Evaluating the Safety of Tranexamic Acid in Cancer Surgery: Clinical Evidence and Biological Rationale

Tranexamic acid (TXA) is widely used to reduce blood loss and red cell transfusion in major surgery. Its safety in oncologic surgery remains uncertain, given theoretical risks of venous thromboembolism (VTE) and tumor progression. We conducted an analytic review of clinical and laboratory evidence evaluating TXA in cancer surgery or cancer-relevant models. We performed a clinically focused review of experimental and clinical evidence examining TXA use in oncologic settings. Key influential studies were prioritized and supplemented by a structured literature search of MEDLINE, Embase, CENTRAL, and Web of Science from database inception through May 2025. Findings were synthesized narratively across preclinical, interventional, and observational evidence, with emphasis on clinical outcomes and biological plausibility. While retrospective and single-center clinical studies in cancer populations demonstrated reduced red cell transfusion with TXA, the oncology trials demonstrated decreased blood loss but no reduction in transfusion, suggesting that any effect is attenuated under modern perioperative practice. Across studies reporting VTE, postoperative DVT/PE rates were typically 0% to 3% and did not differ between TXA and controls. Only a small number of clinical studies evaluated oncologic outcomes, alssssl observational and underpowered, with no evidence of harm. Laboratory findings were equivocal, with some models showing increased invasion or migration at supratherapeutic concentrations, whereas others demonstrated neutral or protective effects. The impact of TXA on transfusion need in oncologic surgery is ambiguous, and recent randomized trials in oncology do not show reductions in allogeneic transfusion. Available data do not indicate increased VTE risk, and no clinical signals of oncologic harm have been observed, though evidence remains limited. Cancer-specific studies with long-term follow-up are needed to define oncologic safety and to clarify whether indirect effects through transfusion avoidance influence cancer outcomes.