Anticoagulation in cancer patients with atrial fibrillation: recent advances

: Atrial fibrillation (AF) and cancer frequently coexist, particularly in elderly patients, creating a complex clinical scenario with both increased thromboembolic and hemorrhagic risk. In these patients, in addition to established risk factors, cancer-related factors, such as thrombocytopenia, organ dysfunction, and drug-drug interactions, should be considered when managing anticoagulant treatment. Despite the growing prevalence of this clinical overlap, cancer patients have been under-represented in randomized controlled trials of direct oral anticoagulants for AF. Consequently, evidence guiding anticoagulation decisions in this population derives largely from post-hoc analyses and observational studies. The CHA₂DS₂-VA(Sc) and HAS-BLED scores, widely used for thromboembolic and bleeding risk stratification in the general AF population, have demonstrated suboptimal predictive performance in cancer patients, underscoring the need for a risk factor based approach specific for cancer patients. Emerging data consistently suggest that direct oral anticoagulants (DOACs) are at least as effective and safe as vitamin K antagonists (VKAs) in cancer patients with AF, with potential advantages in reducing stroke, major and intracranial bleeding, and mortality. However, DOACs use is still debated in some settings such as gastrointestinal and genitourinary cancer, brain metastasis and in case of strong drug-drug interactions. This review summarizes current evidence on ischemic and bleeding risk assessment in cancer patients with AF, evaluates the performance of existing risk stratification tools, identifies cancer-specific bleeding risk factors, and proposes a practical management algorithm for anticoagulation in this challenging population.