Cancer Recurrence Following Immune-Suppressive Therapies in Patients With Immune-Mediated Diseases: A Systematic Review and Meta-analysis

Shelton, Edward; Laharie, David; Scott, Frank I.; Mamtani, Ronac; Lewis, James D.; Colombel, Jean–Frédéric; Ananthakrishnan, Ashwin N.

doi:10.1053/j.gastro.2016.03.037

Cited by 124 publications

(83 citation statements)

References 64 publications

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“…In theory, this balance may be altered by immunosuppression and IS should be avoided for life. Of note however, the meta-analysis by Shelton et al [18] did not show an increased rate of recurrent cancer associated with IS in the group of patients who had had cancer more than 6 years ago, while in this particular population, the risk of bias was probably lower than in patients with a shorter interval from the diagnosis of cancer.…”

Section: Safe Interval For Starting Is After Successful Treatment Of mentioning

confidence: 64%

“…The incidence rate of cancer was 84.5 per 1,000 patient-years [22] . In the metaanalysis of Shelton et al [18] , rates of cancer recurrence were not different among IBD patients treated with an anti-TNF agent (pooled incidence rate 48 per 1,000 patient-years) and IBD controls (pooled incidence rate 36 per 1,000 patient-years). However, pooling data from rheumatology and IBD studies showed a higher, albeit not significant, incidence of cancer recurrence in patients receiving combotherapy (pooled incidence rate 54 per 1,000 patient-years).…”

Section: Anti-tnf Agentsmentioning

confidence: 91%

“…A similar negative finding was noted in 405 patients from the CESAME cohort including 20% of patients on thiopurines [3] . The recent meta-analysis of Shelton et al [18] pooled data from 11,702 patients with IBD, rheumatoid arthritis or psoriasis with a history of cancer, and did not show an increased risk of new or recurrent cancer in patients treated with immunomodulators when compared to controls receiving no immunosuppression. Of note, incidence rates were similar with thiopurines and methotrexate.…”

Section: Immunomodulatorsmentioning

confidence: 99%

“…This delay is extended to 5 years if the cancer is associated with an intermediate or high risk of recurrence. Despite the re-assuring meta-analysis of Shelton et al [18], it seems still reasonable to require a delay of a minimum of 2 years before starting IS, including anti-TNF agents in every case of cancer, and a delay of 5 years in cancer of the urinary tract, HPV-related cancer, gastrointestinal cancer, leukemias, and multiple myeloma. Particular attention should be paid to patients with malignancies with a high risk for late metastasis, particularly breast cancer, melanoma, and renal cell carcinoma.…”

Section: Safe Interval For Starting Is After Successful Treatment Of mentioning

confidence: 99%

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What Should Be Done in Inflammatory Bowel Disease Patients with Prior Malignancy?

Cosnes

2017

Dig Dis

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Background: Treatment of inflammatory bowel disease (IBD) in patients with prior malignancy is challenging because therapeutic immunosuppression required for controlling IBD activity may increase the risk of cancer recurrence. Key Messages: Contrary to the observations in the post-transplant population, retrospective observational studies of IBD patients with prior malignancy have not demonstrated that immunosuppressive drugs increased significantly the risk of new or recurrent cancer. However, these studies are highly biased and do not permit the use of these drugs. Factors like the time since treatment completion, severity, and subtype of prior cancer should be weighed along with the current IBD activity before choosing the best therapeutic strategy. In practice, most cases of prior cancer require a delay of at least 2 years before starting or resuming immunosuppressants, including anti-TNF agents. This delay should be extended to 5 years in cancer with a high risk of recurrence including cancer of the urinary tract, gastrointestinal cancer, leukemias, and multiple myeloma. A special attention should be paid to cancers with a high risk of late metastasis (breast, melanoma, renal cell carcinoma). Enteral nutrition, Budesonide, mesalamine, and limited intestinal resection should be considered following the completion of cancer treatment and prior to the safe initiation of immunosuppressive treatment for IBD. Thiopurines should be avoided in case of prior Epstein-Barr virus-related lymphoma, HPV-related carcinomas, and cancer of the urinary tract. Methotrexate and anti-TNF agents seem to be safe except for the risk of recurrent melanoma for the latter. Conclusion: IBD patients with prior malignancy should benefit from individual decisions made on a case-by-case basis.

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Section: Safe Interval For Starting Is After Successful Treatment Of mentioning

confidence: 64%

Section: Anti-tnf Agentsmentioning

confidence: 91%

Section: Immunomodulatorsmentioning

confidence: 99%

Section: Safe Interval For Starting Is After Successful Treatment Of mentioning

confidence: 99%

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What Should Be Done in Inflammatory Bowel Disease Patients with Prior Malignancy?

Cosnes

2017

Dig Dis

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“…Indeed, monotherapy with anti-tumor necrosis factor (TNF)-α antagonists or methotrexate is known to increase the risk for melanomatous and non-melanomatous skin cancers, but its risk for hematological disorders, such as MDS and lymphoproliferative diseases, is not clear [18]. Moreover, a recent metaanalysis on patients who were given immunosuppressive therapy for immuno-mediated diseases after a prior malignancy showed that the incidence rates of new primary cancer (i.e., skin cancer, melanoma, hematological malignancy, breast and solid cancers) were not significantly different among patients who did not receive immunosuppression, those who receive anti-TNF-α antagonists and those who received conventional immunosuppression with thiopurines and methotrexate [19]. [20,21].…”

Section: Discussionmentioning

confidence: 99%

Trisomy 8-Associated Intestinal Behcet’s Disease That Achieved Complete Remission With Mesalazine

et al. 2018

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A 39-year-old man was referred to our hospital because of ileocecal ulcer and pancytopenia. Past medical history included psoriatic arthritis and acne vulgaris. Physical examination findings showed recurrent oral ulcerations and acneiform eruptions on his body. Colonoscopy confirmed the presence of an ulcer at the ileocecal valve. Human leukocyte antigen was positive for B51. Based on the bone marrow findings of hypercellularity accompanied by trilineage dysplastic changes and cytogenetic findings of 47,XY,dup(1)(q21q32), idem+8, a definite diagnosis of intestinal Behcet's disease (BD), incomplete type, associated with myelodysplastic syndrome (MDS) with positivity for trisomy 8 was finally confirmed. Treatment of intestinal BD with mesalazine at 3,000 mg daily induced complete ulcer healing after 4 months. Thereafter, two cycles of azacytidine was administered, followed by bone marrow transplantation. The patient has done well with continuous healing of the ulcer for a year. Differentiating episodic MDS with positivity for trisomy 8 from drug-induced MDS by examination of the bone marrow and the cytogenetic changes is indispensable. Intestinal BD patients who develop pancytopenia would probably need sufficient doses of mesalazine for treatment.

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Management of Crohn Disease

Cushing

Higgins

2021

JAMA

167

117

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ImportanceCrohn disease, a chronic gastrointestinal inflammatory disease, is increasing in incidence and prevalence in many parts of the world. Uncontrolled inflammation leads to long-term complications, including fibrotic strictures, enteric fistulae, and intestinal neoplasia. Therefore, early and effective control of inflammation is of critical importance.ObservationsThe optimal management approach for Crohn disease incorporates patient risk stratification, patient preference, and clinical factors in therapeutic decision-making. First-line therapy generally consists of steroids for rapid palliation of symptoms during initiation of anti–tumor necrosis factor α therapy. Other treatments may include monoclonal antibodies to IL-12/23 or integrin α4β7, immunomodulators, combination therapies, or surgery. Effective control of inflammation reduces the risk of penetrating complications (such as intra-abdominal abscesses and fistulae), although more than half of patients will develop complications that require surgery. Adverse reactions to therapy include antibody formation and infusion reactions, infections, and cancers associated with immune modulators and biologics and toxicity to the bone marrow and the liver. Both Crohn disease and corticosteroid use are associated with osteoporosis. Vaccinations to prevent infections, such as influenza, pneumonia, and herpes zoster, are important components of health maintenance for patients with Crohn disease, although live vaccines are contraindicated for patients receiving immune suppression therapy.Conclusions and RelevanceThe treatment of patients with Crohn disease depends on disease severity, patient risk stratification, patient preference, and clinical factors, including age of onset and penetrating complications, and includes treatment with steroids, monoclonal antibody therapies, immunomodulators, and surgery. Physicians should be familiar with the advantages and disadvantages of each therapy to best counsel their patients.

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Cancer Recurrence Following Immune-Suppressive Therapies in Patients With Immune-Mediated Diseases: A Systematic Review and Meta-analysis

Cited by 124 publications

References 64 publications

What Should Be Done in Inflammatory Bowel Disease Patients with Prior Malignancy?

What Should Be Done in Inflammatory Bowel Disease Patients with Prior Malignancy?

Trisomy 8-Associated Intestinal Behcet’s Disease That Achieved Complete Remission With Mesalazine

Management of Crohn Disease

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