Background Anti TNF therapy has revolutionised the management of Rheumatic diseases. However, this effective therapy is contraindicated in patients with past or current malignancy. Currently, there are a lack of clear guidelines, other than in RA, where rituximab is used. Current practice is to discontinue anti-TNF therapy and alternative non TNF biologics are usually considered. Current evidence does not suggest this group of patients are at risk of recurrence. Further clarity is needed so that this patient cohort can be better managed.
Objectives 1) To assess the time of anti-TNF discontinuation following the diagnosis of malignancy
2) To explore the commonly used non anti-TNF therapy (if any) used after confirming malignancy
3) To explore the management practice of various rheumatic diseases, post malignancy diagnosis
Methods This is a retrospective audit of patients who received anti TNF therapy at a busy teaching Hospital. The data was obtained from the department's biologics database. Patients who developed malignancy whilst on anti TNF therapy were identified and cross-referenced with the oncology database. Clinical letters and notes were subsequently reviewed. This data was then collated and analysed.
Results A total of 950 patients who are currently on anti-TNF therapy were included in this Audit. 27 (2.8%) were diagnosed with malignancy whilst on anti-TNF therapy - 17 (63%) female and 10 (37%) male. 56% (15) had solid malignancy, 15% (5) had skin cancers. The remainder were leukaemia and lymphoid malignancy. Of the solid malignancies, 26% (4) were lung carcinoma and 20% (3) were breast carcinoma. All patients had the anti-TNF therapy discontinued post malignancy diagnosis. Average time of discontinuation was within a month of diagnosis. 55% (15) were previously on adalimumab, 26% (7) had etanercept and the remainder had infliximab and golimumab. 16 (59%) of the patients diagnosed with malignancy were on anti-TNF therapy for RA. 10 (63%) of these patients went on to have rituximab as an alternative therapy, the remainder did not have further biologic therapy. Of the 27 patients, 15% were on anti-TNF therapy for ankylosing spondylitis and 26% for psoriatic arthritis. A death rate of 19% (5) was recorded for this cohort. The cause of death was widespread metastasis.
Conclusions Although the numbers of patients who developed malignancy whilst on anti-TNF are small, deductions can still be made based on these results. The majority of patients (63%) who had anti-TNF therapy discontinued, were not treated with further biological therapy. The reasons were varied from patient choice, ongoing treatment for malignancy and lack of evidence for alternative biologic therapy. The most common solid malignancy from this cohort was lung carcinoma. Interestingly all patients in this group were smokers which may play a role in its occurrence. Adalimumab was used most frequently and this mirrors results obtained from other Biologics registries. None of the patients with ankylosing spondylitis had further treatment due to poor data availability on alternate biologic therapy. Evidence based clear guidelines are required to manage this group of patients.
Furst DE, et al Updated consensus statement on biological agents for the treatment of rheumatic diseases, 2008. Ann Rheum Dis 2008;67(Suppl.3):iii225.
British Society for Rheumatology. Guidelines for prescribing TNF-blockers in adults with rheumatoid arthritis. 2010.
Disclosure of Interest None declared
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