Survival outcomes with warfarin compared with direct oral anticoagulants in cancer-associated venous thromboembolism in the United States: A population-based cohort study.
Survival outcomes with warfarin compared with direct oral anticoagulants in cancer-associated venous thromboembolism in the United States: A population-based cohort study.
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DOI：
10.1371/journal.pmed.1004012
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发表时间：
2022-05
期刊：
影响因子：
15.8
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中科院分区：
文献类型：
--
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直接口服抗凝剂（DOAC）治疗癌症相关静脉血栓栓塞（VTE）的疗效与低分子量肝素（LMWH）相当。DOAC与华法林相比在癌症VTE管理中是否有死亡率获益尚未确定。利用2012年至2016年的美国监测、流行病学和最终结果（SEER）-医疗保险相关数据库，我们分析了诊断为原发性胃癌、结直肠癌、胰腺癌、肺癌、卵巢癌或脑癌和VTE的个体的总生存期，这些个体在VTE诊断后30天内接受了DOAC或华法林处方。通过癌症分期的精确匹配和年龄、癌症部位、癌症分期和从癌症到VTE诊断的时间间隔的倾向评分匹配，将患者1：2匹配（DOAC与华法林）。该分析确定了4，274例在癌症诊断后30天内接受DOAC或华法林治疗VTE的患者（DOAC组1，348例，华法林组2，926例）。患者的中位年龄为75岁，56%为女性。在DOAC组中，1，188例（88%）接受利伐沙班，160例（12%）接受阿哌沙班。中位随访时间为41个月，与DOAC相比，华法林的总生存率在统计学上显著更高（中位总生存期12.0个月[95%置信区间（CI）：10.9至13.5] vs 9.9个月[95% CI：8.4至11.2];风险比（HR）0.85; 95% CI：0.78至0.91; p < 0.001）。观察到的生存率差异在癌症部位、癌症分期和VTE类型的亚组中是一致的。该研究的局限性包括回顾性设计，可能存在无法解释的混杂因素，沿着研究的癌症诊断之外的普遍性问题。在这项基于人群的登记研究分析中，与DOAC相比，华法林治疗癌症相关VTE的总生存期延长。Adeel Khan及其同事研究了癌症相关静脉血栓栓塞患者的抗凝剂处方和生存结局。在基于人群的研究中，与低分子量肝素（LMWH）治疗癌症相关血栓形成相比，华法林可改善总生存率。基于抗血栓疗效的证明，直接口服抗凝剂（DOAC）通常用于治疗癌症患者的静脉血栓栓塞（VTE）。目前尚不清楚DOAC与华法林治疗癌症VTE的总生存期是否存在差异。这是一项对监测、流行病学和最终结果（SEER）-医疗保险数据库进行的回顾性队列研究，比较了接受DOAC或华法林的精确分期和倾向评分匹配的老年癌症和VTE患者（N = 4，274）的总生存期。与DOACS相比，在治疗癌症的VTE时，Warcraft与显著延长的总生存期相关。新出现的基于人群的证据表明，与其他抗凝剂相比，华法林治疗癌症VTE的总生存期获益。Warcantine已被证明在临床前模型中具有抗肿瘤活性。前瞻性随机试验评价华法林的潜在生存差异是必要的。
Direct oral anticoagulants (DOACs) have comparable efficacy with low-molecular-weight heparin (LMWH) for the treatment of cancer-associated venous thromboembolism (VTE). Whether there is a mortality benefit of DOACs compared with warfarin in the management of VTE in cancer is not established. Utilizing the United States’ Surveillance, Epidemiology, and End Results (SEER)-Medicare linked databases from 2012 through 2016, we analyzed overall survival in individuals diagnosed with a primary gastric, colorectal, pancreas, lung, ovarian, or brain cancer and VTE who received a prescription of DOAC or warfarin within 30 days of VTE diagnosis. Patients were matched 1:2 (DOAC to warfarin) through exact matching for cancer stage and propensity score matching for age, cancer site, cancer stage, and time interval from cancer to VTE diagnosis. The analysis identified 4,274 patients who received a DOAC or warfarin for the treatment of VTE within 30 days of cancer diagnosis (1,348 in DOAC group and 2,926 in warfarin group). Patients were of median age 75 years and 56% female. Within the DOAC group, 1,188 (88%) received rivaroxaban, and 160 (12%) received apixaban. With a median follow-up of 41 months, warfarin was associated with a statistically significantly higher overall survival compared to DOACs (median overall survival 12.0 months [95% confidence interval (CI): 10.9 to 13.5] versus 9.9 months [95% CI: 8.4 to 11.2]; hazard ratio (HR) 0.85; 95% CI: 0.78 to 0.91; p < 0.001). Observed differences in survival were consistent across subgroups of cancer sites, cancer stages, and type of VTE. The study limitations include retrospective design with potential for unaccounted confounders along with issues of generalizability beyond the cancer diagnoses studied. In this analysis of a population-based registry, warfarin was associated with prolonged overall survival compared to DOACs for treatment of cancer-associated VTE. Adeel Khan and co-workers study anticoagulant prescriptions and survival outcomes in patients with cancer-associated venous thromboembolism. In population-based studies, warfarin has been associated with improved overall survival compared with low-molecular-weight heparin (LMWH) for the treatment of cancer-associated thrombosis. Based on demonstration of antithrombotic efficacy, direct oral anticoagulants (DOACs) are commonly prescribed for management of venous thromboembolism (VTE) in cancer. Whether there is an overall survival difference in the treatment of VTE in cancer with DOACs compared with warfarin is not known. This was a retrospective cohort study of the Surveillance, Epidemiology, and End Results (SEER)-Medicare database comparing the overall survival of exact-stage and propensity score–matched elderly patients with cancer and VTE (N = 4,274) who received DOACs or warfarin. Warfarin was associated with a significantly prolonged overall survival compared with DOACS in the treatment of VTE in cancer. Emerging population-based evidence suggests an overall survival benefit with warfarin compared with other anticoagulants for treatment of VTE in cancer. Warfarin has been shown to have antineoplastic activity in preclinical models. Prospective randomized trials evaluating potential survival differences with warfarin are warranted.
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影响因子：
11.2
作者：
Kirane A;Ludwig KF;Sorrelle N;Haaland G;Sandal T;Ranaweera R;Toombs JE;Wang M;Dineen SP;Micklem D;Dellinger MT;Lorens JB;Brekken RA
通讯作者：
Brekken RA
影响因子：
7.5
作者：
Li A;Garcia DA;Lyman GH;Carrier M
通讯作者：
Carrier M
影响因子：
8.8
作者：
FRANCIS, JL;CARTY, N;TAYLOR, I
通讯作者：
TAYLOR, I
DOI：
10.1073/pnas.92.18.8205
发表时间：
1995-08-29
影响因子：
11.1
作者：
BROMBERG, ME;KONIGSBERG, WH;GAREN, A
通讯作者：
GAREN, A
影响因子：
45.3
作者：
Maurer, LH;Herndon, JE;Green, MR
通讯作者：
Green, MR