Direct Oral Anticoagulation in Cancer Patients

Thrombosis is a leading cause of mortality in cancer patients. Cancer patients are at an increased risk of developing atrial fibrillation, and venous thromboembolism is a leading cause of mortality, especially in patients undergoing chemotherapy. The anticoagulant strategy to be administered in these cases is particularly difficult to choose due to an altered state of coagulation that makes the balance between hypercoagulation and bleeding risk in anticoagulated cancer patients fragile. Historically, warfarin and even more low molecular weight heparins are the preferred anticoagulant drugs in this population as direct acting anticoagulants, with a more favorable drug profile, have collected less evidence in cancer patients with atrial fibrillation and venous thromboembolism. Recent evidences from retrospective studies and meta-analyses in the literature suggest that direct acting oral anticoagulants may be as effective as vitamin K antagonists and low molecular weight heparins for the prevention of stroke and systemic embolism in patients with atrial fibrillation and cancer, and more interestingly, some randomized clinical trials are already available to compare direct oral anticoagulants and heparins for the treatment of VTE in the cancer population. Due to the clinical interest of the field, this chapter review aims to collect and summarize the most important findings related to the use of direct oral anticoagulants in cancer patients with atrial fibrillation and venous thromboembolism.