Purpose of Review <p>Patients with autoimmune rheumatic diseases (ARDs) and active malignancy pose a unique therapeutic dilemma: controlling autoimmune disease while preserving tumor immune surveillance. This review synthesizes existing evidence, identifies knowledge gaps, and proposes practical considerations for co-management.</p> Recent Findings <p>Emerging studies suggest conventional synthetic and biologic DMARDs, particularly TNF inhibitors, may be safer than previously assumed in patients with cancer, with limited evidence of increased recurrence risk. Some therapies, including abatacept and JAK inhibitors, warrant caution due to potential malignancy signals. Immune checkpoint inhibitors (ICIs) frequently trigger autoimmune flares; however, most are manageable with corticosteroids or DMARDs, and ICI therapy can often continue. Data on concurrent chemotherapy or radiation remain sparse, and treatment decisions require individualized assessment of cancer type, prognosis, and autoimmune disease activity.</p> Summary <p>Overall, shared decision-making integrating rheumatology and oncology perspectives is essential. While TNF inhibitors remain the preferred biologics when needed, therapy should be tailored to cancer stage, autoimmune disease severity, and patient values. Prospective studies are urgently needed to guide immunomodulatory therapy use in this complex, high-risk population.</p>