Which biologic (biological) medicines for rheumatoid arthritis (RA) are safe in cancer patients?

Biologic Medicines for Rheumatoid Arthritis in Cancer Patients

Rituximab is the safest biologic medicine for rheumatoid arthritis patients with a history of cancer, particularly for those with a cancer diagnosis within the past 5 years. 1

Safety of Biologics in Cancer Patients - Decision Algorithm

For Patients with Recent Cancer (within 5 years)

1. First Choice: Rituximab

   • Strongly recommended for patients with:
     • Previously treated solid malignancy within the last 5 years
     • Previously treated non-melanoma skin cancer within the last 5 years
     • Previously treated melanoma skin cancer
     • Previously treated lymphoproliferative malignancy 1
   • Rituximab is particularly appropriate as it is also an approved treatment for certain lymphoproliferative disorders 1

2. Avoid TNF inhibitors (TNFi)

   • TNF inhibitors may have a signal for induction and/or increased risk of lymphoma in clinical trials 1
   • Examples include etanercept, adalimumab, infliximab, golimumab, and certolizumab

3. Other non-TNFi biologics (abatacept, tocilizumab)

   • Use with caution
   • Limited evidence regarding safety in recent cancer patients
   • May be considered if rituximab is contraindicated 1
   • Note: Abatacept has been associated with a slightly increased overall cancer risk (RR 1.13) and non-melanoma skin cancer risk (RR 1.26) compared to conventional DMARDs or TNFi 2

For Patients with Remote Cancer History (>5 years)

1. Any biologic can be considered if the patient:

   • Has been treated for solid malignancies more than 5 years ago
   • Has been treated for non-melanoma skin cancer more than 5 years ago 1

2. Special considerations:

   • For patients with a history of melanoma (regardless of timing), rituximab remains the safest option 1
   • For patients with a history of lymphoproliferative malignancy (regardless of timing), rituximab remains the safest option 1

Important Safety Monitoring

1. Skin cancer surveillance

   • All biologics are associated with increased risk for skin cancers (OR 1.5 for non-melanotic skin cancer, OR 2.3 for melanoma) 3
   • Regular dermatologic evaluations recommended, especially for patients with history of skin cancer
   • Consider dermatology co-management 1

2. Infection risk management

   • Screen for tuberculosis before starting any biologic therapy 1
   • Consider temporary withholding of biologics during active infections 4
   • Monitor for atypical presentations of infections, as biologics may mask typical symptoms 5

3. Vaccination considerations

   • Administer age-appropriate killed/inactivated vaccines before starting biologic therapy 1
   • Avoid live vaccines in patients on biologics 1
   • If herpes zoster vaccine is indicated, administer at least 2 weeks before starting biologic therapy 1

Practical Approach

The utilization of biologics in cancer patients is evolving, with approximately 26% of RA patients with cancer history receiving biologics after their cancer diagnosis in recent studies 6. When selecting therapy:

1. Assess cancer type and timing:

   • Recent cancer (<5 years): Strongly prefer rituximab
   • Remote cancer (>5 years): Consider any biologic based on RA disease activity and other factors

2. Consider cancer recurrence risk:

   • High-risk cancers (e.g., melanoma, lymphoma): Prefer rituximab regardless of timing
   • Lower-risk cancers in remission >5 years: Wider range of biologics may be appropriate

3. Balance RA disease activity with cancer risk:

   • For severe, refractory RA with remote cancer history: Benefits of effective biologic therapy may outweigh theoretical cancer risks
   • For mild-moderate RA with recent cancer: More conservative approach warranted

By following this algorithm and maintaining vigilant monitoring, rheumatoid arthritis can be effectively managed in patients with a history of cancer while minimizing risks of cancer recurrence or progression.