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RESEARCH: John H Kempen, Ebenezer Daniel, James P Dunn, C Stephen Foster, Sapna Gangaputra, Asaf Hanish, Kathy J Helzlsouer, Douglas A Jabs, R Oktay Kaçmaz, Grace A Levy-Clarke, Teresa L Liesegang, Craig W Newcomb, Robert B Nussenblatt, Siddharth S Pujari, James T Rosenbaum, Eric B Suhler, and Jennifer E Thorne Overall and cancer related mortality among patients with ocular inflammation treated with immunosuppressive drugs: retrospective cohort study BMJ 2009; 339: b2480 [Abstract] [Full text]

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What about therapy-related cancer morbidity?

Jane M McGregor, Conal M Perrett, Catherine A Harwood   (31 July 2009)

Re: What about therapy-related cancer morbidity?

John H Kempen, Ebenezer Daniel, James P Dunn, C Stephen Foster, Sapna Gangaputra, Asaf Hanish, Kathy Helzlsouer, Douglas Jabs, R Oktay Kaçmaz, Grace Levy-Clarke, Teresa Liesegang, Craig Newcomb, Robert Nussenblatt, S S Pujari, James Rosenbaum, Eric Suhler, J E Thorne   (14 August 2009)

What about therapy-related cancer morbidity? 31 July 2009
Jane M McGregor, Consultant Senior Lecturer in Dermatology Centre for Cutaneous Research, Barts and The London School of Medicine and Dentistry, Conal M Perrett, Catherine A Harwood Send response to journal: Re: What about therapy-related cancer morbidity?	A study may find no association between a given treatment and increased cancer mortality(1) but this may nonetheless obscure a real increase in cancer morbidity. Such is the case for nonmelanoma skin cancer which is rarely fatal but may require multiple surgical procedures resulting in facial scarring and permanent disfigurement. Kempen et al (1) conclude that, as single agents, methotrexate, azathioprine, mycofenolate mofetil, ciclosporin, dapsone, and systemic corticosteroids given to patients with ocular inflammatory diseases do not increase the risk of overall or cancer mortality. Certainly this is reassuring for clinicians, but it misses the point that single agents, particularly ciclosporin (2) and azathioprine (3,4) which becomes a photocarcinogen on exposure of the skin to sunlight (5), do increase the risk of skin cancer. An informed clinician can empower the patient to reduce this risk by taking sun avoidance measures and by seeking early treatment for premalignant lesions, before it is too late. 1) Kempen JH, Daniel E, Dunn JP et al. Overall and cancer related mortality among patients with ocular inflammation treated with immunosuppressive drugs: retrospective cohort study. BMJ. 2009 Jul 3;339:b2480. 2) Paul CF, Ho VC, McGeown C et al. Risk of malignancies in psoriasis patients treated with cyclosporine: a 5 y cohort study. J Invest Dermatol. 2003;120:211-6. 3) Azathioprine, IARC Monographs 26 (Suppl. 7), 119 (1987). 4) Maddox JS and Soltani K. Risk of nonmelanoma skin cancer with azathioprine use Inflamm Bowel Dis. 2008 Oct;14(10):1425-31. 5) O'Donovan P, Perrett CM, Zhang X et al. Azathioprine and UVA light generate mutagenic oxidative DNA damage. Science. 2005 Sep 16;309(5742):1871-4. Competing interests: None declared
Re: What about therapy-related cancer morbidity? 14 August 2009
John H Kempen, Associate Professor of Ophthalmology and Epidemiology University of Pennsylvania School of Medicine, Philadelphia, PA 19104, Ebenezer Daniel, James P Dunn, C Stephen Foster, Sapna Gangaputra, Asaf Hanish, Kathy Helzlsouer, Douglas Jabs, R Oktay Kaçmaz, Grace Levy-Clarke, Teresa Liesegang, Craig Newcomb, Robert Nussenblatt, S S Pujari, James Rosenbaum, Eric Suhler, J E Thorne Send response to journal: Re: Re: What about therapy-related cancer morbidity?	McGregor et al have noted correctly that our methodology evaluating the risk of overall and cancer mortality would not capture non-fatal cases of skin malignancy (or other non-fatal morbidities). In another publication, we also have made the point that skin cancer risk may be elevated in patients receiving immunosuppressive therapy.1 We concur with the recommendation that patients receiving immunosuppression should be particularly careful to limit ultraviolet exposure, and should seek care promptly for suspicious skin lesions. We thank these colleagues for their interest in our paper and in this important topic. References 1. Kempen JH, Gangaputra S, Daniel E, Levy-Clarke GA, Nussenblatt RB, Rosenbaum JT, Suhler EB, Thorne JE, Foster CS, Jabs DA, Helzlsouer KJ. Long-term risk of malignancy among patients treated with immunosuppressive agents for ocular inflammation: A critical assessment of the evidence. Am J Ophthalmol 2008;146:802-812. Competing interests: Our statement of interests has not changed from that in our original manuscript.