Oral anticoagulation in patients with active cancer and atrial fibrillation: current challenges

Atrial fibrillation and cancer are common comorbidities. Given an increased risk of arterial thrombosis caused by the former and an increased risk of bleeding in patients with the latter, the management of anticoagulation in patients in whom they coexist is complex. On the basis of generally low‑quality evidence, numerous documents have been published in the past 3 years providing practice points for physicians to offer the best treatment plan to their patients. The present review begins with a summary of these recommendations and then proceeds to outline 9 practical challenges that fit into the larger questions of when and in whom anticoagulation is indicated, and what is the best agent in patients with atrial fibrillation and active cancer. For each of these 9 challenges, the evidence available is presented, the author's personal practical advice is given and the most pressing need to move the field forward is stated. I conclude by emphasizing the need for high‑quality evidence and, more practically, by stressing 1) the importance of patient preference and values in the decision on whether and how to anticoagulate, and 2) the need for periodic reassessment of the benefits of anticoagulation with changes in cancer status and treatment plan.