EULAR Annual Scientific Meeting 2023
Lourdes Gonzalez Arreola, Jeremiah Tan, Alexandra Ladouceur, Marie Hudson, Carrie Ye, Janet Roberts, Aurore Fifi-Mah, May Choi, Sabrina Hoa, Tom Appleton, Janet Pope, Nancy Maltez, Shahin Jamal on behalf of the Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO).
Title: Safety and Efficacy of Immune Checkpoint Inhibitors in Patients with Rheumatic Autoimmune Disease: Experience from the Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO)
Background: Immune checkpoint inhibitors (ICI) have changed the landscape of treatment for many cancers. However, most cancer clinical trials for ICI excluded patients with pre-existing autoimmune disease (PAD). Efficacy and safety data on the use of ICI in patients with rheumatic PAD (Rh-PAD) is limited to retrospective case series and reports, and many do not differentiate between Rh-PAD and non-rheumatic PAD. In a large French retrospective cohort, patients on immunosuppression at baseline had poorer tumor outcomes (1).
Objectives: To explore the safety and efficacy of ICI in patients with Rh-PAD and to determine if immunosuppression at baseline impacts early tumor outcomes using data from the CanRIO prospective cohort.
Methods: The CanRIO cohort includes adult patients with Rh-PAD treated with immune checkpoint inhibitors (ICI, including CTLA-4, PD-1 or PDL-1 inhibitors), recruited across 9 Canadian academic sites and followed prospectively at regular intervals as per a standardized study protocol. In this study, we evaluated patients with Rh-PAD who received at least one dose of ICI.
Results: Forty patients with Rh-PADs were recruited into the CanRIO prospective cohort between Jan 2020 and Nov 2022, including 14 (35%) with rheumatoid arthritis, 11 (27.5%) psoriatic arthritis, 7 (17.5%) polymyalgia rheumatica, 5 (12.5%) ankylosing spondylitis and 7 (17.5%) other. The most frequently observed cancers were melanoma 14 (35%) and lung cancer 10 (25%), with stage 3 and stage 4 disease each making up 37.5% of all cases. 25 patients (62.5%) were on baseline immunosuppression prior to ICI start. Anti-PD-1 therapy was most common (45%), followed by combination ICI therapy (22.5%), with a median exposure of 2 months (IQR: 0.5-3.0). Over a median (IQR) follow-up of 3.0 (1.0–6.0) months, 55% experienced a de-novo irAE (68.2% Rh-irAE out of which 46.7% were on baseline immunosuppression) and Rh-PAD exacerbations occurred in 25% out of which 60% were on baseline immunosuppression. Of these, 40% were severe with 50% being on baseline immunosuppression; 70% required corticosteroid treatment; and 40% required a change in immunosuppression. ICI was continued in 50%, transiently held or delayed in 40% and stopped in only 10%. Of the 9 patients on baseline immunosuppression who had been re-staged, 8 had a favorable tumor response (i.e., stabilization, partial or complete response) and only 1 had disease progression.
Conclusion: Early data from patients with Rh-PAD in the CanRIO multi-center prospective cohort suggests that (1) ICI can be effective for cancer treatment in patients with Rh-PAD and should be offered as indicated; (2) flares of Rh-PAD are common but can be managed with corticosteroids or change in baseline immunosuppression; (3) most patients with Rh-PADs had good tumour response despite baseline immunosuppression when starting ICI.
 Tison A, Quéré G, Misery L, Funck‐Brentano E, Danlos FX, Routier E, et al. Safety and efficacy of immune checkpoint inhibitors in patients with cancer and preexisting autoimmune disease: A nationwide, Multicenter Cohort Study. Arthritis & Rheumatology. 2019;71(12):2100–11.