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No link observed between immune-suppressive therapies, cancer recurrence
Patients with immune mediated diseases who had a prior cancer had similar rates of cancer recurrence whether they received anti-tumor necrosis factor therapy, immune-modulator therapy, combination therapy, or no immunosuppression, according to the results of a systematic review and meta-analysis.
“Our study provides reassurance about restarting immunosuppressive therapy in patients with prior cancer, with the caveat that we were unable to ascertain the exact interval at which recommencement would be safe as this was at the discretion of the treating physician in each of the studies,” Ashwin N. Ananthakrishnan, MD, MPH, of Harvard Medical School and Massachusetts General Hospital, and colleagues wrote.
Ashwin N. Ananthakrishnan
The researchers searched relevant literature published up to April 2015, and included 16 studies in the analysis, representing 11,702 patients with immune mediated diseases and a prior cancer, with 31,258 person-years of follow-up after prior cancer diagnosis. There were an equal number of studies involving patients with inflammatory bowel disease and rheumatoid arthritis and one study involving patients with psoriasis. The included studies most often grouped all prior cancers together.
After stratifying studies based on type of immune-suppressive therapy, the researchers performed a random effects meta-analysis to calculate pooled cancer incidence rates and risk differences between treatments.
Overall, 1,698 new primary or recurrent cancers occurred. Comparable rates of cancer recurrence were observed in patients who received anti-TNFs, conventional immunosuppressant therapy or no immunosuppression, but cancer recurrence rates were numerically higher in patients who received combination immunosuppression.
Among 4,222 patients who received no immunosuppression, 609 new or recurrent cancers occurred (37.5 per 1,000 person-years; 95% CI, 2.02-54.7). Among 1,753 patients who received anti-TNFs, 215 new or recurrent cancers occurred (33.8 per 1,000 person-years; 95% CI, 22.3-45.2). Among 4,382 patients who received conventional immunosuppressant therapy, 718 new or recurrent cancers occurred (36.2 per 1,000 person-years; 95% CI, 17.7-54.7). The pooled incidence rate for patients who received combination immunosuppression therapy was 54.5 per 1,000 person-years (95% CI, 29.7-79.3).
Comparable results were observed in subgroup analyses separating new and recurrent cancers, types of immunomodulators or types of immune-mediated disease.
Pooled incidence values were also found to be similar for new or primary cancers when immunosuppression was started within 6 years vs. more than 6 years after the index cancer.
When stratifying types of index cancer, analysis of two studies that included index skin cancer only showed significantly higher risk for new or recurrent cancer with immunomodulators (71.6 per 1,000 person-years; 95% CI, 58.9-84.2) vs. no immunosuppression (50.8 per 1,000 person years; 95% CI, 43.7-57.8; P = .035). This risk associated with immunomodulators was also numerically but not statistically higher compared with anti-TNF therapy.
“Treatment decisions following a cancer diagnosis are complex and must take into account the natural history of cancer, histological type and stage, time from diagnosis and course of underlying chronic inflammatory disease,” the researchers concluded. “Our findings suggest that anti-TNF therapy, conventional immunosuppressant therapy, or combination immunosuppression are not associated with increased risk of cancer recurrence in this population.” – by Adam Leitenberger
Disclosure: Ananthakrishnan reports he has served on scientific advisory boards for AbbVie, Cubist and Exact Sciences. Please see the full study for a list of all other researchers’ relevant financial disclosures.