Background/Purpose: To compare the recommendations of clinical practice guidelines (CPGs) and consensus statements (CSs) regarding the management of rheumatoid arthritis (RA) in patients with cancer. We identified similarities, discrepancies, and areas not covered and summarized the key areas for future research.

Methods: We searched electronic databases, guideline registries and relevant websites for CPGs and CSs on the management of RA in patients with cancer. Two pairs of reviewers independently selected studies and appraised selected papers according to the 23-item Appraisal of Guidelines for Research and Evaluation (AGREE) II Instrument. Cancer-specific guidelines per drug, cancer type and time frame were extracted and compared.

Results: Of 2,980 citations, 51 guidelines were included from 17 countries and seven international collaborations. Of the 29 that reported funding sources, 15 were financed by the pharmaceutical industry, eight by national or international agencies and six by other means. Scores for the AGREE II domains ranged from 32% for ‘Applicability’ to 85% for ‘Scope and Purpose’ with the other domains scoring 41 to 66%. Recommendations were categorized as i) malignancy risk associated with RA disease modifying anti-rheumatic drugs (DMARDs), ii) management of RA in de novo malignancies, and iii) management of patients with RA and cancer history. Eleven guidelines discussed the risk of cancer associated with DMARDs and while most note no or unknown increased risk, some urged caution due to suspected increased risk of non-melanoma skin cancer, melanoma and lymphoma. Nine papers referred to the diagnosis of a new malignancy. All agreed that therapy must be re-evaluated: biologic DMARDs should unequivocally be ceased and, while some conventional DMARDs such as sulfasalazine, hydroxycholoroquine and gold salts may be continued, cyclosporine, methotrexate and leflunomide must be reconsidered. Three guidelines also required reporting new cancers to pharmacovigilance units. All mentioned that decisions regarding resumption of treatment must be made on a case-by-case basis. Almost all guidelines (46/51) made some mention of past history of cancer. They differed in terms of the drugs evaluated, the cancer types included (solid tumors, skin cancers, lymphoproliferative and/or hematological diseases) as well as the time since treatment (not specified, less than 5 and/or 10 years). The consensus was that caution should be exercised, particularly in the first five years and it is best to consult with the treating specialist before coming to a decision with the patient. Tumor Necrosis Factor inhibitors (TNFi) and cyclosporine are contraindicated in all cases while some conventional DMARDs and non-TNFi agents, particularly rituximab can be used with caution within the five-year time frame.

Conclusion: The guidelines for treatment of RA reviewed often failed to meet expected methodologic criteria varying in quality as well as with respect to the question of how to treat RA in patients with cancer. Since there is a lack of evidence, research is needed focusing on the daily practice of healthcare providers or expert opinion to guide and standardize the management of these patients.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/recommendations-on-the-management-of-rheumatoid-arthritis-in-patients-with-cancer-a-systematic-review-of-clinical-practice-guidelines-and-consensus-statements/