95% CI 1.01-3.55, I2 = 46%, P = 0.05). Rivaroxaban reduces the risk of DVT (RR 0.70, 95% CI 0.44-1.12, I2 = 0%, P = 0.13) and increases the risk of major bleeding (RR 1.47, 95% CI 0.86-2.53, I2 = 0%, P = 0.16) compared to LMWH; however, results are not statistically significant. Conclusions: Our findings suggest that rivaroxaban had 48% lower risk of recurrent VTE, but a 90% higher risk of minor bleeding compared to LMWH. Results for DVT and major bleeding were non-significant, indicating that rivaroxaban may be a reasonable alternative to LMWH for patients with CAT, but caution is required in patients with bleeding risk.