Background: Inflammatory rheumatic diseases (IRDs) are associated with an increased occurrence of comorbidities, including the risk of cancer, and especially lymphoma. It has been also hypothesized that the treatment, in some cases, may further increase this risk, particularly with the biologic disease modifying anti-rheumatic drugs (bDMARDs).

Objectives: to review available data for increased cancer risk in IRDs (rheumatoid arthritis – RA; psoriatic arthritis – PsA; axial spondyloarthritis – AS) and any possible correlation between the use of bDMARDs and cancer, as well as the evidence for the management of patients on bDMARDs in the setting of existing cancer.

Methods: 587 patients were included since 2003. More specifically, 295 with RA, 173 with PsA, and 119 with AS under treatment with bDMARDs (anti-TNF). More specifically, 157 infliximab, 243 adalimumab, 148 etanercept, and 39 certolizumab pegol.

Results: in total, 64 patients have been diagnosed with a neoplastic disease and 3 of them died. 31 RA patients (5,28%), 22 PsA patients (3,74%), and 11 AS patients (1,87%). The types of cancer have been found to be as follows: 18 lymphomas (14 in RA), 5 leukemias (all in RA), 12 lung cancer, 7 liver, 5 breast, 5 colon, 4 prostate, 3 brain, 2 urinary bladder, 2 pancreas, and 1 sarcoma (Table 1). Median time of onset from initiation of an anti-TNF 11 ±3 years. The was no statistical significance among the anti-TNF treatment and cancer development. Average time to relapse after discontinuing systemic treatment 2 ±1 year. All our patients required intervention after a relapse. In 32 cases the disease was controlled with synthetic DMARDs and low to medium dose of corticosteroids. 14 RA patients needed to receive rituximab, and 8 with PsA had apremilast added to standard therapy. Finally, in 10 patients, free of cancer according to the treating oncologists (7 AS patients), it has been decided on a shared-decision basis with the patients and after explaining the possible risks, to restart anti-TNF therapy due to significant disease activity. In 8 of them, before the five-year period that it is used to wait until re-initiation. Mean time of starting anti-TNFs from the diagnosis of neoplasia was 3,4 ±1 year from the completion of cancer treatment.

Conclusion: the management of inflammatory rheumatic diseases in cancer patients is complex and requires a multidisciplinary approach. It appears that the risk of relapse of inflammation in patients receiving bDMARDs is high. Although these agents appear to be safe in patients with a history of cancer (without evidence of tumor activity), additional data is needed to determine the correct timing of restarting the treatment. Finally, patients with a history of neoplasia treated with bDMARDs should be carefully monitored because of the potential risk of recurrence. Furthermore, there is a potential risk of additional adverse effects from the previous oncological interventions and the treating doctor should always have them in mind.

REFERENCES: NIL.

Acknowledgements: NIL.

Disclosure of Interests: None declared.