Decisions for patients with IBD, cancer must be made case-by-case
ORLANDO — Inflammatory bowel disease is a life-altering condition that takes a lifetime of care. Adding it to another life-altering disease, like cancer, makes management decisions much more complicated for physicians, according to experts.
At the Advances in Inflammatory Bowel Disease annual meeting, David P. Hudesman, MD, co-director of the Inflammatory Bowel Disease Center at NYU Langone Health, participated in an expert panel discussing several cases weighing the benefit of IBD drugs with cancer risks.
A primary concern was how to handle biologics in patients who develop a solid tumor.
“You have someone on a biologic, like an anti-TNF agent, and they develop a solid cancer, such as breast or prostate cancer, what do you now do with that biologic agent? How do you manage their Crohn’s disease or ulcerative colitis long-term?” Hudesman said in an interview with Healio Gastroenterology and Liver Disease.
Reviewing some of the recent data on patients with IBD and cancer taking a biologic, Hudesman said some prospective studies now show about a 30% chance of developing a new or recurring cancer, while a smaller study on the use of anti-TNF and thiopurines showed that combined therapy did not increase that risk for newer recurrent cancer. Additionally, Hudesman said cytotoxic chemotherapy may keep disease under control and allow patients to discontinue biologic or immunosuppressant therapies.
“Obviously, all these decisions are made on a case-by-case basis,” he said.
For patients with IBD and skin cancer, the panel focused on thiopurines and patients with IBD have an increased risk for non-melanoma skin cancer, including squamous cell and basal cell.
“When deciding what to do in a patient who develops a skin cancer, what do you do with that thiopurine,” Hudesman said. “We might want to separate the basals and squamous cell.”
Patients with basal tend to be a bit older and potentially have been on thiopurines and doing very well with them. Hudesman said it might better to keep them on that thiopurine, while younger patients with a squamous cell present an opportunity to switch to another agent, particularly something more targeted, like Entyvio (vedolizumab, Takeda) or Stelara (ustekinumab, Janssen).
For any patient on immunosuppressants, Hudesman said it is critical to screen them for skin cancer regularly.
“They should be seeing the dermatologist once a year, and it’s important not only to recommend that dermatology visit but also talk about sun protection strategies, wearing a hat, using suntan lotion,” he said. “Unfortunately, a lot of times you tell the patient to go see the dermatologist, and they never go.”
For patients with a lymphoma, Hudesman said thiopurines and anti-TNF come with the most concern, while more targeted therapies should be prioritized.
“It’s not an absolute contraindication to say, ‘Let’s say go back on an anti-TNF,’ but that's a really select patient,” he said. “For patients with a history of lymphoma, we want to use some more of our targeted therapies like vedolizumab and ustekinumab.”
For any decision on what therapy to use, Hudesman urged physicians to use their colleagues as a resource because solid data are still limited.
“All of these decisions are made speaking with the oncologist, speaking with the dermatologist, and maybe speaking with another one of your gastroenterology colleagues,” he said. “Although we have more evidence now and some meta-analyses looking at this, looking at overall immune-mediated diseases and immune suppression of cancer, it’s still not prospective data. We don’t have great data looking at that.” – by Alex Young
Cross R, et al. Malignancy and Management of IBD. Presented at: Advances in Inflammatory Bowel Disease; Dec. 12-14, 2019; Orlando.
Disclosure: Hudesman reports no relevant financial disclosures.