EULAR: Start inflammatory arthritis therapies ‘without delay’ after cancer remission
Key takeaways:
- Cancer recurrence risk should be assessed individually for each patient when starting targeted therapies for inflammatory arthritis.
- Targeted therapies can be started immediately if cancer is in remission.
Targeted therapies for active inflammatory arthritis should be started “without delay” for patients with cancer in remission, according to new EULAR points to consider published in Annals of the Rheumatic Diseases.
“In clinical practice, the potential association between targeted antirheumatic therapies and the recurrence of a past cancer in patients with [inflammatory arthritis] is a growing concern,” Eden Sebbag, of Strasbourg University Hospitals, in France, and colleagues wrote. “These concerns extend to the initiation of [biologic/targeted synthetic (b/ts) DMARDs] in patients who were previously naïve to such therapies (but with a history of cancer) and the re-initiation of b/ts DMARDs in patients who discontinued such treatment at the time of a cancer diagnosis.
“This issue is shared by patients, primary care physicians, rheumatologists, dermatologists, gastroenterologists and oncologists,” they added. “... International expert guidance regarding the use of b/ts DMARDs in patients with a history of cancer and inflammatory or autoimmune disease is limited.”
To draft points to consider regarding the initiation of targeted inflammatory arthritis therapy in patients with previous cancer, Sebbag and colleagues convened a 27-member EULAR task force. Members conducted a systematic review of literature published between January 2010 and July 15, 2022, the findings of which informed a steering committee that developed proposals for the wider group to consider.
Task force members anonymously indicated their level of agreement, ranging from zero to 10, for each proposal. Ultimately, the mean level of agreement ranged from 9.6 to 9.9 for the overarching principles, and from 8.9 to 9.8 for the individual points to consider.
The overarching principles state that each patient’s risk for cancer recurrence should be assessed individually, accounting for comorbidities and lifestyle, the history of the cancer and the characteristics of the inflammatory arthritis. In addition, treatment should be based on shared decision-making between the patient and rheumatologist.
The eight points to consider are:
- For patients with a history of cancer, effective inflammatory arthritis treatment is critical to reduce the potential risk for malignancy.
- Rheumatologists should balance the risk for complications due to undertreating inflammatory disease against the potential risk for cancer recurrence due to targeted antirheumatic therapy.
- Rheumatologists should co-manage patients with inflammatory arthritis and a history of cancer with other specialists.
- Targeted therapy for inflammatory arthritis can start “without delay” in patients with cancer currently in remission.
- JAK inhibitors and abatacept (Orencia, Bristol Myers Squibb) “may be used with caution” — and only when there are no alternatives — in patients with previous cancer.
- When targeted antirheumatic therapy is indicated in patients with a history of solid cancer, TNF inhibitors may be preferred over other treatment options.
- B-cell-depleting agents “may be preferred” over other drugs when targeted antirheumatic treatment is indicated in patients with a history of lymphoma.
- Among patients with cancer not currently in remission alongside active inflammatory arthritis, shared decision making between the patient, rheumatologist and cancer specialist should dictate when to start targeted antirheumatic treatment.
The task force also proposed avenues for future research, including the safety of targeted therapies aside from TNF inhibitors, safety in types of inflammatory arthritis beyond rheumatoid arthritis, and studies with longer follow-up periods.
Overall, the points to consider represent “urgently needed” guidance in the management of patients with inflammatory arthritis and cancer history, Sebbag and colleagues wrote.
“Implementation of these [points to consider] is a critical next step, which requires a collaborative approach,” they added. “The task force proposed to disseminate [points to consider] in oncology in multidisciplinary tumor boards, to integrate them in continuous medical education programs and to provide them to patient representatives and associations of patients.”
Perspective
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Sebbag and colleagues address a question that is very important to many of our patients and their families. As patients with inflammatory arthritis are living longer, more of them are either developing or surviving cancer, and are concerned that any treatment of their inflammatory arthritis could make their cancer recur.
This paper reviews the evidence that is available but emphasizes that there are many data-free zones. There is an emphasis on joint decision making as well as coordination of care with the treating oncologist. In my experience, when patients have been in remission for years, often the oncologist has moved or retired, so I have asked patients to consult with an oncologist who is new to them. I also feel that part of the joint decision making should involve the family, as they are also affected if the patient’s cancer recurs.
The paper suggests the use of TNF inhibitors over rituximab (Rituxan, Genentech) in patients with a history of a solid tumor, based on emerging data that B cells might contribute to the anti-tumor immunity. This recommendation is based on 14 available studies, which hopefully will empower rheumatologists and patients to begin therapy with these agents in those who present with inflammatory arthritis.
Recommendations are made against the use of abatacept (Orencia, Bristol Myers Squibb) based on five of seven observational studies that reported an increase in cancer incidence, compared with other targeted therapies, in patients with RA and no history of cancer. This is the first time that I have been made aware of this data. Due to the boxed warning regarding malignancy in patients taking JAK inhibitors, this class of drugs is recommended only in the absence of therapeutic alternatives.
I, like many of us, have been using rituximab in patients with lymphoma. This is still recommended in this paper but only for this specific type of cancer, rather than for all types of cancer, as has been recommended for the past decade.
Finally, no recommendation was made regarding the treatment of patients with melanoma, due to the lack of data.
When discussing treatment options with patients, I always like to make my recommendations based on data. Now I have data to use when discussing the very difficult and sensitive topic of using aggressive therapy to treat inflammatory arthritis in patients with a history of cancer.
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