Key result
Warfarin was associated with a significantly prolonged median overall survival compared to DOACs (12.0 vs 9.9 months; HR 0.85) for the treatment of cancer-associated venous thromboembolism.
Why the study?
Whether there is a mortality benefit of DOACs compared with warfarin in the management of cancer-associated venous thromboembolism is not established.
Does warfarin improve overall survival compared to direct oral anticoagulants in older adults with cancer-associated venous thromboembolism?
Cohort (n=4,274)
Does warfarin improve overall survival compared to direct oral anticoagulants in older adults with cancer-associated venous thromboembolism?
Hazard Ratio: 0.85 (95% CI 0.78–0.91)
Absolute Event Rate: 12% vs 9.9%
p-value: p=< 0.001
In older adults with cancer-associated VTE, warfarin was associated with prolonged overall survival compared to DOACs, suggesting a potential survival benefit independent of anticoagulation.
Warfarin was associated with higher survival than DOACs in cancer VTE; this observational link leaves open whether randomized trials would confirm a mortality difference.
BACKGROUND: Direct oral anticoagulants (DOACs) have comparable efficacy with low-molecular-weight heparin (LMWH) for the treatment of cancer-associated venous thromboembolism (VTE). Whether there is a mortality benefit of DOACs compared with warfarin in the management of VTE in cancer is not established. METHODS AND FINDINGS: Utilizing the United States' Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases from 2012 through 2016, we analyzed overall survival in individuals diagnosed with a primary gastric, colorectal, pancreas, lung, ovarian, or brain cancer and VTE who received a prescription of DOAC or warfarin within 30 days of VTE diagnosis. Patients were matched 1:2 (DOAC to warfarin) through exact matching for cancer stage and propensity score matching for age, cancer site, cancer stage, and time interval from cancer to VTE diagnosis. The analysis identified 4,274 patients who received a DOAC or warfarin for the treatment of VTE within 30 days of cancer diagnosis (1,348 in DOAC group and 2,926 in warfarin group). Patients were of median age 75 years and 56% female. Within the DOAC group, 1,188 (88%) received rivaroxaban, and 160 (12%) received apixaban. With a median follow-up of 41 months, warfarin was associated with a statistically significantly higher overall survival compared to DOACs (median overall survival 12.0 months [95% confidence interval (CI): 10.9 to 13.5] versus 9.9 months [95% CI: 8.4 to 11.2]; hazard ratio (HR) 0.85; 95% CI: 0.78 to 0.91; p < 0.001). Observed differences in survival were consistent across subgroups of cancer sites, cancer stages, and type of VTE. The study limitations include retrospective design with potential for unaccounted confounders along with issues of generalizability beyond the cancer diagnoses studied. CONCLUSIONS: In this analysis of a population-based registry, warfarin was associated with prolonged overall survival compared to DOACs for treatment of cancer-associated VTE.
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Khan et al. (2022) conducted a cohort in Cancer-associated venous thromboembolism (n=4,274). Warfarin vs. Direct oral anticoagulants (DOACs) was evaluated on Overall survival (median months) (HR 0.85, 95% CI 0.78 to 0.91, p=< 0.001). Warfarin was associated with a significantly prolonged median overall survival compared to DOACs (12.0 vs 9.9 months; HR 0.85) for the treatment of cancer-associated venous thromboembolism.
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