Management Considerations in Cancer Patients With Rheumatoid Arthritis

Rheumatoid arthritis is the most common inflammatory arthritis, affecting 1% of the general population. It is a chronic disease in which inflammation of the synovium leads to bony erosions and joint destruction. The etiology of rheumatoid arthritis remains unclear, but its development likely requires a high-risk genetic background and an environmental trigger, leading to autoimmune dysregulation and an autoinflammatory response; the latter can affect not only the joints, but also other organs and systems. Patients with rheumatoid arthritis usually require treatment for the duration of their lifespan. Drugs used to treat rheumatoid arthritis fall primarily into three general categories: nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and disease-modifying antirrheumatic drugs (DMARDs); DMARDs can be synthetic drugs or biologic agents targeting specific cytokines or other molecules involved in the regulation of the immune response (Table). DMARDs can suppress the inflammatory response, primarily by downregulating the immune system.

Patients with cancer and concomitant rheumatoid arthritis are at increased risk for morbidity and mortality, in part because of their therapeutic needs.[1] Immunosuppressant drugs used to treat rheumatoid arthritis can increase the risk of infection in patients undergoing surgery, or in those receiving chemotherapy. In addition, there are concerns that chronic immunosuppression from these therapies could result in downregulation of immune antitumor responses. It has been proposed that the use of biologic therapies for rheumatoid arthritis may conceivably increase the risk of malignancy, or of tumor progression in patients with a coexisting cancer. Patients with rheumatoid arthritis already have an increased risk of certain types of cancer, specifically lymphoma and lung cancer, likely as a result of their chronic inflammatory state.[2] There is no evidence so far that rheumatoid arthritis therapies increase the risk of developing non-skin solid tumors.[3,4] There is some controversy as to whether biologic agents, specifically tumor necrosis factor (TNF) inhibitors, may increase the risk of nonmelanoma skin cancer, melanoma, and lymphoma; any increased risk, however, appears to be small.[3,4] Whether this class of agents may accelerate tumor progression in patients with pre-existing cancer remains debatable. While in theory this could be possible, the data are scarce, since patients with cancer are typically excluded from clinical trials of these immunosuppressive therapies, and few case series or observational studies have addressed the issue.

Cancer patients may undergo tumor resection, chemotherapy, radiation treatment, or, more recently, immunotherapy—all of which can make their management more challenging if they have concomitant rheumatoid arthritis. Coordination of care with a rheumatologist will be essential, especially if the patient has active rheumatoid arthritis or is receiving…

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