Transcript
Announcer:
You’re listening to ReachMD. This episode of Living Rheum, titled “Identifying Malignancies in SpA” is sponsored by Novartis US Clinical Development and Medical Affairs. The host and speaker have been compensated for their time. This program is intended for health care professionals.
Here’s your host, Dr Anisha Dua.
Dr Dua:
The risk of developing cancer is higher in patients with spondyloarthritis, although research studies vary on how much higher that risk is.
This is ReachMD, and I’m Dr Anisha Dua. Joining me to discuss malignancies in SpA is Dr Elaine Husni. Dr Husni is an associate professor and director of the Arthritis and Musculoskeletal Center at the Cleveland Clinic. Dr Husni, thanks for being here today.
Dr Husni:
Thanks so much for having me.
Dr Dua:
Of course. So, you know, we know that it can be challenging to identify specific factors or tease out those factors that drive malignancies. So, tell me a little bit just about how you approach malignancy risk in your spondyloarthritis patients. What are some of the screening tools you can recommend to identify malignancies, or how are you just approaching this concept in general with your patients?
Dr Husni:
Yeah, I think this is a really interesting topic that many of us kind of deal with malignancies in SpA and other rheumatic diseases. For me, I think this particular patient group is a little more challenging ‘cause they tend to be younger than my other autoimmune disease patients, such as rheumatoid arthritis. So in the younger patients, I think there’s a little bit more uncertainty of how to approach age-appropriate malignancy screening. So, we all know that people should have their colonoscopy by age 50 and also have a mammogram in your middle age. But when you’re talking about a younger population I think it does get a little bit more difficult, so I do go into their family history. I do recommend them to do their normal age-appropriate things as doing a breast exam, but whether or not there’s a particular driving force in SpA patients versus others I probably don’t really counsel them on that in particular.
Dr Dua:
Yeah. And I tend to work a lot with the primary care docs, honestly, because even all of the regular screening, recommendations for colon cancer, or PAP smears and mammograms—I mean, those are things that keep changing, and personally, I’m not on top of that literature as well.
So I definitely do work with the patients and tell them to discuss with their primary care, what are the new guidelines, and what should they be getting in terms of their age, and of course, like you mentioned, their family history, to assess their risk and get the appropriate screening tests. But when we think about some of our diseases, like spondyloarthropathies, but also like rheumatoid arthritis, we know that there’s just overall more chronic inflammation. Can you talk a little bit about some of the risk factors that our patients face that can lead to malignancies, and that maybe we could try to mitigate if possible?
Dr Husni:
Yes, I think it’s important to remind everyone that there are just general risk factors for malignancy. So, if you are a heavy smoker, for example, we want you to stop because of the strong research that’s been correlating with lung cancer, for instance. We also know that sun exposure increases your risk for any of the types of skin cancer as well as being overweight and obese also can contribute to an increased risk of malignancy.1
So, there’s these general risk factors, but in terms of SpA patients I know that many of us are always worried about the chronic inflammation. And even though we have amazing drugs now that can treat this, there’s always some low-grade or subclinical inflammation that we’re always worried about that could sort of perpetuate more cytokines and chemokines and that could result possible in some DNA damage that could lead to malignancy.2 So, there’s always that fear that we think of, in terms of treating a chronic autoimmune disease. In SpA patients in particular there’s also been a lot about the medications that we use, so things like biologics versus non-biologics. Is there concern about the use of tumor necrosis factor inhibitors and certain malignancies? And we certainly heard about that a lot. And then there was a more recent meta-analysis that took a much bigger undertaking of the literature and they actually concluded that there was no difference in the risk of malignancies in those that were on biologics.3 So once again, some sort of conflicting conclusions that we have and that, but I think that’s reassuring. There’s less of a worry in terms of using biologics in these patients and the risk of cancer.4
Dr Dua:
Yeah. No, I think that’s an important point. I think that’s something that patients definitely bring up, right, when you start talking about all these different types of medicines you might be using. They’re comfortable when you start talking about NSAIDs, but once you start kind of going beyond that, and especially because they are so young, they’re always curious about what are the risk factors for things like malignancy down the road and how long are they gonna have to be on these medications?
And our answers to those questions are obviously changing as we get more research, but it’s something that we do need to address when counseling our patients on starting medicines and the risks for many things with chronic disease. So, when we think about a holistic approach to our SpA patients, I know we’ve talked about a couple of different ways to care for our patients and deal with some of the many manifestations of their disease and outside of their disease. We know there’s a lot of different comorbid complications, so do you have just any overall thoughts on malignancy risk in SpA, and also interestingly, any areas where you think future research should be focused in terms of our SpA patients?
Dr Husni:
Yeah, I think it’s important for us to still play a little bit of a primary care role because we tend to see our patients more frequently with ankylosing spondylitis, meaning we may be touching base with them more so than their primary care doctors. And this gives us an opportunity to remind them of age-appropriate cancer screening, so I think that is an important message. And then second, when you are looking at the literature as we had talked about earlier, that there are conflicting evidence on the association between SpA and malignancies overall.2 There are some studies that show a higher incidence of non-melanomic skin cancer, especially in patients with psoriatic arthritis,5,6 but in SpA patients in general we’ve also heard a little bit about monoclonal gammopathy of unknown significance and multiple myeloma—something that we see a little bit more higher incidence.7,8 So I think overall, given sort of conflicting evidence at this point we probably don’t have specific screening recommendations for malignancy and SpA, but I do think that we can wear our internal medicine hats and do promote age-appropriate screening as well as a good history taking.2 Family history of any malignancy should alert us to maybe screen a little bit sooner. So, as you know, colonoscopies at age 50, but if you have a family history, you might have them speak with their primary care to do a screening a little bit, several years earlier. So I think those are always important. And then, the drugs that they take to really open up that conversation. Yes, we hear that these drugs can sometimes be associated, but we have not been able to find anything directly causal to understand the mechanism that would cause more.
And then we also have that recent meta-analysis that shows that there is no association more with tumor necrosis factor or IL-17 inhibitors, for instance.3 So in light of that, I think getting good history and doing age-appropriate is still something that we can recommend, but we don’t have specific screening recommendations.
Dr Dua:
Absolutely. I completely agree, and I think that’s a great way to round out our discussion on this topic. I want to thank you, Dr Husni, for helping us better understand this relationship between malignancies and SpA, and just helping us put back on our internal medicine hats and think about some of the issues that our patients are facing. It was really great speaking with you today.
Dr Husni:
Yeah, thanks for a list of really interesting topics, and always good for us to dialogue and to remind others when we’re taking care of these patients with chronic diseases that these issues come up and that we are always working together to try to get health outcomes better.
Announcer:
This industry podcast was sponsored by Novartis US Clinical Development and Medical Affairs. If you missed any part of this discussion or to find others in this series, visit reachmd.com/living-rheum.
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References:
- Chiesa Fuxench ZC, Shin DB, Ogdie Beatty A, Gelfand JM. The risk of cancer in patients with psoriasis: a population-based cohort study in the health improvement network. JAMA Dermatology. 2016;152(3):282-290. doi:10.1001/jamadermatol.2015.4847
- Karmacharya P, Shahukhal R, Ogdie A. Risk of malignancy in spondyloarthritis: a systematic review. Rheum Dis Clin North Am. 2020;46(3):463-511. doi:10.1016/j.rdc.2020.04.001
- Kwan YH, Lim KK, Fong W, et al. Risk of malignancies in patients with spondyloarthritis treated with biologics compared with those treated with non-biologics: a systematic review and meta-analysis. Ther Adv Musculoskelet Dis. 2020;12:1-11. doi:10.1177/1759720X20925696
- Hellgren K, Dreyer L, Arkema E V., et al. Cancer risk in patients with spondyloarthritis treated with TNF inhibitors: a collaborative study from the ARTIS and DANBIO registers. Ann Rheum Dis. 2017;76(1):105-111. doi:10.1136/annrheumdis-2016-209270
- Gross R, Schwartzman-Morris J, Krathen M, et al. A comparison of malignancy incidence among psoriatic and rheumatoid arthritis patients in a large US cohort. Arthritis Rheumatol. 2014;66(6):1472-1481. doi:10.1002/art.38385.A
- Chiesa Fuxench ZC, Shin DB, Beatty AO, Gelfand JM. The risk of cancer in patients with psoriasis: a population-based cohort study in the health improvement network. JAMA Dermatology. 2016;152(3):282-290. doi:10.1001/jamadermatol.2015.4847
- Moon H-I, Chang H-J, Kim J-E, Ko H-Y, Ann S-H, Min C-K. The association between multiple myeloma and ankylosing spondylitis: a report of two cases. Korean J Hematol. 2009;44(3):182-187. doi:10.5045/kjh.2009.44.3.182
- Chang CC, Chang CW, Nguyen PAA, et al. Ankylosing spondylitis and the risk of cancer. Oncol Lett. 2017;14(2):1315-1322. doi:10.3892/ol.2017.6368
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