Is there truly a risk of lymphoma from biologic therapies?

Abstract

The treatment of psoriasis has undergone a revolution with the advent of biologic therapies, including infliximab, etanercept, adalimumab, efalizumab, and alefacept. Biologics are generally safe and well tolerated. However, there has been concern over the risk of lymphoma with use of these agents due to their immunosuppressive properties. This review summarizes the current evidence in regards to lymphoma risk with biologic therapy obtained from case reports and case series, observational studies, clinical trials, and meta-analyses. The majority of data for T-cell inhibitors comes from case reports and relatively small, short term clinical trials. In addition to published case reports and case series, TNF-α inhibitors have also been studied extensively in large cohort studies and meta-analyses of clinical trials derived primarily from the rheumatoid arthritis population. Current data are not sufficient to completely rule out an increased risk of lymphoma associated with biologics, nor has a causal relationship between lymphoma and biologics been well established. Short- to intermediate-term treatment with biologics (e.g. up to 4 years) appears to be very safe with respect to lymphoma risk, especially with TNF-α inhibitors in which their potential risks appear to be well defined. Continued vigilance is warranted, however, in the appropriate patient, the risk-to-benefit profile of psoriasis treatment with respect to lymphoma risk appears highly favorable.

Lymphomatoid Papulosis in a Patient Treated with Adalimumab for Juvenile Rheumatoid Arthritis

“…The other manifestations included infiltrative nodules and plaques (n = 5), eczematous changes (n = 1) and hypopigmented patches (n = 1). According to recent research, 34 lymphomas were associated with biological therapy in 2009, while 81 were detected in 2011 [23,24]. Specifically, the study from 2009 reported 2 cases (2.7%) of cutaneous T-cell lymphoma, 15 (20%) of B-cell non-Hodgkin lymphoma and 29 (38.7%) of T-cell lymphoma [24].…”

“…According to recent research, 34 lymphomas were associated with biological therapy in 2009, while 81 were detected in 2011 [23,24]. Specifically, the study from 2009 reported 2 cases (2.7%) of cutaneous T-cell lymphoma, 15 (20%) of B-cell non-Hodgkin lymphoma and 29 (38.7%) of T-cell lymphoma [24]. Conversely, the data from 2011 showed 29 cases (35.8%) of B- cell non-Hodgkin lymphoma and 31 cases (38.3%) of T/natural killer cell non-Hodgkin lymphoma [23].…”

Use of biologics in a patient with rheumatoid arthritis refractory to methotrexate

“…7 Biologics do not seem to be associated with an increased risk of cancer overall among patients with rheumatoid arthritis, 8,9 although there may be a slight increase in the risk of skin cancers. 10,11 Whether biologic use increases the risk of lymphoma beyond that associated with rheumatoid arthritis is controversial; 5,11,12 major limitations of the current data are lack of long-term follow-up and the need for very large samples because of the rarity of this event.…”

Psoriasis Vulgaris: An Evidence-Based Guide for Primary Care

“…36,55,57 However, when meta-analyses of these randomized controlled trials were considered, most of the patients who populated the original trials were from cohorts with rheumatoid arthritis and Crohn's disease, which usually combined biological therapies with additional immunosuppressive agents, therefore introducing selection bias and confounding. 61 In the absence of TNF-␣ blocking therapy, patients with moderate to severe rheumatoid arthritis, for example, have a 5-to 25-fold increased risk of developing lymphoma. 57 It is therefore unclear whether the increases in the rate of lymphoma observed in these trials were related to TNF-␣ blocking therapy.…”