Worth a visit to the skin doctor?

[Guest guest]

Some interesting observations on skin cancer - are the addition of

more and more immunosuppresive drugs causing this, or is it the

underlying severity of the disease? Not sure this really proved which

it is. I have had basal cell carcinomas but my guess that is more

from being fair skinned and probably being in the sun more than I

should have been at an earlier age. I take metho, but have not added

other agents to the mix, so I shouldn't be in danger of this problem,

but my guess is that more important is how much you were in the sun

and how dark your skin is. Something to be aware of and one more

lousy thing to think about with this disease.

Mark

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 inhibitors with 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].

" 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.

Sources

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

arthritis and tumor necrosis factor inhibitors. J Rheumatol 2005;

32:2130- 2135.

2. Gridley G, McLaughlin JK, Ekbom A, et al. Incidence of cancer

among patients with rheumatoid arthritis. J Natl Cancer Inst 1993;

85:307-311.

3. Mellemkjaer L, Linet MS, Gridley G, et al. Rheumatoid arthritis

and cancer risk. Eur J Cancer 1996; 32A:1753-1757.

4. 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.

5. 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.

6. 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:

http://www.eular.org.