Safety of Tumor Necrosis Factor Inhibitor Use in Patients with Concomitant Malignancy

BACKGROUND: Tumor necrosis factor (TNF) inhibitors are considered contraindicated in patients with a history of malignancy. However, data to support this notion is limited. We hypothesize TNF inhibitors can be used safely in patients with chronic inflammatory diseases, like IBD, who have concomitant malignancy or develop malignancy while on these agents. METHODS: Retrospective chart review performed 1996-2015 at our local VA. Cases and controls (matched 2:1 for cancer type) were identified using pharmacy and pathology databases and then charts manually reviewed. Cases were patients with inflammatory disease including inflammatory bowel disease (IBD), rheumatoid arthritis (RA), psoriatic arthritis (PsA), psoriasis or spondyloarthropathy (SpA), concomitant malignancy, and TNF inhibitor use while controls were patients with inflammatory disease, concomitant malignancy but no TNF inhibitor use. Data was collected for cases and controls including survival at 1-yr, 2-yrs, 5-yrs after malignancy diagnosis and end of study time points. RESULTS: 36 cases (3 IBD, 22 RA, 5 PsA, 2 SpA, 1 IBD+SpA, 3 psoriasis) and 70 controls (6 IBD, 44 RA, 12 psoriasis, 6 PsA, 2 SpA) were identified. Age, cancer stage at diagnosis, and Charlson comorbidity index was not significantly different between cases and controls.Treatments with other immunosuppressives at diagnosis were not significantly different between the cases and controls and cancer specific therapies were similar between cases and controls. For cases, survival at 1-yr, 2-yrs, 5-yrs and at end of study follow-ups were 32 (89%), 31(86%), 29 (81%) and 24 (64%), respectively compared to 63 (90%), 61 (87%), 51 (73%) and 45 (64%) for the control group (p=NS for all time points). For cases, recurrence rates at 1-yr, 2-yrs, 5-yrs and at end of study follow-ups were 3 (8%), 5 (14%), 6 (17%), and 8 (22%), respectively compared to 2 (3%), 5 (7%), 7 (10%), 9 (13%) for the control group (p=NS for all time points). CONCLUSION: Survival rates and cancer recurrence after a malignancy is diagnosed in patients with inflammatory diseases treated with TNF inhibitors are not different from similar patients not treated with TNF inhibitors. This preliminary data suggests that TNF inhibitors should not be withheld for fear of worsening survival or tumor recurrence after diagnosis with a malignancy if the agent is needed for adequate inflammatory disease control.