Long-term Risk of Malignancy Among Patients Treated With Immunosuppressive Agents for Ocular Inflammation: A Critical Assessment of the Evidence

John H. Kempen, Sapna Gangaputra, Ebenezer Daniel, Grace A. Levy-Clarke, Robert B. Nussenblatt, James (Jim) Rosenbaum, Eric Suhler, Jennifer E. Thorne, C. Stephen Foster, Douglas A. Jabs, Kathy J. Helzlsouer

Research output: Contribution to journalArticle

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Abstract

Purpose: To critically assess potentially carcinogenic effects of immunosuppressive therapy in the ocular inflammation setting. Design: Focused evidence assessment. Methods: Relevant publications were identified by MEDLINE and EMBASE queries and reference list searches. Results: Extrapolation from transplant, rheumatology, skin disease, and inflammatory bowel disease cohorts to the ocular inflammation setting suggest that: 1) alkylating agents increase hematologic malignancy risk and cyclophosphamide increases bladder cancer risk, but less so with ≤18 months' duration of therapy and hydration, respectively; 2) calcineurin inhibitors and azathioprine probably do not increase total cancer risk to a detectable degree, except perhaps some other risk factors (uncommon in ocular inflammation patients) might interact with the former to raise risk; 3) tumor necrosis factor (TNF) inhibitors may accelerate diagnosis of cancer in the first six to 12 months, but probably do not increase long-term cancer risk; and 4) changes in risk with methotrexate, mycophenolate mofetil, and daclizumab appear negligible, although nontransplant data are limited for the latter agents. Immunosuppression in general may increase skin cancer risk in a sun exposure-dependent manner. Conclusion: Use of alkylating agents for a limited duration seems justifiable for severe, vision-threatening disease, but otherwise cancer risk may be a relevant constraint on use of this approach. Antimetabolites, daclizumab, TNF inhibitors, and calcineurin inhibitors probably do not increase cancer risk to a degree that outweighs the expected benefits of therapy. Monitoring for skin cancer may be useful for highly sun-exposed patients. Data from ocular inflammation patients are needed to confirm the conclusions made in this analysis by extrapolation.

Original languageEnglish (US)
JournalAmerican Journal of Ophthalmology
Volume146
Issue number6
DOIs
StatePublished - Dec 2008

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Immunosuppressive Agents
Inflammation
Neoplasms
Alkylating Agents
Skin Neoplasms
Solar System
Tumor Necrosis Factor-alpha
Mycophenolic Acid
Antimetabolites
Azathioprine
Rheumatology
Hematologic Neoplasms
Inflammatory Bowel Diseases
Skin Diseases
Urinary Bladder Neoplasms
Methotrexate
MEDLINE
Cyclophosphamide
Immunosuppression
Publications

ASJC Scopus subject areas

  • Ophthalmology

Cite this

Long-term Risk of Malignancy Among Patients Treated With Immunosuppressive Agents for Ocular Inflammation : A Critical Assessment of the Evidence. / Kempen, John H.; Gangaputra, Sapna; Daniel, Ebenezer; Levy-Clarke, Grace A.; Nussenblatt, Robert B.; Rosenbaum, James (Jim); Suhler, Eric; Thorne, Jennifer E.; Foster, C. Stephen; Jabs, Douglas A.; Helzlsouer, Kathy J.

In: American Journal of Ophthalmology, Vol. 146, No. 6, 12.2008.

Research output: Contribution to journalArticle

Kempen, John H. ; Gangaputra, Sapna ; Daniel, Ebenezer ; Levy-Clarke, Grace A. ; Nussenblatt, Robert B. ; Rosenbaum, James (Jim) ; Suhler, Eric ; Thorne, Jennifer E. ; Foster, C. Stephen ; Jabs, Douglas A. ; Helzlsouer, Kathy J. / Long-term Risk of Malignancy Among Patients Treated With Immunosuppressive Agents for Ocular Inflammation : A Critical Assessment of the Evidence. In: American Journal of Ophthalmology. 2008 ; Vol. 146, No. 6.
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AU - Daniel, Ebenezer

AU - Levy-Clarke, Grace A.

AU - Nussenblatt, Robert B.

AU - Rosenbaum, James (Jim)

AU - Suhler, Eric

AU - Thorne, Jennifer E.

AU - Foster, C. Stephen

AU - Jabs, Douglas A.

AU - Helzlsouer, Kathy J.

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