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Thromb Haemost
DOI: 10.1055/a-2628-3967
Stroke, Systemic or Venous Thromboembolism

Direct Oral Anticoagulants for Prevention of Venous Thromboembolism after Cancer-related Surgery: Systematic Review and Network Meta-analysis

Gerardo N. Pititto‡   *
1   Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese and Como, Italy
,
Giorgio Maraziti‡   *
2   Internal, Vascular and Emergency Medicine - Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
,
Alessandro Squizzato 
3   Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria - ASST Lariana, Como, Italy
,
Cecilia Becattini
2   Internal, Vascular and Emergency Medicine - Stroke Unit, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
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Abstract

Background

The risk of venous thromboembolism (VTE) is high after cancer surgery and is reduced by antithrombotic prophylaxis.

Material and Methods

We conducted a systematic review and network meta-analysis to evaluate the effectiveness and safety of direct oral anticoagulants (DOACs) for VTE prophylaxis after cancer surgery. The primary study outcome was 30-day VTE after surgery. Pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were estimated.

Results

Five randomized controlled trials (RCTs; two gynecological, one abdominal, one neurosurgical, and one thoracic; 1,694 patients) and seven observational studies (three urological, two abdominal, and two gynecological; 2,042 patients) were included. DOACs reduced the incidence of 30-day (OR 0.52, 95% CI 0.27-0.98, I2 22.7%) and 90-day VTE (OR 0.51, 95% CI 0.28-0.92, I2 0%) compared to LMWH. No difference was observed between DOACs and LMWH in 30 and 90-day bleeding outcomes. In random effect analyses, apixaban (OR 0.31, 95% CI 0.11-0.84) and not rivaroxaban reduced the risk of 30 day-VTE compared to LMWH (OR 0.69, 95% CI 0.35-1.34) without increasing the risk of bleeding at 30 or 90 days. No difference in the risk of VTE or bleeding was observed between DOACs and placebo/no treatment, but these analyses were probably underpowered. Subgroup analyses were conducted on LMWH pre-treatment, extended prophylaxis, duration of surgery, and type of surgery.

Conclusion

Our study supports apixaban and rivaroxaban as promising alternatives to LMWH in post-operative prophylaxis of VTE after cancer surgery. Further high-quality data are needed in specific surgical settings.

Keywords

venous thromboembolism - cancer surgery - network meta-analysis - direct oral anticoagulants - antithrombotic prophylaxis

Data Availability Statement

All data generated or analyzed during this study are included in this article or its supplementary material files. The study protocol is available on PROSPERO (CRD42024500972). Further inquiries can be directed to the corresponding author.


Authors' Contribution

G.N.P., G.M., and C.B. prepared the study concept. G.N.P., G.M., and C.B. performed study selection and data extraction. G.N.P., G.M., A.S., and C.B. wrote and reviewed the full article. G.M. performed statistical analysis.


* These authors contributed equally to this study.


Supplementary Material



Publication History

Received: 20 January 2025

Accepted: 04 June 2025

Accepted Manuscript online:
05 June 2025

Article published online:
25 June 2025

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