Nonmelanoma skin cancer increased in RA patients

[Guest guest]

Nonmelanoma skin cancer increased in RA patients

----------

Dec 19, 2005

----------

Zosia Chustecka

----------

Wichita, KS - Rheumatoid arthritis (RA) patients are known to be at

an increased risk of developing lymphoproliferative disorders,

particularly non-Hodgkin's lymphoma. Now a large US study suggests

that they may also be at an increased risk of developing nonmelanoma

skin cancer, such as basal cell carcinoma and squamous cell carcinoma

[1].

The results come from an analysis of data collected by the National

Data Bank for Rheumatic Diseases, directed by Dr Frederick Wolfe

(University of Kansas, Wichita), and are reported in the November

2005 issue of the Journal of Rheumatology.

----------

" Together, these findings suggest that skin-cancer screening at

regular intervals may be warranted for all patients with RA,

especially those receiving chronic immunosuppressive therapy. "

The researchers compared data collected since 1999 on 15 789 patients

with RA and 3639 patients with osteoarthritis (OA). Although the

crude incidence rates were similar for both populations, after

adjustment for covariates, there was a small but significant

increased hazard of developing nonmelanoma skin cancer in patients

with RA compared with those with OA (hazard ratio

---

=1.19, p=0.042).

Among the RA patients, the development of nonmelanoma skin cancer was

associated with use of prednisone (HR=1.28, p=0.014) and with the use

of TNF inhibitorswith concomitant methotrexate (HR=1.97, p=0.001). No

association was found with the use of methotrexate alone (HR=1.12,

p=0.471) or leflunomide (HR=0.83, p=0.173). The researchers comment

that the use of any TNF inhibitor (adalimumab, etanercept, or

infliximab) was associated with a slightly increased risk (HR=1.24,

p=0.89), but this did not reach statistical significance, whereas the

use of a TNF inhibitor with concomitant methotrexate raised the risk

twofold and was significant.

" This suggests that increasing immunosuppression, particularly with

the use of TNF inhibitors, may be associated with increased risk for

developing nonmelanoma skin cancer, " the authors write. " However, it

is possible that the trend toward increased hazard of nonmelanoma

skin cancer with increased immunosuppressive medications is actually

confounding by indication: a function of the severity of the

underlying RA rather than the direct effects of immunosuppression

itself. "

" Together, these findings suggest that skin-cancer screening at

regular intervals may be warranted for all patients with RA,

especially those receiving chronic immunosuppressive therapy, " the

researchers conclude.

Findings " in concert " with European studies

The finding of an increased risk of nonmelanoma skin cancer in RA

patients from this study is " in concert " with earlier studies from

Europe, the researchers comment. They note that two studies from

Northern Europe have also suggested an increased risk: they compared

the incidence in RA patients with that in the general population and

found relative risks ranging from 1.17 [2] to 1.4 [3]. There have

also been several case reports of a rapid development of squamous

cell carcinoma after administration of TNF inhibitors [4,5], the

authors note, but a study of patients in clinical trials with

etanercept found no increase in squamous cell carcinoma compared with

the general population [6,7].

" Basal cell carcinoma and squamous cell carcinoma are among the

commonest types of malignancies, and although they rarely metastasize

to distant sites or lead to death, their high prevalence and

associated morbidity contribute to the overall public-health burden, "

the authors comment.

Chakravarty EF, Michaud K, Wolfe F. Skin cancer, rheumatoid arthritis

and tumor necrosis factor inhibitors. J Rheumatol 2005; 32:2130-

2135. 16265690 Gridley G, McLaughlin JK, Ekbom A, et al. Incidence of

cancer among patients with rheumatoid arthritis. J Natl Cancer Inst

1993; 85:307-311. 8426374 Mellemkjaer L, Linet MS, Gridley G, et al.

Rheumatoid arthritis and cancer risk. Eur J Cancer 1996; 32A:

1753-1757. 8983286 KJ, Skelton HG. Rapid onset of cutaneous

squamous cell carcinoma in patients with rheumatoid arthritis after

starting tumor necrosis factor receptor IgG1-Fx fusion complex

therapy. J Am Acad Dermatol 2001; 45:953-956. 11712048 Esser AC,

Abril A, Fayne S, et al. Acute development of multiple

keratoacanthomas and squamous cell carcinomas after treatment with

infliximab. J Am Acad Dermatol 2004; 50 (Suppl 5):S75-S77. 15097933

Lebwohl M, Kim D, Do T, et al. Cutaneous squamous cell carcinoma

incidence is not increased in rheumatoid arthritis patients receiving

etanercept. EULAR 2003; June 12-15 2003; Lisbon, Portugal. Available

at: .