Treatment of Psoriasis With Biologics and Apremilast in Patients With a History of Malignancy: A Retrospective Chart Review
April 2019 | Volume 18 | Issue 4 | Original Article | 387 | Copyright © 2019
Jared S. Kahn MS BS,a,b Rachel G. Casseres BA,a,b Min J. Her PharmD,b Nicole Dumont,b Alice B. Gottlieb MD PhD,c David Rosmarin MDa,b
ªTufts University School of Medicine, Boston, MA bTufts Medical Center, Department of Dermatology, Boston, MA cNew York Medical College, Metropolitan Hospital, Department of Dermatology, Valhalla, NY
INTRODUCTION: Biologics have transformed the management of moderate-to-severe psoriasis. The risk of developing a malignancy during treatment is an important consideration, and many studies have been conducted to determine the magnitude of this risk. However, there is little research on the use of biologic treatment in psoriasis patients with a history of established malignancy.
METHODS: We preformed a retrospective chart review of patients with psoriasis and a history of malignancy that were treated with biologics or apremilast. A list was created containing the 690 patients with psoriasis who were treated in our clinic with biologics or apremilast between January 1st, 2012 and May 31, 2018. The charts were examined, and 16 patients were found to have a history of malignancy excluding non-melanoma skin cancer.
RESULTS: Sixteen patients met criteria to be included in this review. The average time from cancer diagnosis to initiation of biologics or apremilast was 4.7 years, and 9 patients (56%) started treatment within five years. Three patients (19%) received concurrent cancer therapy during biologic treatment. None of the 16 patients had recurrence or progression of their cancer noted clinically or radiographically during biologic or apremilast treatment. Most patients had improvement of their psoriasis.
DISCUSSION: The data reviewed here show successful treatment on biologics despite concurrent malignancy, though confirmatory research is needed.
J Drugs Dermatol. 2019;18(4):387-390.
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Biologics for moderate-to-severe psoriasis have transformed the management of the disease. The risk of developing malignancy during biologic treatment is an important yet controversial consideration in medication choice. One study found that long-term treatment with anti-tumor necrosis factor biologics—but not ustekinumab or methotrexate—was associated with an increased risk of malignancy.1 Another study found that biologics did not increase the risk of malignancy compared to non-biologics.2 Additionally, others have found that cumulative length of exposure to biologic therapies in psoriasis patients is not linked with a higher risk of cancer.3Less is known about the effects of biologics in patients with prior malignancy. In clinical trials for biologic medications, patients with cancer diagnosed within 5 years are automatically excluded. Studies looking at biologics registry data did not find an increased risk of malignancy in rheumatoid arthritis patients with prior malignancies, but there are no such studies on psoriasis patients.4,5
We preformed a retrospective chart review of patients with psoriasis and a history of malignancy who were treated with biologics or apremilast. A report listing all patients with “specialty” in their medication list between January 1st, 2012 and May 31st, 2018 was created in the electronic medical records system for the Tufts Medical Center Department of Dermatology. This time frame included the start date of the electronic medical records system for our clinic. Thirty patients taking tofacitinib were removed, leaving 690 patients on biologics or apremilast. Biologics included adalimumab, infliximab, etanercept, ustekinumab, guselkumab, secukinumab, ixekizumab, certolizumab, and golimumab. Charts were reviewed for three criteria: 1) psoriasis diagnosis, 2) treatment with biologics or apremilast and 3) history of malignancy excluding non-melanoma skin cancer. Sixteen patients met these criteria and data from their electronic medical records was recorded.
Demographic and treatment information for the 16 patients is shown in Table 1. The patients were on average 62 years old.