OC 54.2 - Comparison of Direct Oral Anticoagulants versus Low Molecular Weight Heparin in Primary and Metastatic Brain Cancers: A Meta-Analysis and Systematic Review

Tuesday, June 27, 2023

11:00 – 11:15 ET

Room: 511

Session Available As: On-Demand

Co-Author(s)

VI

Varun Iyengar

Resident
Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Brookline, Massachusetts, United States

Presenting Author(s)

Shubham Agrawal, MBBS (he/him/his)

Resident
Department of Internal Medicine, Mercy Catholic Medical Center, Darby, PA
Darby, Pennsylvania, United States

Co-Author(s)

TC

Thita Chiasakul

Research fellow
Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
Washington, District of Columbia, United States
KT

Kian Tehranchi

Resident
Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, MA
Brookline, Massachusetts, United States
MM

Megan Mcnichol

Manager
Division of Knowledge Services, Department of Information Services, Beth Israel Deaconess Medical Center, Boston, MA
Boston, Massachusetts, United States
BC

Brian J. Carney

Medical Director of Apheresis Services
Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, USA
Boston, Massachusetts, United States
Avi Leader, MD (he/him/his)

Hematologist
Institute of Hematology, Rabin Medical Center, Petah Tikva
Petah Tikva, HaMerkaz, Israel
Jeffrey I. Zwicker, MD

Chief of the Hematology Service
Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York City, NY
New York, New York, United States
Rushad Patell, MD (he/him/his)

Assistant Professor of Medicine
Beth Israel Deaconess Medical Center, Boston, MA, USA
Boston, Massachusetts, United States

Background: Therapeutic anticoagulation in patients with primary and metastatic brain cancer is a challenging clinical scenario due to the risk of intracranial hemorrhage (ICH). Low-molecular-weight heparins (LMWHs) have long been the standard of care. However, direct-acting oral anticoagulants (DOACs) are increasingly used in patients with cancer. Individual studies are underpowered to compare the relative safety of different oral anticoagulants.

Aims: We performed a meta-analysis and systematic review of studies that compared the risk of ICH in patients with primary or metastatic brain cancer treated with DOACs versus LMWH.

Methods: A search of the literature was conducted using PubMed, EMBASE, and Cochrane databases. Summary statistics were obtained by calculating the risk ratio (RR) using a random effects model, and heterogeneity across studies was estimated using the I2 statistic.

Results: A total of 7 retrospective cohort studies, with a total of 812 patients, met criteria for inclusion. (Figure 1) The pooled RR for ICH in all patients receiving DOACs versus those receiving LMWH was 0.51 (95% confidence interval [CI], 0.29-0.88; P = 0.02; I2 = 23%). (Figure 2) In studies evaluating primary brain cancer, there was an apparent reduction in risk of ICH with DOACs (RR, 0.20; 95% CI, 0.07-0.52; P = 0.001). However, in patients with metastatic brain cancer, there was no difference in the risk of ICH with type of anticoagulation (RR, 0.74; 95% CI, 0.45-1.21; P = 0.24). There was little evidence of heterogeneity within primary or metastatic brain tumor cohorts (I2 = 0%).

Conclusion(s): The risk of ICH in patients with brain cancer receiving therapeutic anticoagulation varies by anticoagulation agent and diagnosis of primary or metastatic disease. DOACs were associated with a reduced risk of ICH in the setting of primary brain cancer, whereas no difference was seen in metastatic brain cancer.

Learning Objectives:

Upon completion, participants will be able to review current evidence for anticoagulation for venous thromboembolism in patients with brain cancer.
Upon completion, participants will be able to better compare intracranial bleeding rates for direct oral anticoagulants to low molecular weight heparin in patients with primary brain cancer and venous thromboembolism.
Upon completion, participants will be able to better compare intracranial bleeding rates for direct oral anticoagulants to low molecular weight heparin in patients with metastatic brain cancer and venous thromboembolism.