Cost-Effectiveness of Anticoagulants for Cancer-Associated Thrombosis

Quick Takes

  • In general, apixaban therapy is more cost-effective than enoxaparin or edoxaban for treatment of cancer-associated thrombosis.
  • Rivaroxaban is more cost-effective than apixaban when apixaban costs are higher than $530/month when treating cancer-associated thrombosis.
  • Clinicians should discuss both the effectiveness and the cost burden of anticoagulant therapy when treating patients with cancer-associated thrombosis.

Study Questions:

What is the cost-effectiveness of direct oral anticoagulant (DOAC) therapy versus low-molecular-weight heparin (LMWH) therapy for patients with cancer-associated thrombosis (CAT)?


The authors conducted a cohort-state transition decision analysis using data from a network meta-analysis comparing DOAC to LMWH therapy in patients with CAT. The authors took a health care sector perspective and analyzed cost-effectiveness over a lifetime horizon. The outcome measures included incremental cost-effectiveness ratio (ICER) in 2022 US dollar per quality-adjusted life-year (QALY) gained. Drug costs were obtained from the US Department of Veterans Affairs (base-case) and GoodRx (“real-world”). Analyses were conducted based on a 63-year-old patient diagnosed with CAT, as this was the average age from the network meta-analysis that informed the effectiveness data. Probabilistic sensitivity analyses were conducted for a willingness-to-pay threshold of $50,000 per QALY.


In the base-case using US Department of Veterans Affairs drug costs, apixaban dominated both enoxaparin and edoxaban by being less costly and more effective. Rivaroxaban was slightly more effective than apixaban, with an ICER of $493,246 per QALY. In the “real-world” scenario using drug prices from GoodRx, rivaroxaban was cost-effective with an ICER of $50,053 per QALY. Overall results were highly sensitive to the monthly drug price. In sensitivity analyses, apixaban was preferred in 80% of simulators but only remained cost-effective if monthly medication costs were below $530. Above the monthly cost of $530 for apixaban, rivaroxaban became cost-effective due to its slightly improved effectiveness over apixaban in the network meta-analysis.


The authors concluded that DOAC therapy is more effective and more cost-effective than LMWH. The most cost-effective DOAC depends on the relative cost of each agent.


DOACs are guideline-recommended first-line therapy for the treatment of venous thromboembolism, including CAT. However, their higher cost as compared to warfarin has made selecting the best anticoagulant strategy challenging for noncancer venous thromboembolism. Given the cost of LMWH therapy, data were lacking on the cost-effectiveness of DOAC vs. LMWH therapy specific for patients with CAT in whom LMWH has been demonstrated to have improved outcomes as compared to warfarin. This study shows that DOAC therapy, particularly apixaban, is cost-effective as compared to LMWH in most scenarios. Rivaroxaban becomes the most cost-effective agent when apixaban therapy monthly costs exceed $530. Clinicians should discuss various anticoagulant options with patients when treating CAT. These conversations should address the monthly cost to patients to ensure they are receiving the most cost-effective therapy and one that they can adhere to reliably.

Clinical Topics: Anticoagulation Management, Cardio-Oncology, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism

Keywords: Anticoagulants, Cardiotoxicity, Cost-Benefit Analysis, Drug Costs, Enoxaparin, Heparin, Low-Molecular-Weight, Neoplasms, Outcome Assessment, Health Care, Rivaroxaban, Secondary Prevention, Thrombosis, Vascular Diseases, Venous Thrombosis, Venous Thromboembolism, Veterans, Warfarin

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