Cancer and atrial fibrillation (AF) are two very frequent conditions that share common pathophysiological and epidemiological features. Spontaneous coagulation is associated with malignant neoplasia as well as prothrombotic potential due to the overexpression of procoagulants. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult. The use of direct oral anticoagulants (DOACs) is now first line anticoagulation in common clinical practice, but no specific study addressing the use of DOACs in cancer patients has been published to date. In this review we aimed to retrieve all studies comparing the use of DOACs to warfarin.
We searched for all relevant articles published in English. Articles included RCTs sub-studies and observational trials comparing the use of DOACs therapy to warfarin in cancer patients with AF. Efficacy outcomes comprised three efficacy endpoints: ischemic stroke (IS), systemic embolism (SE) and venous thromboembolism/pulmonary embolism (VTE/PE) and five safety endpoints: cerebral bleedings (CB), minor bleedings (mB), gastrointestinal bleedings (GI-B) major bleedings (MB) and overall mortality (OM). Not all endpoints were available for all the retrieved articles.
We retrieved 3 RCTs sub-studies and 7 observational studies for a total of 219952 patients. DOACs patients have lower risk of ischemic stroke; Odds Ratio (OR) 0.65 (95%IC 0.48-0.98). Both SE and VTE/PE did not significantly differ between the two groups OR 0.61 (95%IC 0.26-1.42) OR 0.49 (95%IC 0.22-1.07), respectively. All safety endpoints except for overall mortality were significantly lower in the DOACs group: CB OR 0.42 (95%IC 0.27-0.66), mB OR 0.62 (95%IC 0.45-0.87), GI-B OR 0.65 (95%IC 0.45-0.95), MB OR 0.55 (95%IC 0.45-0.95). Overall mortality did not statistically differ between the two anticoagulation strategies OR 0.75 (95%IC 0.46-1.22).
Overall DOACs may be an effective and safe option for cancer patients suffering from atrial fibrillation.