Apixaban Versus Low-Molecular-Weight Heparin in Cancer-Associated Thrombosis: An Indication-Stratified Systematic...

Apixaban is increasingly used as an alternative to low-molecular-weight heparin (LMWH) in patients with cancer, but evidence spans distinct clinical settings, including treatment of established cancer-associated thrombosis/venous thromboembolism (CAT/VTE) and postoperative thromboprophylaxis. We performed an indication-stratified systematic review and meta-analysis comparing apixaban with LMWH in patients with cancer.

PubMed, Scopus, and Web of Science were searched from inception to April 2026 for comparative studies evaluating apixaban versus LMWH in adults with cancer. Studies were categorized as treatment of established CAT/VTE or postoperative thromboprophylaxis after cancer surgery. Outcomes included major bleeding (MB), VTE, clinically relevant non-major bleeding (CRNMB), deep vein thrombosis (DVT), pulmonary embolism (PE), and mortality. Random-effects models generated pooled risk ratios (RRs) with 95% confidence intervals (CIs).

Seventeen studies involving 31,632 patients were included. Apixaban was not associated with a significant increase in major bleeding in postoperative thromboprophylaxis studies (RR, 0.79; 95% CI, 0.29-2.12) or treatment studies (RR, 0.93; 95% CI, 0.56-1.55). In treatment studies, apixaban was associated with a significantly lower risk of recurrent VTE than LMWH (RR, 0.62; 95% CI, 0.51-0.75). In postoperative thromboprophylaxis studies, apixaban showed a numerically lower but non-significant risk of incident postoperative VTE (RR, 0.56; 95% CI, 0.30-1.06). CRNMB was lower with apixaban in postoperative studies (RR, 0.60; 95% CI, 0.38-0.95), but not in treatment studies.

Apixaban may be an effective alternative to LMWH for selected patients with established CAT/VTE and was associated with a lower risk of recurrent VTE. No clear increase in major bleeding was observed, but this finding should be interpreted cautiously because the certainty of evidence for bleeding outcomes was low. Evidence for postoperative thromboprophylaxis is promising but less definitive.