French Recommendations 2025: Assessment and Management of Cancer Risk Before Initiating Targeted Therapies for Chronic Inflammatory Rheumatic DiseasesLa Société...

Journal: Joint Bone Spine, 2025; Published by SFR (Société Française de Rhumatologie)La Société... Multidisciplinary working‑group: rheumatologists, oncologists, pulmonologists, gynaecologists, patient representatives. Systematic review 2005‑May 2024; Delphi consensus voting. 3 overarching principles + 8 formal recommendations. Targeted therapies covered: bDMARDs (anti‑TNF, IL‑6‑i, IL‑17‑i, IL‑23‑i, abatacept, rituximab), tsDMARDs (JAK‑inhibitors). ⚠️ For academic note‑taking only; clinical decisions refer to original full‑text.

Abstract

Chronic inflammatory rheumatic diseases (CIRDs) are associated with elevated malignancy risk driven by persistent inflammation, immune dysregulation and prior immunosuppressive exposure. Targeted therapies may further alter anti‑tumour immune surveillance. These French recommendations provide a practical pre‑treatment framework for cancer‑risk evaluation, screening, prevention and shared decision‑making, balancing rheumatic disease control and oncological safety. Immunocompromised CIRD patients should follow population‑based cancer screening adapted with earlier onset and/or increased screening frequency. Multidisciplinary discussion is mandatory for high‑risk agents such as JAK‑inhibitors and abataceptPubMed.

Keywords: chronic inflammatory rheumatic diseases; targeted therapy; biologic DMARD; JAK inhibitor; malignancy risk; pre‑treatment screening; cancer prevention

Three Overarching Principles

1. Malignancy risk in CIRD results from disease‑related inflammation, host factors and prior immunosuppression. Targeted agents have heterogeneous tumour‑safety profiles. Risk‑benefit must be individually assessed.
2. Pre‑targeted‑therapy cancer assessment combines medical‑history taking, risk‑factor evaluation and adapted population‑level cancer screening, not systematic extensive “tumour marker” laboratory testing.
3. Shared decision‑making between rheumatologist, patient and other specialists (oncology, dermatology, gynaecology) is essential, especially for patients with prior malignancy or when considering higher‑risk therapies (JAK‑i, abatacept)PubMed.

8 Formal Recommendations

Rec 1: Pre‑treatment baseline cancer‑risk assessment

Before any targeted therapy, systematically collect:

• Age, smoking history, alcohol exposure, obesity;
• Personal history of cancer (type, date, stage, current remission status), prior radiotherapy/chemotherapy;
• Family history of malignancy;
• Skin history (non‑melanoma skin cancer, melanoma);
• Completion status of routine population cancer‑screening programmes.

Routine serum tumour‑marker panels are not recommended for asymptomatic patients solely before starting targeted therapyLa Société....

Rec 2: Adapt general‑population cancer‑screening for immunocompromised CIRD patients

CIRD patients shall participate in national population‑based screening programmes (breast, cervical, colorectal cancer). For immunocompromised individuals:

• Initiate screening earlier and/or use shorter screening intervals compared to general population according to individual risk profile.
• Perform low‑dose chest‑CT in heavy smokers instead of plain chest radiograph.
• At least one baseline full‑body dermatological evaluation before or shortly after starting targeted therapy, given elevated skin‑cancer risk (NMSC, melanoma) under immunomodulatory treatmentPubMed.

Rec 3: Preventive measures before targeted therapy

• Strongly encourage smoking cessation.
• Prioritise HPV vaccination in eligible patients before immunosuppression initiation.
• Update age‑appropriate cancer‑related vaccinations.
• Lifestyle counselling (weight control, alcohol limitation, sun‑protection for skin‑cancer prevention)La Société....

Rec 4: Patients with personal history of solid‑organ cancer

1. Confirm complete remission of malignancy with oncologist. No rigid mandatory waiting‑off period for targeted therapy; decision is individualised (cancer type, stage, time since treatment completion, relapse risk, rheumatic‑disease activity).
2. Multidisciplinary rheumatology‑oncology discussion for high‑relapse‑risk tumours.
3. Avoid agents with known signal for that specific cancer when alternatives exist.
4. After starting targeted therapy, maintain oncological surveillance according to oncologist advice, possibly increased frequency for immunocompromised statusPubMed.

Rec 5: Patients with prior haematological‑lymphoproliferative disorders

• Multidisciplinary discussion (rheumatology + haematology‑oncology) is mandatory.
• Assess complete haematological remission, residual disease status, relapse risk.
• Rituximab may be considered in selected cases given its B‑cell‑depleting mechanism; careful benefit‑risk evaluation remains required.
• JAK‑inhibitors are generally avoided in past or active lymphoproliferative disease unless no therapeutic alternative exists and after MDT consensusLa Société....

Rec 6: Drug‑specific risk stratification when selecting targeted therapy

• Anti‑TNF: well‑documented increased risk of non‑melanoma skin cancer; caution with prior melanoma history.
• Abatacept: signals for skin cancer; MDT discussion recommended in patients with prior skin malignancy.
• JAK‑inhibitors: higher overall malignancy signal in some real‑world cohorts, particularly in older adults, smokers and patients with prior cancer history. MDT is strongly advised before prescribing JAK‑i for these high‑risk subgroups.
• IL‑6‑i, IL‑17‑i, IL‑23‑i: currently show neutral‑to‑reassuring overall malignancy profiles in available registries, though long‑term real‑world data remain accumulating.

Drug choice should integrate cancer risk profile alongside rheumatic phenotype, comorbidities and contra‑indicationsPubMed.

Rec 7: Active, newly‑diagnosed cancer

Targeted therapy for rheumatic disease should generally be deferred while active malignancy is being treated. Rheumatic‑disease control is achieved with conventional csDMARDs whenever feasible, under joint follow‑up with oncology. Re‑evaluate for targeted therapy once sustained cancer remission is obtainedLa Société....

Rec 8: Information for patients

Inform every candidate for targeted therapy about:

1. Baseline elevated cancer risk related to underlying CIRD;
2. Potential additional malignancy risks of targeted agents;
3. Importance of adhering to cancer‑screening;
4. Warning symptoms prompting rapid medical review (new skin lesions, unexplained weight‑loss, persistent pain, lymphadenopathy etc.)PubMed.

Key differences compared with 2024 EULAR cancer‑and‑targeted‑therapy guidance

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