EULAR POINTS TO CONSIDER ON THE INITIATION OF TARGETED THERAPIES IN PATIENTS WITH INFLAMMATORY ARTHRITIDES AND A HISTORY OF CANCER
Authors: Jacques-Eric Gottenberg et al.
Immunomodulatory drugs might increase the risk of cancer, which is of particular concern in patients with a prior history of cancer. On the other hand, uncontrolled inflammatory disease activity constitutes in itself a risk factor for cancer, in particular for lymphoma. To address this conundrum, EULAR has commissioned a task force to make practical recommendations, after performing a systematic literature review and a meta-analysis.
The task force has put forward a number of overarching principles and practical points to consider. I will highlight a few of the most relevant ones:
- PTC 4. Appropriate targeted anti-rheumatic treatment can be initiated without delay in patients with a cancer in remission
- PTC 6. When targeted antirheumatic therapy is indicated in patients with a history of solid cancer, anti-cytokine bDMARDs may be preferred over other treatment options.
- PTC 5. In patients with a history of cancer, JAK inhibitors and Abatacept should be used with caution, and only in the absence of therapeutic alternatives.
Because rheumatologists may be reluctant to use more potent antirheumatic therapies in patients with RA and history of cancer, some patient may be undertreated for their inflammatory condition. The recommendation has the merit of clearly stating some guidelines in these murky waters: The importance of treating inflammatory arthritis effectively, even in patients with a history of cancer in order to reduce the potential associated risk of malignancy, and to do so without delay (no more specific durations of cancer remission …). If second line therapies are needed, the recommendation to use anti-cytokine first (anti-TNFs, anti-IL6, …), and only in few specific situations, other second line therapies (rituximab…).
Several other difficult situations remain unclear, in particular in patients with active inflammatory arthritis and a malignancy not in remission or with a pre-cancer state. Overall, we still need to balance the risk of complications associated with undertreated inflammatory activity against the potential risk of targeted antirheumatic therapy related cancer recurrence.