Use of oral anticoagulants among individuals with cancer and atrial fibrillation in the United States, 2010–2016

Abstract

Background Anticoagulation among patients with cancer and atrial fibrillation is challenging due to elevated risk of bleeding and stroke. We characterized use of oral anticoagulants among patients with cancer and non‐valvular atrial fibrillation (NVAF). Methods We used Surveillance, Epidemiology, and End Results (SEER)‐Medicare data and included patients with cancer aged ≥66 years with an incident diagnosis of NVAF from 2010 to 2016. We used a Cox proportional hazard model and multivariable logistic regression to identify factors associated with anticoagulant use versus no use and direct oral anticoagulants (DOACs) versus warfarin use, respectively. Results Of 27,702 patients with cancer and NVAF, 4469 (16.1%) used DOACs and 3577 (12.9%) used warfarin. Among 8046 anticoagulant users, DOACs use increased from 21.8% in 2011 to 76.2% in 2016, with a corresponding decline in warfarin use from 78.2% to 23.8%. Nearly 7 out of 10 patients with cancer and NVAF did not initiate anticoagulation in 2016. Anticoagulant use was more likely among those with higher CHA₂DS₂‐VASc scores (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.27–1.90 for score ≥6 vs. 1) or with lower HAS‐BLED scores (HR 1.96, 95% CI 1.67–2.30 for score 1 vs. ≥6). Among anticoagulant users, DOAC use was less likely than warfarin in those with higher CHA₂DS₂‐VASc scores (odds ratio [OR] 0.53, 95% CI 0.33–0.84 for score ≥6 vs. 1). Conclusions Nearly 7 out of 10 patients with cancer and NVAF did not receive anticoagulation. Use of DOACs increased from 2010 to 2016, with a corresponding decline in warfarin use. DOACs are used less than warfarin among those at higher risk of stroke.

Oral anticoagulant prescribing among patients with cancer and atrial fibrillation in England, 2009–2019

“…Moreover, our findings also highlighted that when patients are stratified by socioeconomic deprivation, the difference in OAC prescribing between patients with and without cancer remained relatively constant across all quintiles, with the most deprived quintile having the lowest probability of OAC prescribing overall regardless of cancer status. These findings are consistent with previous data from the United States that looked at OAC prescribing in patients with cancer with AF 35 . These results also reflect on what we have observed earlier in our previous analysis, that socioeconomic inequalities in the prescribing of OACs in England exist, with low socioeconomic status associated with the prescription of aspirin only or no treatment compared with patients with higher socioeconomic status 15 .…”

“…States that looked at OAC prescribing in patients with cancer with AF. 35 These results also reflect on what we have observed earlier in our previous analysis, that socioeconomic inequalities in the prescribing of OACs in England exist, with low socioeconomic status associated with the prescription of aspirin only or no treatment compared with patients with higher socioeconomic status. 15 In our previous work, we also captured ethnic inequalities in the care of patients with AF 15 ; however, in this study, we could not exclude the possibility of ethnic inequalities in OAC prescribing between patients with and without cancer because of the small number of ethnic groups per cancer type.…”

Hypercoagulable State and Thrombosis of Bioprosthetic Transcatheter Aortic Valve Replacement (TAVR) Refractory to Common Anticoagulation Methods in the Setting of Protein S Deficiency

“…From 2011 to 2016, the use of DOACs increased from 21.8% to 76.2% and the use of warfarin decreased from 78.2% to 23.8%. At this time, DOACs are recommended instead of warfarin therapy for patients with atrial fibrillation, but there are no specific and widely accepted guidelines for the anticoagulation of patients with protein S deficiency, especially in the setting of TAVR [ 13 ].…”

Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

“…A retrospective database analysis from Taiwan reported that the use of dabigatran might be linked to a reduced risk of mortality from all causes and cancer-related causes when compared to rivaroxaban [ 133 ]. However, in recent decades, an increase in DOACS use in cancer patients has been observed, although a considerable proportion of them remain without anticoagulation [ 134 ]. Moreover, the use of DOACs in this subset of patients has been recently encouraged [ 118 ].…”