LAUSR

According to a meta-analysis reported in 20151), among solid malignancies (cancers), only lung cancer was at an increased risk in patients with rheumatoid arthritis (RA) compared with the general population. A Japanese cohort study reported that the incidence of cancers in patients with RA treated with biological DMARDs was not significantly elevated compared to the Japanese general population2). However, in recent years, malignancy has been one of the major causes of death in Japanese patients with RA3). It has been reported that there was an increased incidence of malignancies in patients treated with tofacitinib compared to TNF-alpha inhibitors. Clinicians need to pay more attention to emerging malignancies.We explored how to detect cancer early in patients attending rheumatology outpatient clinics.In this retrospective study, we studied 545 patients with RA who visited our rheumatology clinic between April 2011 and December 2021. Forty-five cases of cancer in 38 patients (31 women, 7 men) with RA were reviewed.Cancer types: 9 breast, 8 lung, 6 colon, 5 uterus, 4 stomach, 2 prostate, 2 pancreas and 9 others. Five female patients had metachronous or simultaneous double cancers and one male patient had metachronous triple cancers. The median age at diagnosis of 45 cancers was 72 years old (IQR 63–76.5) and the median duration of RA prior to cancer diagnosis was 10 years (IQR 5–20.5).Lung: Seven cases were found by chest CT at the outpatient clinics; two at the start of bDMARDs and five during RA treatment.Stomach and Colon: Two cases of four stomach cancers were discovered due to the progression of anemia. Both patients were at an advanced stage with distant metastasis and died 2 months after diagnosis. On the other hand, four of six colon cancers were detected by the fecal occult blood test, and three were in remission.Of the 45 cases, only 8 cases were detected by cancer screening. In 15 cases, blood samples or imaging tests were the triggers cancer detection. Eight of the 15 cases were detected by routine examinations in the rheumatology outpatient clinic, but five cases were already in the advanced stage.Table 1.Forty-five cancers in 38 patients with rheumatoid arthritisSite of cancer nClue to cancer diagnosis and prognosis at the final visit (death - under treatment - remission)noticing symptomsVarious tests in outpatient clinic symptoms(-)Cancer ScreeningBreast98(1-4-3)　1(0-0-1)Lung81(1-0-0)7(2-3-2)　Colon6　1(1-0-0)5(0-1-4)Stomach41(0-0-1)3(3-0-0)　Cervix uteri31(0-0-1)　2(0-0-2)Corpus uteri22(0-2-0)　　Pancreas2　2(0-2-0)　Prostate22(0-1-1)　　Skin*22(0-0-2)　　Oral/throat22(0-2-0)　　Duodenum11(0-0-1)　　Biliary tract11(0-1-0)　　Anus1　　1(0-0-1)Bladder1　1(0-0-1)　Brain1　1(0-1-0)　Total4521(2-10-9)15(6-6-3)9(0-1-8)We have been performing cancer screening before RA treatment and performing routine blood, urine, and imaging tests to identify adverse effects. However, they cannot always find cancers at the early stage. Screening procedures for malignancy are strongly recommended4), but the consultation rates for breast and cervical cancer screening are lower in Japan than in European nations. We should encourage our patients to undergo usual age- and sex-appropriate cancer screening.[1]Simon TA, et al. Incidence of malignancy in adult patients with rheumatoid arthritis: a meta-analysis. Arthritis Research and Therapy 2015; 17:212[2]Harigai M, et al. Risk for malignancy in rheumatoid arthritis patients treated with biological disease-modifying antirheumatic drugs compared to the general population: A nationwide cohort study in Japan. Modern Rheumatology 2016; 26:642[3]Nakajima A, et al. Mortality and cause of death in Japanese patients with rheumatoid arthritis based on a large observational cohort, IORRA. Scand J Rheumatol 2010; 39:360[4]Baillet A, et al. Points to consider for reporting, screening for and preventing selected comorbidities in chronic inflammatory rheumatic disease in daily practice: a EULAR initiative. Ann Rheum Dis 2016; 75:965None declared