Anticoagulation in malignancy: the patient who bleeds and clots simultaneously

Patients with active malignancy frequently require anticoagulation for a variety of indications, including thrombosis, atrial fibrillation, or mechanical heart valves. Cancer-associated thrombosis is associated with significant morbidity and mortality and necessitates extended anticoagulation for the duration of active cancer. However, the bleeding risk in this population is heightened due to tumor-related factors such as cancer site (eg, primary or secondary brain tumors), invasive procedures (surgeries, biopsies, etc), and side effects of cancer-directed therapies such as thrombocytopenia. Moreover, there are specific bleeding risk factors unique to individual patients, including medications and preexisting bleeding disorders. Together, these factors substantially increase the likelihood of bleeding events in patients receiving anticoagulation for cancer-associated thrombosis. In this review, we outline the various risk factors contributing to increased bleeding risk in patients with cancer and thrombosis and describe management strategies to ensure safe anticoagulation aimed at minimizing thrombotic complications and hemorrhagic risk.