Eular’s Points to Consider
- The landscape of therapies for rheumatoid arthritis, spondylarthritis, and psoriatic arthritis has dramatically changed as the 1990s. Though, concerns have emerged regarding the potential link between these inflammatory...
- To address these concerns, the European alliance of Rheumatology Associations (EULAR) has released a series of recommendations designed to guide clinicians in determining the most appropriate therapeutic strategies...
- A team of EULAR experts conducted a systematic review of existing literature focusing on cancer incidence in inflammatory arthritis patients with a history of cancer who were treated...
EULAR Issues Guidance on Arthritis Treatment for Cancer Survivors
The landscape of therapies for rheumatoid arthritis, spondylarthritis, and psoriatic arthritis has dramatically changed as the 1990s. Though, concerns have emerged regarding the potential link between these inflammatory arthritis (AI) diagnoses, along with conventional, biological, and targeted synthetic treatments, and an elevated risk of certain cancers. This is especially concerning when considering innovative therapies for patients with a prior cancer diagnosis, possibly leading to undertreatment in this vulnerable group.
To address these concerns, the European alliance of Rheumatology Associations (EULAR) has released a series of recommendations designed to guide clinicians in determining the most appropriate therapeutic strategies for these complex cases.
Systematic Review of Cancer Incidence
A team of EULAR experts conducted a systematic review of existing literature focusing on cancer incidence in inflammatory arthritis patients with a history of cancer who were treated with biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). The review, published in the journal Annals of the Rheumatic Diseases, analyzed 15 articles encompassing 4,428 patients receiving targeted therapy and a control group of 13,698 patients treated with conventional synthetic disease-modifying antirheumatic drugs.
The studies included patients with both inflammatory arthritis and inflammatory bowel disease (IBD). The average age at cancer diagnosis was 52.5 years, with an average follow-up period of 4.52 years. The average time from cancer diagnosis to the start of bDMARDs was four years.The review documented a total of 460 new or recurring cancer diagnoses: 428 in the tumor necrosis factor inhibitor (TNFi) group, 9 in the rituximab group, 19 in the vedolizumab group, and 3 in the ustekinumab group. No cases were reported in patients treated with csDMARDs. In the group treated with synthetic DMARDs, 1,394 new or recurring cancer cases were documented.
The risk ratio (RR) of recurrence or new cancer was 0.90 (95% CI: 0.74 to 1.1). Tumor necrosis factor inhibitors showed a risk ratio of 0.94 (95% CI: 0.76 to 1.18), while the rituximab group had a risk ratio of 0.49 (0.14 to 1.65). Sub-analysis based on the duration of biological disease-modifying drug use (less than or greater than 5 years) yielded similar results. For non-melanoma skin cancer (NMSC), the risk ratio for tumor necrosis factor inhibitors was 1.23 (95% CI: 0.90 to 1.70).When analyzing only patients with inflammatory arthritis, excluding IBD cases, the risk ratio for new cancer or recurrence was 1.03 (95% CI: 0.79 to 1.34) compared to synthetic disease-modifying antirheumatic drugs.
Key Recommendations for Managing Inflammatory Arthritis
Based on the findings of this systematic review, EULAR issued specific recommendations for managing inflammatory arthritis in patients with a history of cancer. These recommendations emphasize the need to assess the risk of cancer recurrence, considering both patient and disease characteristics. While rheumatologists are primarily responsible for managing inflammatory arthritis, close collaboration with oncologists and shared decision-making with the patient are crucial.
The recommendations highlight that effective treatment of inflammatory arthritis is essential to minimize the risk of malignancy. Thus,treatment can be initiated without delay in patients with cancer in remission. Though, JAK and abatacept inhibitors should be used cautiously and only when no alternatives exist, due to published reports of increased cancer risk associated with these drugs. In patients with a history of solid cancer (excluding melanoma, where sufficient data is lacking), TNF inhibitors are preferred. For patients with a history of lymphoma, B-cell depletion therapy is recommended.
In patients with active cancer and inflammatory arthritis, the decision to initiate anti-rheumatic therapy should be made in consultation with the oncologist, notably in the context of immunotherapy, where the effects of b/tsDMARDs remain unclear.
Limitations and Future research
EULAR acknowledges that these recommendations, while intended to cover all therapies involving biological and targeted synthetic disease-modifying antirheumatic drugs, are limited by a lack of sufficient data on certain cancer types, such as melanoma. Similarly, information is lacking on specific therapies, including IL-12/23 inhibitors, IL-23 inhibitors, abatacept, belimumab, and JAK inhibitors.Furthermore, most available data is limited to patients with rheumatoid arthritis, highlighting the need for more research on other types of inflammatory arthritis and systemic autoimmune diseases.
Expert Opinion
Balancing the risk of cancer recurrence with the need for effective inflammatory arthritis treatment is paramount.These recommendations underscore the importance of shared decision-making and interdisciplinary collaboration. the recommendations are intentionally broad,reflecting the limited evidence available for manny biological and targeted synthetic disease-modifying antirheumatic drugs across various systemic autoimmune diseases. Until more data becomes available, managing inflammatory arthritis in patients with a history of cancer or active cancer will require a collaborative approach involving the rheumatologist, the oncology team, and the patient.
Arthritis Treatment for Cancer Survivors: A Comprehensive Guide
This article offers a comprehensive look at managing inflammatory arthritis in cancer survivors, based on the latest guidance from the European Alliance of Rheumatology associations (EULAR). We’ll address common questions and concerns, providing actionable insights for patients and healthcare providers alike.
What is the connection between inflammatory arthritis and cancer?
There’s growing concern about a potential link between inflammatory arthritis (IA) diagnoses, including rheumatoid arthritis, spondylarthritis, and psoriatic arthritis, and an increased risk of certain cancers. The use of conventional, biological, and targeted synthetic treatments for IA has also raised questions about their impact on cancer risk, especially in patients with a prior cancer diagnosis. This has led to the advancement of specific treatment guidelines for this vulnerable group.
Why did EULAR issue new recommendations?
The primary reason EULAR released these recommendations is to help clinicians determine the most appropriate therapeutic strategies for inflammatory arthritis in patients with a history of cancer. The treatments for inflammatory arthritis have changed dramatically in recent decades, but there have been concerns about a potential link between the medications used to treat inflammatory arthritis (like rheumatoid arthritis, spondylarthritis, and psoriatic arthritis) and an increased risk of cancer. This is especially important when considering new therapies for patients who have had cancer before. The guidelines are meant to address these concerns and guide decisions.
What did the EULAR review analyze?
A team of EULAR experts conducted a systematic review of existing literature focusing on cancer incidence in inflammatory arthritis patients with a history of cancer who were treated with biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs). The review, published in the journal Annals of the Rheumatic Diseases, analyzed 15 articles encompassing 4,428 patients receiving targeted therapy and a control group of 13,698 patients treated with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs). The study included a mix of patients with both inflammatory arthritis and inflammatory bowel disease (IBD).
What were the key findings of the systematic review?
The review documented a total of 460 new or recurring cancer diagnoses among patients treated with b/tsDMARDs. In contrast, there were 1,394 new or recurring cancer cases documented in the group treated with csDMARDs. The average age at cancer diagnosis was 52.5 years,with an average follow-up period of 4.52 years.
Key findings include:
Risk Ratio: The risk ratio (RR) of recurrence or new cancer was 0.90 (95% CI: 0.74 to 1.1), suggesting no important increased risk overall with b/tsDMARDs compared to a control group.
TNFi: Tumor necrosis factor inhibitors showed a risk ratio of 0.94 (95% CI: 0.76 to 1.18), the results were similar to that of b/tsDMARDs.
Rituximab: Interestingly, the rituximab group showed a risk ratio of 0.49 (0.14 to 1.65).
NMSC (Non-Melanoma Skin Cancer): For non-melanoma skin cancer, the risk ratio for tumor necrosis factor inhibitors was 1.23 (95% CI: 0.90 to 1.70).
Inflammatory Arthritis onyl (excluding IBD): When analyzing only patients with inflammatory arthritis, the risk ratio for new cancer or recurrence was 1.03 (95% CI: 0.79 to 1.34).
What are the main EULAR recommendations for managing inflammatory arthritis in cancer survivors?
EULAR’s recommendations put emphasis on assessing the risk of cancer recurrence. Here’s a summarized version:
Collaboration is Crucial: Rheumatologists should work closely with oncologists.
Treatment in Remission: arthritis treatment can be started without delay in patients who are in cancer remission.
Cautious Use of Certain Drugs: JAK and abatacept inhibitors should be used cautiously and only if no alternatives exist, as of reports of their increased cancer risk.
TNF Inhibitors preferred (Solid Cancers): In patients with a history of solid cancer (excluding melanoma, where data is lacking), TNF inhibitors are the preferred choice.
B-cell Depletion (Lymphoma):