A Practical Approach to the Use of Conventional Synthetic, Biologic and Targeted Synthetic Disease Modifying Anti-Rheumatic Drugs for the Treatment of Inflammatory Arthritis in Patients with a History of Malignancy

Abstract

Data from randomised controlled trials is limited as patients with pre-existing malignancy are often excluded. Reassuringly, an increasing range of "real world" data from various national b/tsDMARD registries has not provided a convincing signal that these drugs increase tumour recurrence. Nevertheless, awareness of, and adherence to, national screening guidelines for malignancy is important. Given the improvement in quality of life achieved with these novel and well-tolerated therapeutic agents, the benefit/risk profile remains overwhelmingly favourable in most patients.

Challenges in the treatment of psoriasis with biologics: vaccination, history of malignancy, human immunodeficiency virus (HIV) infection, and pediatric psoriasis

“…A recent Swedish population‐based study on 467 patients with a history of solid cancer and rheumatoid arthritis (RA), that were treated with TNF inhibitors, showed no increased risk for cancer recurrence in these patients, although clinically meaningful risk increases could not be ruled out completely . These data seem to be in accordance with a study of the British Society for Rheumatology Biologics Register, as well as with a meta‐analysis by Mimic et al However, existing data on patients with previous NMSC indicate an increased risk of reappearance in patients treated with anti‐TNF agents . Although a history of malignancy is not stated as a clear contraindication in the BGD, it is recommended to prescribe the biologic agent with caution and after consulting the relevant oncologist, especially if the malignancy was diagnosed and treated <5 years previously and/or the baseline risk of skin cancer is increased (e.g., previously treated NMSC) .…”

“…Because of the fact that patients with a history of malignancy are usually excluded from clinical trials, data on the effect of a treatment with biologics on a possible tumor recurrence are rather limited . Although long‐term exposure (≥12 months) to TNF inhibitors may be generally associated with a higher risk of malignancy, such as lymphomas and nonmelanocytic skin cancer (NMSC), there are only limited large scale data on the aspect of tumor recurrence under these agents .…”

“…The lack of published data on patients with previous malignancy, that received ustekinumab or secukinumab, makes it difficult to draw safe assumptions regarding the administration of these agents in this particular patient population …”

“…Because of the fact that patients with a history of malignancy are usually excluded from clinical trials, data on the effect of a treatment with biologics on a possible tumor recurrence are rather limited. 17 Although long-term exposure (≥12 months) to TNF inhibitors may be generally associated with a higher risk of malignancy, 18 aspect of tumor recurrence under these agents. 19 A recent Swedish population-based study on 467 patients with a history of solid cancer and rheumatoid arthritis (RA), that were treated with TNF inhibitors, showed no increased risk for cancer recurrence in these patients, although clinically meaningful risk increases could not be ruled out completely.…”

“…19 These data seem to be in accordance with a study of the British Society for Rheumatology Biologics Register, 20 as well as with a meta-analysis by Mimic et al 21 However, existing data on patients with previous NMSC indicate an increased risk of reappearance in patients treated with anti-TNF agents. 17 Although a history of malignancy is not stated as a clear contraindication in the BGD, it is recommended to prescribe the biologic agent with caution and after consulting the relevant oncologist, especially if the malignancy was diagnosed and treated <5 years previously and/or the baseline risk of skin cancer is increased (e.g., previously treated NMSC). 5 Finally, the German Guidelines for Psoriasis 2017 tend to favor the administration of ustekinumab or secukinumab over TNF inhibitors in patients with a history of malignancy, 6 whereas the American College of Rheumatology recommends starting or resuming biological therapy for patients treated for a solid malignancy >5 years prior, without differentiating between anti-TNF agents and non-anti-TNF agents.…”