Efficacy and safety of apixaban versus enoxaparin in gynecologic oncology surgery: a systematic review and meta-analysis.

Abstract

Venous thromboembolism is a common complication after gynecologic cancer surgery. While enoxaparin is the standard for prevention, oral apixaban may improve adherence. This review compares apixaban and enoxaparin for post-operative venous thromboembolism prevention. Following Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 guidelines, 6 databases were searched through August 2025 for studies comparing apixaban and enoxaparin for venous thromboembolism prevention after gynecologic cancer surgery. Eligible studies included randomized controlled trials and cohort studies. The systematic review and meta-analysis was registered in International Prospective Register of Systematic Reviews (CRD42024490564). The databases searched were PubMed, Embase, Web of Science, ClinicalTrials.gov, Scopus, and Cochrane Library. Outcomes included venous thromboembolism incidence at 30 and 90 days, and major and minor bleeding. Adherence and cost-effectiveness data, initially listed as secondary outcomes, could not be formally combined because of inconsistent reporting across studies, and are thus presented as a narrative summary only. Pooled odds ratios with 95% confidence intervals were calculated using random-effects models (DerSimonian-Laird estimator). Risk of bias was assessed using the Cochrane RoB 2 (Risk of Bias 2) tool for randomized controlled trials and the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool for observational studies. Certainty of evidence was evaluated using the GRADE approach. Four studies with 1108 patients found no significant difference between apixaban and enoxaparin in 30- and 90-day rates of venous thromboembolism. Bleeding rates were similar; minor bleeding favored apixaban, but the difference was not statistically significant. Bias concerns were noted in the randomized controlled trials and cohort studies. Adherence to apixaban was >80% in 2 studies. Overall, the certainty of evidence was low to moderate owing to risk of bias and imprecision. Apixaban and enoxaparin demonstrated similar outcomes for venous thromboembolism and bleeding after gynecologic oncology surgery; however, the evidence is limited by risk of bias and imprecision. Apixaban may be convenient for some patients, but current data do not support it as a first-line therapy. Larger, high-quality trials are needed. Until then, treatment should be individualized. The oral route offers practical advantages for select patients.