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Treatment of Persons with Rheumatoid Arthritis with a History of Cancer
Beeta Shasti-Nazem1, Sanyogita Chandra2, Jennifer Strouse3
1Resident, Internal Medicine, Legacy Health, Portland, OR, 97201, USA.
Purpose Of Review:
This review article examines the evolving evidence on cancer recurrence and new malignancy risk associated with disease-modifying antirheumatic drugs (DMARDs), including TNF inhibitors, rituximab, IL-6 inhibitors, and JAK inhibitors, in patients with rheumatoid arthritis and a prior malignancy.
Recent Findings:
Conventional synthetic DMARDs are generally considered safe in patients with a history of cancer, with earlier concerns about skin and hematologic malignancies largely disproven. Hydroxychloroquine, sulfasalazine, and leflunomide similarly show no consistent cancer risk. Biologic DMARDs, including TNF inhibitors, rituximab, and abatacept, have not been linked to increased cancer recurrence, though caution is advised in patients with a history of skin cancer. Despite supportive evidence, bDMARD use has declined following cancer diagnoses. JAK inhibitors, however, have shown increased risk of lung cancer in older patients with cardiovascular risk factors, prompting cautious use until more data is available. Although large population clinical trials are lacking, current evidence does not demonstrate any increased risk with initiation of csDMARDs, TNF inhibitors, and rituximab in RA patients with a history of cancer. Abatacept and IL-6 inhibitors may also be reasonable options but require further data. JAK inhibitors should be used cautiously until more reliable data becomes available. These findings support cautious but not prohibitive use of bDMARDs in RA patients with a history of cancer, emphasizing individualized risk assessment and shared decision-making. Further high-quality, prospective studies are needed to guide therapy in this complex clinical population.
Insights
Disease-modifying antirheumatic drugs (DMARDs) generally show no increased cancer risk in rheumatoid arthritis patients with prior malignancy. Use JAK inhibitors cautiously due to potential lung cancer risk in specific populations.
Area of Science:
- Rheumatology
- Oncology
- Pharmacology
Background:
- Rheumatoid arthritis (RA) patients often have comorbidities, including a history of cancer.
- The use of disease-modifying antirheumatic drugs (DMARDs) in this population requires careful consideration of cancer recurrence and new malignancy risks.
Purpose of the Study:
- To review current evidence on the association between various DMARDs and cancer risk in RA patients with a history of malignancy.
- To evaluate risks associated with conventional synthetic DMARDs (csDMARDs), biologic DMARDs (bDMARDs) like TNF inhibitors, rituximab, IL-6 inhibitors, abatacept, and targeted synthetic DMARDs (tsDMARDs) such as JAK inhibitors.
Main Methods:
- Systematic review of evolving scientific literature.
- Analysis of data regarding cancer recurrence and new malignancy incidence in RA patients treated with different DMARD classes.
- Assessment of safety profiles based on available clinical evidence and observational studies.
Main Results:
- Conventional synthetic DMARDs (csDMARDs) and most biologic DMARDs (bDMARDs), including TNF inhibitors and rituximab, are generally considered safe, with no proven increased cancer risk. Caution is advised for skin cancer history with bDMARDs.
- Janus kinase (JAK) inhibitors show a potential increased risk of lung cancer in older patients with cardiovascular risk factors.
- Evidence does not support increased cancer risk with csDMARDs, TNF inhibitors, and rituximab in RA patients with prior cancer. Abatacept and IL-6 inhibitors appear reasonable, but require more data.
Conclusions:
- Current evidence supports the cautious, individualized use of most DMARDs, including bDMARDs, in RA patients with a history of cancer.
- Shared decision-making and risk assessment are crucial, especially considering the potential risks associated with JAK inhibitors.
- Further high-quality prospective studies are needed to refine therapeutic strategies for this complex patient group.
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