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RA patients did not display increased risk for total malignancy
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Patients with rheumatoid arthritis receiving anti-tumor necrosis factor therapy did not present an increased risk for total malignancy, except for possible nonmelanoma skin cancers, according to study data.
French researchers reviewed Embase and Medline databases for literature up to January 2010 and abstracts from the 2008 and 2009 annual meetings of the American College of Rheumatology and the European League Against Rheumatism.
From an initial literature search of 634 articles and 110 abstracts, 12 articles and five abstracts were analyzed. Meta-analysis was performed on four articles and three abstracts for total malignancy and nonmelanoma skin cancer (NMSC) risk. In comparing the tumor necrosis factor (TNF) antagonist and disease-modifying antirheumatic drug (DMARD) groups, odds ratios were 0.81 (95% CI, 0.71-0.94) for total malignancy and 0.79 (95% CI, 0.62-1.02) for NMSC. Heterogeneity was not significant.
There was no significant increase in total malignancy incidence in four long-term extension studies and four registries compared with the general population. In two registries comparing synthetic DMARD and one registry comparing the general population, the only indication of malignancy was related to skin cancers, particularly NMSCs, with a statistically significant or nearly significant increased risk.
“Besides this specific risk of NMSC, the absence of increased risk of neoplasms with TNF antagonist treatment seems to be a general trend, either from [long-term extension] studies or registries,” the researchers said. “No registry or long-term extension studies found an increased risk of total malignancy and of solid cancers with anti-TNF therapy in RA, either as compared with synthetic DMARDs or the general population.
“Even if our meta-analysis did not conclude to an elevated risk of NMSC with anti-TNF, because of the frequent use of these treatments, strict selection of patients and careful monitoring remain mandatory.”
Disclosure: See the study for a full list of relevant disclosures.
Perspective
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Wen-Jen Hwu, MD, PhD
TNF-alpha antagonists have become a standard care in the treatment of moderate and severe rheumatoid arthritis since 1998. It is an immune modulation therapy, not an immune suppressive therapy as traditional synthetic disease-modifying anti-rheumatic drugs. Although this meta-analysis of data from registries and systematic review of long-term extension studies did not reveal an increased risk of malignancy in rheumatoid arthritis patients receiving anti-TNF therapy, there may be an increased risk of non-melanoma skin cancers (NMSC) such as squamous cell carcinomas and basal cell carcinomas.
The limitations of this study include the possibility of concomitant immunosuppressive treatment and the missing information of patients’ history and prior therapy. In addition, the most important risk factors for NMSC – usage of ultraviolet-sensitizing agents, history of sun exposure and severe sun damaged skin, and geologic location of patient population (Arizona vs. Minnesota) – are not included in the data sets. In order to better assess the risk of NMSC with anti-TNF therapy, additional studies which include the known risk factors for NMSC are needed.
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