Overall survival in patients with rheumatoid arthritis and solid malignancies receiving biologic disease-modifying antirheumatic therapy

Managing Rheumatoid Arthritis in Older Adults with Cancer

Rheumatoid arthritis (RA) is a chronic autoimmune condition disproportionately affecting older adults (> 60 years), who often experience increased disease severity and comorbidities, including cancer. A comprehensive review of the literature was conducted, examining the prevalence of malignancy in patients with RA, associated risk factors, and treatment challenges, including management considerations such as psychological distress and lifestyle modifications. Clinical guidelines and consensus statements were summarized to provide practical insights for optimizing care. Older adults with RA are at an elevated risk for developing cancer due to chronic inflammation, immunosenescence from aging, and shared risk factors such as smoking. Patients with RA tend to have poorer cancer survival rates than individuals without RA, particularly for lung cancer and lymphoma. Immunosuppressive therapies used to treat RA may modestly increase cancer risks but are critical for disease control. Current guidelines emphasize discontinuation or adjustment of RA therapies upon cancer diagnosis, with tailored approaches based on cancer type and stage. Non-pharmacologic interventions, including lifestyle modifications and psychological support, play a vital role in improving quality of life and mitigating disease flares during cancer treatment. The management of RA in older adults with a history of cancer requires a personalized, multidisciplinary approach that balances the need for RA symptom control without affecting cancer outcomes. Shared decision-making, incorporating patient preferences and comorbidities, is critical for optimizing care. Further research is needed to strengthen evidence-based guidelines for this population and address gaps in understanding treatment safety and efficacy.

Survival in patients with rheumatoid arthritis and recently diagnosed early-stage colorectal, lung, or prostate cancer receiving tumour necrosis factor inhibitors: a retrospective cohort study

BACKGROUND

Tumor necrosis factor (TNF) inhibitors could impair tumoural immunity in patients with rheumatoid arthritis and cancer. We aimed to investigate the association between survival and TNF inhibitor treatment during the first 3 years after a diagnosis of colorectal, lung, or prostate cancer in patients with rheumatoid arthritis.

METHODS

In this cohort study, we conducted a secondary data analysis of the Surveillance, Epidemiology, and End Results Medicare-linked dataset. We included patients aged 66 years and older with rheumatoid arthritis diagnosed with colorectal, lung, or prostate cancer between Jan 1, 2008, and Dec 31, 2019, using ICD-O-3 site and histology codes. We limited the cohort to patients who had early-stage cancer (localised or regional). We only included patients who received TNF inhibitors, conventional synthetic disease-modifying antirheumatic drugs (DMARDs), or no DMARDs in the first year after cancer diagnosis. The primary outcomes were 5-year overall survival and cancer-specific survival. Exposures were use of TNF inhibitors, conventional synthetic DMARDs, or no DMARDs within 3 years after cancer diagnosis. Other covariates included demographics and comorbidities. We conducted landmark analyses at years 1, 2, and 3, with Cox regression adjusted by propensity scores. People with lived experience of rheumatoid arthritis and cancer were not involved in the design or conduct of this study.

FINDINGS

We identified three cohorts of patients diagnosed with early-stage colorectal cancer (n=514), lung cancer (n=864), or prostate cancer (n=603) between Jan 1, 2008, and Dec 31, 2019. In the colorectal cancer cohort, the mean age was 76·1 years (SD 6·4), 385 (75%) of 514 patients were female, 129 (25%) were male, and 405 (79%) were White and non-Hispanic. In the lung cancer cohort, the mean age was 74·8 years (SD 5·9), 632 (73%) of 864 patients were female, 232 (27%) were male, and 743 (86%) were White and non-Hispanic. In the prostate cancer cohort, the mean age was 73·1 years (SD 5·1), 603 (100%) patients were male, and 492 (82%) were White and non-Hispanic. 80 (16%) of 514 patients with colorectal cancer, 102 (12%) of 864 patients with lung cancer, and 120 (20%) of 603 patients with prostate cancer received TNF inhibitors with or without conventional synthetic DMARDs at any time during the first year after cancer diagnosis. No significant deleterious association was observed for overall survival or cancer-specific survival for any of the cancers at any of the three landmark points. Hazard ratios and 95% CIs for overall survival for year 1 comparing TNF inhibitors with conventional synthetic DMARDs in the three cohorts were 0·72 (0·43-1·21) for colorectal cancer, 0·70 (0·49-1·00) for lung cancer, and 0·80 (0·44-1·44) for prostate cancer. Patients who received glucocorticoids in the first year had significantly worse overall survival and cancer-specific survival than those who did not in the multivariable Cox proportional hazards models for the three cancers.

INTERPRETATION

Treatment with TNF inhibitors during the first 3 years after diagnosis of colorectal, lung, or prostate cancer was not associated with poorer survival compared with those who received conventional synthetic DMARDs or those who did not receive any DMARDs. However, these findings might not be generalisable to other populations or types of cancer.

FUNDING

National Institutes of Health (NIH)/National Institute of Arthritis and Musculoskeletal and Skin Diseases and NIH/National Cancer Institute through MD Andeson's Cancer Center Support Grant and Komen.

Different prevalence and spectrum of malignancy between Chinese patients and American patients with rheumatoid arthritis: a comparative study

Objective

To characterize the epidemiological characteristics of malignancy in Chinese patients with rheumatoid arthritis (RA) versus American patients and investigate their associated factors.

Methods

Data were collected from a real-world Chinese RA population and American patients with RA from the National Health and Nutritional Examination Survey. The prevalence and subtypes of malignancy and their potential associated factors were investigated in both populations.

Results

A total of 2,073 Chinese and 2,928 American patients with RA were included. There was a lower prevalence of malignancy in Chinese than in their American counterparts before (5.7% vs. 17.1%) and after matching (6.2% vs. 12.6%, both P < 0.001). Gender discrepancies in malignancy prevalence were observed, with a male predilection for RA with malignancy in China (8.2% vs. 5.5%), while it was the opposite in American patients (10.1% vs. 13.5%, both P < 0.05). The top type of malignancy among male patients with RA was lung cancer in Chinese (2.29%), but non-melanoma skin cancer (3.43%) in American; while among female patients was breast cancer both in Chinese (1.72%) and American (3.43%). Multivariate logistic regression analyses showed that older age (odds ratio (OR) = 1.050) and positive anti-cyclic citrullinated peptide antibody (OR = 2.752) were independently associated with malignancy in Chinese patients with RA, while female (OR = 1.395), older age (OR = 1.033), active smoking (OR = 1.580) and cardiovascular diseases (OR = 1.523) in American patients.

Conclusion

The prevalence, subtypes and risk factors of malignancy were substantially different in Chinese patients with RA and their American counterparts, which implied the importance of individualized malignancy screening strategies for patients with RA.

Survival in patients with rheumatoid arthritis and early breast cancer treated with tumor necrosis factor inhibitors

BACKGROUND

There have been concerns about the use of tumor necrosis factor inhibitors (TNFi) for autoimmune disease in patients with recently diagnosed cancer. We assessed the survival of patients with rheumatoid arthritis (RA) and newly diagnosed early breast cancer (BC) treated with TNFi in the first two years after BC diagnosis.

METHODS

We identified patients in two datasets: (1) Optum's de-identified Clinformatics® Data Mart Database (CDM), (2) Surveillance, Epidemiology, and End Results program (SEER) and Texas Cancer Registry (TCR) Medicare-linked cohort. We grouped patients according to whether they received TNFi, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) only, or no DMARDs within 2 years after BC. Outcomes were overall survival (OS) and BC-specific survival (BCSS). We conducted landmark analyses at years 1 and 2, with multivariable Cox regressions using propensity scores for adjustment.

RESULTS

In the first year after BC, 165/970 (17.0%) and 201/1246 (16.1%) patients received TNFi in CDM and SEER/TCR-Medicare respectively. In the 1 year landmark, no significant differences in OS were observed between patients treated with TNFi and patients treated with csDMARDs only in CDM (hazard ratio [HR] = 0.77, 95% confidence interval [CI] 0.42-1.40) or SEER/TCR-Medicare (HR = 0.84, 95% CI 0.54-1.31). BCSS (SEER/TCR-Medicare) was better in patients receiving TNFi than in those receiving csDMARDs only (HR = 0.28, 95% CI 0.08-0.98). In CDM, glucocorticoid therapy had worse OS than those without glucocorticoids (HR = 2.18, 95% CI 1.13-4.18). This was also observed in SEER/TCR-Medicare (not statistically significant). Similar results were observed for the 2 year landmark.

CONCLUSIONS

TNFi treatment during the first two years after early BC was not associated with worse survival.

Trends in the use of biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis and recently diagnosed colorectal, lung, or prostate cancer

INTRODUCTION

Biologic disease-modifying antirheumatic drugs (bDMARD) are often discontinued when a patient with rheumatoid arthritis (RA) is diagnosed with cancer. Our aim was to determine trends in bDMARD utilization in patients with RA and recently diagnosed cancer.

METHOD

We examined two national claims databases to identify adults with RA and recently diagnosed colorectal, lung, or prostate cancer (Optum's de-identified Clinformatics® Data Mart Database 2008-2022, and Surveillance, Epidemiology, and End Results Program (SEER) Medicare-linked 2008-2017). We determined time trends in bDMARD and tumor necrosis factor inhibitor (TNFi) prescriptions during the first 3 years after cancer with Cochram-Armitage tests and multivariable logistic regression. Cancer cohorts were analyzed separately.

RESULTS

We included 3595 patients in all six cohorts (in Clinformatics® 503 with colorectal, 468 with lung, and 440 with prostate cancer; in SEER-Medicare 580 with colorectal, 1010 with lung, and 594 with prostate cancer). No significant increase was observed in bDMARD or TNFi utilization over time. Overall, use of bDMARD within the first 3 years of follow-up ranged from 16.7% (Clinformatics® lung cohort) to 29.7% (SEER-Medicare colorectal cohort). The major predictor of bDMARD utilization was prior use in the 3 months before cancer diagnosis (p < 0.001 for all cancers) and earlier cancer stage (p < 0.001 in colorectal and lung cancer and p = 0.05 in prostate cancer).

CONCLUSIONS

Use of bDMARD in patients with RA and recently diagnosed common cancers has not increased since 2008. Additional evidence on the safety of bDMARD in patients with early cancer is needed to ensure appropriate management of their RA. Key Points • Use of bDMARD and TNFi in patients with RA and early colorectal, lung, or prostate cancer has been stable since 2008, with no significant increases over time. • The major determinant of receiving bDMARD after cancer diagnosis was prior treatment with bDMARD in the prior 3 months before cancer. • Patients with advanced cancer stage and distant metastases were less likely to receive bDMARD and TNFi than those at early stages of disease.

Utilization of Biologic Disease-Modifying Antirheumatic Therapy in Patients With Rheumatoid Arthritis and Recently Diagnosed Breast Cancer

OBJECTIVE

Biologic disease-modifying antirheumatic drugs (bDMARDs) are immunosuppressants, and there have been concerns that they might impact tumor immunity in patients with cancer with rheumatoid arthritis (RA). The purpose of this study was to describe the utilization trends of bDMARD in patients with RA after breast cancer (BC) diagnosis.

METHODS

We performed a retrospective cohort study of adults with RA and BC (2008 onward) from Optum's de-identified Clinformatics® Data Mart Database (CDM); the Surveillance, Epidemiology, and End Results Program (SEER) Medicare; and the Texas Cancer Registry (TCR) Medicare databases. We evaluated bDMARD utilization trends during the first three years after BC. We conducted multivariable logistic regression to evaluate the association of utilization with patient characteristics.

RESULTS

A total 1,412 patients were identified in CDM and 1,439 patients in SEER/TCR-Medicare. During the three months before BC diagnosis, 28.2% (CDM) and 26.9% (SEER/TCR-Medicare) patients had received bDMARDs. Within the first three years after diagnosis, 24.1% (CDM) and 26.4% (SEER/TCR-Medicare) were receiving bDMARDs. About 70% of the patients in the two cohorts received glucocorticoids with no significant time trend increases. The largest predictor of bDMARD utilization was prior use before BC (CDM: odds ratio [OR] 27.15, 95% confidence interval [CI] 19.29-38.19; SEER/TCR: OR 18.98, 95% CI 13.72-26.26). Regional and distant BC compared to in situ or localized were also associated with lower bDMARDs utilization in SEER/TCR-Medicare (OR 0.54, 95% CI 0.36-0.82; OR 0.31, 95% CI 0.13-0.77, respectively).

CONCLUSION

The utilization of tumor necrosis factor inhibitors and other bDMARDs in patients with RA and recent BC has not increased since 2008. Glucocorticoids utilization remained high. The largest predictor of bDMARD utilization was prior use before BC.

The effects of glucocorticoids and immunosuppressants on cancer outcomes in checkpoint inhibitor therapy

The emergence of checkpoint inhibitors has created a paradigm shift for the treatment of various malignancies. However, although these therapies are associated with improved survival rates, they also carry the risk of immune-related adverse events (irAEs). Moderate to severe irAEs are typically treated with glucocorticoids, sometimes with the addition of immunosuppressants as steroid-sparing therapy. However, it is unclear how glucocorticoids and immunosuppressants may impact cancer survival and the efficacy of immune checkpoint therapy on cancer. In this narrative review, we discuss the effects of glucocorticoids and immunosuppressants including methotrexate, hydroxychloroquine, azathioprine, mycophenolate mofetil, tumor-necrosis factor (TNF)-inhibitors, interleukin-6 inhibitors, interleukin-1 inhibitors, abatacept, rituximab, and Janus kinase inhibitors (JAKi) on cancer-specific outcomes in the setting of immune checkpoint inhibitor use.

Use of Disease-modifying Antirheumatic Drugs After Cancer Diagnosis in Rheumatoid Arthritis Patients

Objective

There is no recommendation for the use of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) who developed cancer. We examined changes in the DMARDs prescription patterns associated with cancer diagnosis in RA patients.

Methods

We reviewed the medical records of 2,161 RA patients who visited rheumatology clinic between January 2008 and February 2017 and found 40 patients who developed cancer during RA treatment. In these patients, we examined DMARDs prescription patterns before and right after cancer diagnosis and at recent outpatient clinic visits.

Results

Before cancer diagnosis, methotrexate (MTX)-combined conventional synthetic DMARDs (csDMARDs) were most commonly prescribed (22, 55.0%) and biological DMARDs (biologics) in nine patients (22.5%). For cancer treatment, 19 patients received chemotherapy (including adjuvant chemotherapy) and 21 patients had surgery only. Right after cancer diagnosis, changes in the DMARDs prescription patterns were similar in discontinuation (13, 32.5%), switching (14, 35.0%), and maintenance (13, 32.5%). DMARDs were discontinued more frequently in the chemotherapy group (9/19, 47.4%) than the surgery only group (4/2, 19.0%) (p<0.05). Among the 13 patients who discontinued DMARDs, nine (69.2%) resumed DMARDs after a median of 5.5 months (interquartile range [IQR] 2.9, 18.3) due to arthritis flare. At a median of 4.6 years (IQR 3.3, 6.7) after cancer diagnosis, 25 patients were evaluated at recent outpatient clinic visits. Four patients received no DMARD, three MTX monotherapies, 11 csDMARDs combination therapies, and seven biologics.

Conclusion

A significant number of RA patients who developed cancer during RA treatment were still receiving DMARDs including biologics after cancer diagnosis.

Dual targeting single arrow: Neutrophil-targeted sialic acid-modified nanoplatform for treating comorbid tumors and rheumatoid arthritis

Clinically, rheumatoid arthritis (RA) is frequently accompanied by multi-system diseases. Among them, the incidence of comorbid tumors in RA is relatively high, resulting in a gradual increase in mortality; this poses a considerable challenge to clinical treatment. To date, no effective treatment plan for simultaneous tumor and RA therapy is available. Accordingly, we reported a sialic acid-modified doxorubicin hydrochloride liposome (DOX-SAL) that targets peripheral blood neutrophils (PBNs), which play an important role in tumors and RA. Furthermore, the prepared liposome induced PBN apoptosis by binding to L-selectin, which is highly expressed on the surface of PBNs activated by inflammation. This liposome, in turn, reduced the accumulation of inflammatory neutrophils at the disease site. In the first successfully established mouse model of RA comorbidity, induced by employing S180 sarcoma cells and collagen, DOX-SAL effectively inhibited tumor growth while simultaneously alleviating systemic RA symptoms without side effects. Additionally, the animals demonstrated adequate growth during the 48 days of treatment. This treatment strategy encompasses the best of both worlds, breaking the deadlock that tumors and RA cannot be effectively treated in parallel, highlighting a new concept and reference for the clinical treatment of comorbid tumors and RA.

Inflammation-targeted therapies and cancer

OBJECTIVE

To review and analyze the current knowledge on the risk of malignancy associated with inflammation-targeted therapies in rheumatic diseases.

METHODS

We performed a non-systematic literature review on PubMEd MEDLINE by screening randomized controlled trials, meta-analyses, reviews, and observational studies focusing on malignancies and inflammation-targeted therapies including TNF inhibitors, other biologics and JAK inhibitors in rheumatic diseases.

RESULTS

Data from literature are reassuring regarding the overall risk of incident and recurrent cancer with TNF inhibitors. The risk of lymphoma is more difficult to analyze and data are controversial; however, in most of the studies, this risk does not seem to be significanlty increased. By contrast, there is probably an increased risk of non-melanoma skin cancer associated with TNF inhibitors, as with other immunosuppressants. There is no signal for an increased risk of malignancies with other biological DMARDs, but additional data are needed. A recent post-marketing surveillance study found out an increased risk of malignancies for tofacitinib compared with TNFi; additional data are, therefore, urgently needed to confirm or not these results.

CONCLUSION

Data are presently reassuring regarding the overall risk of cancer, whatever the inflammation-targeted treatment. However, additional data are needed for non-TNF biologics and JAK-inhibitors.