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FRI0192 Clinical practice guide for the treatment of patients with rheumatoid arthritis (RA). systematic review: in patients with ra, which is the safest therapy for patients with previous cancer?
  1. MB Nishishinya1,
  2. CA Pereda2,
  3. P Diaz del Campo3,
  4. A Balsa4,
  5. on behalf of GUIPCAR, Evidence based Rheumatology Working Group (SER) and GUIPCAR Working Group
  1. 1Traumatology Institute Quirόn, Barcelona
  2. 2Rheumatology, Hospital Mediterraneo, Almeria
  3. 3Investigation Unit, Spanish Rheumatology Society
  4. 4Rheumatology, Hospital Universitario la Paz, Madrid, Spain

Abstract

Background Anti TNF therapy, has been used for the treatment of RA patients for several years. Yet, cancer and infections are among the most serious adverse effects described. Unfortunately, little is known about the effect of anti TNF therapy amongst patients with RA and previous cancer, mainly when synthetic DMARds treatment fails.

Objectives To review the evidence on the safety of biological therapy in RA patients with previous neoplasia.

Methods we performed a systematic review through Medline, Cochrane Library, and EMBASE databases. Studies written in English, French and Spanish were considered. Patients 18 years or older, with RA diagnosis (ACR 1987 o ACR/EULAR 2010 criteria), and cancer diagnosis before starting biologic therapy were included. While Systematic reviews, clinical trials and or observational studies with a minimal follow –up of 6 months were considered; case reports or narrative reviews were excluded.

Results 1077 studies were potentially identified, and 6 cohort studies were finally included, (Aaltonen 2015, Dixon 2010, Phillips 2015, Raaschou 2015, Silva-Fernández 2016, Stranfeld 2010). Studies were based on registries of patients with RA treated with DMARds and biological therapy. Registries evaluated between 3.762 and 14.168 patients. The number of patients with documented previous cancer was around 122 to 425 as a whole. Biological therapies evaluated were: IFX, ETN, ADA, RTX, certolizumab pegol, Golimumab, ANAKinRA and synthetic DMARDs. Studies results were organized as anti TNF vs. DMARDs. All studies assessed were cohort trials, SIGN 2+ (Quality Scale). They included solid tumours as breast cancer, lymphoproliferative tumours, skin cancer, neck and brain tumours, as well as in situ uterus cancer.

There was no increment in the risk of incidence of previous cancer in patients treated both with synthetic DMARDs and with anti TNF therapy in all studies assessed.

We point out, that 1 SR (LaForest Divonne 2016) evaluated biological therapy safety in patients with RA. It included 124 trials, while in 27 metanalysis was performed. From these 27, only 3 (Dixon 2010, Mercer 2013 and Strangfeld 2010) where the only studies which assessed risk of recurrence of previous cancer in patients with RA. The RR 0, 77 (IC 95% 0, 29–2,03), did not exhibit an increment in the risk of cancer in these patients.

Conclusions - Studies showed no differences in the incidence of previous cancer in patients treated either with synthetic DMARds or with anti TNF. However, we suggest precaution in the use of these therapies, as the real risk in this population is still unknown.

  • The final decision of treating or not treating these patients (risk factors, limitations etc.) needs to be performed in accordance with oncologists.

  • There is no strong evidence that could identify the real risk of anti TNF therapies in RA patients, with previous cancer.

  • The Individual impact risk of different anti-TNF therapies in this population could not be performed due to incomplete data. Yet, there is not real time schedule considering time since previous cancer and the start of anti TNF therapy.

Well design studies with long follow-up periods are needed to answer these questions

Disclosure of Interest None declared

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