modifying anti-rheumatic drugs].”
Dr. Bathon said she basically agreed. “But sometimes there’s confusion that TNF inhibitors are discouraged for people with cancer. The databases negate a lot of that concern, but what people sometimes mistakenly think is if they avoid a TNF inhibitor, because of the potential association with malignancy, it’s safe to use all the other biologics instead. Safety datasets for those aren’t robust, so I don’t think we should extrapolate to say those are safer in patients with malignancy.”
Dr. Mikuls said not all malignancies are created equal. “With hematologic malignancies, I’m going to be more worried about anti-TNF. But Paul is absolutely right: The long-term observational data make us feel pretty good about anti-TNFs, particularly out a ways from malignancy.”
Dr. Mikuls said that with melanoma patients, he’d be worried about abatacept, “given what we know about checkpoint inhibition. So it depends on the cancer, and it’s always an ongoing risk-benefit analysis in the clinic with patients about these therapies.”
“I think it is a complicated question,” Dr. Bykerk said, “but there are many systematic reviews right now that suggest that with a solid malignancy you might want to wait a while [before starting an anti-TNF].”
Precision Medicine
The panelists were asked about precision medicine; specifically, where did they think this area of research is going?
“Finding the right therapy for the right person at the right time—at the beginning—
would make a huge difference,” said Dr. Emery. “For example, we spend a lot of time trying to predict methotrexate response and anticipate the nonresponders.”
“I think our precision treatments are much more advanced than our ability to determine which ones we should use,” said Dr. Bathon.
“Using just histology at baseline—for when you want to switch therapy—is not yet mature enough,” said Dr. Bykerk. “We need to understand the markers and that work is being done right now.” (Note: Dr. Bykerk has been involved with the Accelerating Medicines Partnership since 2014 to better understand the pathophysiology of RA.)
“There’s a lot of interesting research, but the question remains, ‘Is precision medicine where we all want it?’ It’s an obvious ‘no,’” Dr. Mikuls said. “We have a lot of work to do in that arena. It’s an exciting time, and I hope that in the next five to 10 years we’ll get there.”
Mike Fillon is a healthcare writer living in the Atlanta area.
