Blood Thinners May Be Safe to Keep During Skin Cancer Surgery, Review Suggests

Millions of people take direct oral anticoagulants, the modern class of blood thinners that includes apixaban, rivaroxaban, dabigatran and edoxaban. These drugs have largely replaced warfarin for preventing stroke in atrial fibrillation and for treating venous thromboembolism, because they work quickly, require no routine blood monitoring and carry a lower risk of intracranial hemorrhage. But their popularity has created a persistent clinical dilemma in dermatologic surgery: what should a surgeon do when a patient scheduled for Mohs micrographic surgery arrives still taking one of these medications?

Mohs micrographic surgery is the gold-standard treatment for many skin cancers, particularly basal cell carcinoma and squamous cell carcinoma on the face and other high-risk sites. The technique involves removing thin layers of tissue one at a time, examining each layer under a microscope while the patient waits, and continuing until the margins are completely clear of tumor. Because the surgery can involve multiple stages, extended operative times and deliberate preservation of healthy tissue, surgeons have long worried about bleeding complications. Historically, the reflexive response was to interrupt anticoagulation before the procedure, on the assumption that any bleeding risk outweighed the danger of a temporary drug holiday.

That assumption has been steadily eroding. Interrupting anticoagulation exposes patients to a real risk of thromboembolic events, including stroke, and the 2024 perioperative management guidelines from the American Heart Association and American College of Cardiology have moved the field toward keeping anticoagulants on board for many minor procedures. Dermatologic surgery sits in an interesting middle ground: it is often described as low bleeding risk, yet it involves sharp dissection of vascular skin on elderly patients, precisely the population most likely to depend on these medications. The decision to continue or hold a direct oral anticoagulant before Mohs surgery therefore has consequences on both sides of the ledger, and the evidence base to inform that decision has been scattered across small retrospective studies.

A research letter now published in the Archives of Dermatological Research aims to consolidate that evidence. Rahib K. Islam of Louisiana State University Health Sciences Center and colleagues, including Christopher J. Haas and Shari R. Lipner of Weill Cornell Medicine, conducted a systematic review and meta-analysis of bleeding outcomes in patients who underwent Mohs micrographic surgery while taking direct oral anticoagulants. Rather than generating new primary data, the team extracted study-level information from previously published reports and pooled the findings quantitatively, a standard approach for deriving a more precise estimate of risk than any single small study can provide.

The analysis drew principally on retrospective cohort studies that compared bleeding complications in anticoagulated and non-anticoagulated patients. Two of the most frequently cited investigations in this literature anchor the pooled analysis: a 2017 retrospective study by Antia and colleagues examining perioperative complications with the newer oral anticoagulants in Mohs surgery, and a 2018 retrospective assessment by Eilers and colleagues of postoperative bleeding complications in anticoagulated patients following the procedure. A broader systematic review of direct oral anticoagulants in skin surgery published in 2024 by Ireland and colleagues, along with a 2024 study by Fahmy and colleagues on postoperative bleeding complications associated with these drugs in Mohs surgery, provide the surrounding context for the current work.

The technical logic of a meta-analysis deserves explanation, because it is what gives this kind of research its power. Individual retrospective studies of Mohs surgery typically enroll hundreds of patients at most, and bleeding complications after cutaneous surgery are relatively uncommon events. When an outcome is rare, a single-center study lacks the statistical resolution to distinguish a true difference in risk from random variation. By pooling the raw event counts across studies, a meta-analysis effectively enlarges the sample size, narrows the confidence interval around the estimated bleeding rate, and can reveal whether the direction of effect is consistent across independent patient populations. Heterogeneity between studies, meaning variability in how bleeding was defined and measured, remains an important limitation, since one study may count only bleeding requiring intervention while another counts any postoperative oozing.

The broader trend in this literature has been reassuring for patients who stay on their medication. Across multiple retrospective cohorts, the rate of significant bleeding complications in Mohs surgery has remained low overall, and the difference between patients continuing direct oral anticoagulants and those not taking them has been modest at most. This aligns with the surgical reality of the procedure: Mohs surgeons work under magnification, achieve meticulous hemostasis with electrosurgery and local hemostatic agents, and repair wounds in layers that compress bleeding vessels. The technique itself was designed for precision, and that precision partially offsets the pharmacologic impairment of clotting that anticoagulated patients experience.

The counterweight is the thrombotic risk of interruption. When a patient stops apixaban or rivaroxaban before surgery, the protection against stroke that the drug was prescribed to provide disappears for days. For patients with high thromboembolic risk, such as those with recent stroke, mechanical heart valves on anticoagulation for other indications, or recent venous thrombosis, that unprotected window is exactly when a clot can form. Bridging with injectable heparin products, the traditional workaround for warfarin, has fallen out of favor for many scenarios because it can increase bleeding without clearly reducing clotting events. Continuing the drug, when the procedure is genuinely low bleeding risk, sidesteps the entire problem, which is why the accumulating dermatologic surgery evidence matters far beyond the specialty.

The authors of the new analysis note that all study-level data examined were extracted from previously published reports, with no new individual-level data generated, and that the derived results are reported in the article and its supplementary material. That transparency is useful for clinicians who want to scrutinize the underlying event counts themselves. It also highlights the state of the evidence: everything currently known about direct oral anticoagulants in Mohs surgery comes from observational data, not from a randomized controlled trial. Observational studies can be biased by surgeon decision-making, since the patients in whom surgeons choose to continue anticoagulation may systematically differ from those in whom they choose to interrupt it. Surgeons may, for example, be more cautious with patients on higher doses, with larger tumors or with planned complex repairs, which could skew the observed complication rates in either direction.

For now, the practical message is that the evidence increasingly supports a nuanced, patient-centered approach rather than a blanket policy of stopping blood thinners before skin cancer surgery. The 2024 cardiovascular perioperative guidelines provide the framework on the medical side, and pooled dermatologic surgery data now supply the procedure-specific risk estimates on the surgical side. For the growing population of older adults who need both lifelong anticoagulation and definitive treatment of skin cancer, studies like this one help ensure that the cure for their tumor does not come at the price of a preventable stroke, and that decisions made in the preoperative holding area rest on evidence rather than habit.

Subject of Research: Bleeding with direct oral anticoagulants during Mohs micrographic surgery: a systematic review and meta-analysis

Article Title: Bleeding with direct oral anticoagulants during Mohs micrographic surgery: a systematic review and meta-analysis

Article References: Islam, R. K., Plakotaris, E., Culotta, N., Falgout, L. M., Hilton, D. C., Lipner, S. R., & Haas, C. J. (2026). Bleeding with direct oral anticoagulants during Mohs micrographic surgery: a systematic review and meta-analysis. Archives of Dermatological Research, 318(1), Article 527. https://doi.org/10.1007/s00403-026-04879-y

Image Credits: AI Generated

DOI: 10.1007/s00403-026-04879-y

Keywords: Bleeding, direct, oral, anticoagulants, during, Mohs, micrographic, surgery, systematic, review, meta-analysis, scientific research