Megan H. Noe
There is a small but statistically significant increased risk for cancer in patients with psoriasis, which is mainly driven by lymphoma and nonmelanoma skin cancer, Megan H. Noe, MD, MPH, MSCE, of the department of dermatology at Brigham & Women’s Hospital in Boston, said in an interview with Healio Dermatology.
Noe gave a presentation at the American Academy of Dermatology Summer Meeting on the risk for malignancy in patients with psoriasis and whether treatment type may affect this risk.
“All patients with psoriasis should be monitored for nonmelanoma skin cancer,” Noe said. “There is always a question about how to treat a patient with a history of cancer and what psoriasis treatments are best for them. The take home is every patient should be thought of on an individual basis, as there are many factors to consider: what type of cancer they had, when it was diagnosed and how it was treated.”
Noe suggested managing these patients with oncology and primary care to fully understand the risk for recurrence and find the psoriasis treatment that works best for that patient.
We asked Noe about the risk for malignancy in these patients with various treatments like phototherapy and systemic therapy.
Healio: Can you talk about how the attributable risk for malignancy is tough to determine in patients with psoriasis?
Noe: If you are interested in understanding the attributable risk specifically to psoriasis, it is difficult to understand because there are many risk factors that go into an individual person’s risk for developing cancer. We know patients with psoriasis have higher rates of comorbidities or health behaviors that may make them more likely to develop cancer. Psoriasis patients have higher rates of smoking, alcohol use and obesity.
We also know that some treatments we use for psoriasis may predispose people to malignancy, such as light therapy and certain types of immunosuppressive therapy.
It is difficult to understand the risk related to psoriasis alone, although there are some studies that have been able to adjust for things such as smoking, obesity and alcohol use to try to get a more accurate representation of those risks.
How does phototherapy affect this risk?
The most well-sourced phototherapy and the clearest risk comes from an increased risk for skin cancer from psoralen ultraviolet A (PUVA). Robert S. Stern, MD, created a cohort and followed some patients for 30 years, which gives us a great long-term risk for skin cancer. His studies found that patients who received more than 350 PUVA treatments were at a greater risk for squamous cell carcinoma.
Unfortunately, we do not have this rigorous data for UVB broad- or narrow-band therapy. The data that we do have suggest that there is not an increased risk for skin cancer in patients who receive less than 100 treatments.
Does systemic therapy increase the risk for malignancy in these patients?
The data for systemic therapy is pretty reassuring. There was an initial safety signal for TNF inhibitors and malignancy with clinical trials in rheumatoid arthritis, but multiple population-based studies have shown there is not an increased risk in malignancy.
With newer biologics, we do not have enough data to confidently talk about malignancy risk as malignancy is a rare outcome. You need drugs to be trialed in a large amount of people for a long period of time.
For all the newer biologics, in the limited data we have, there seems to be a low risk compared with the general population.
Noe MH. Malignancy in patients with psoriasis and atopic dermatitis: Understanding risk and appropriate management. Presented at: American Academy of Dermatology Summer Meeting; July 25-28, 2019; New York.
Disclosure: Noe reports she receives research funding from Boehringer Ingelheim and is an independent contractor for Derm101 and UpToDate Inc.