Biologic treatment for psoriasis in cancer patients: should they still be considered forbidden?

Drug Survival and Clinical Course of Patients with Cancer Treated with Biologic Therapy for Psoriasis

Background/Objectives: Patients with treated solid tumors (TST) are a highly heterogeneous and difficult-to-treat population due to the risk of disease progression/recurrence or infection. Methods: We conducted an observational, retrospective, single-center study at the Dermatology Clinic of Turin with a focus on the special population of cancer patients with psoriasis treated with biologics. Results: As of July 2023, 52 psoriatic patients with a prior/concomitant history of malignancy had taken biologic drugs. The median age was 67 years, and the median age of cancer onset was 55 years. The most common tumors were gastrointestinal cancer and melanoma. After the tumor diagnosis, 61% received an anti-IL17 drug; 37 patients continued the initiated biologic therapy, while 12 switched drugs due to secondary inefficacy. The estimated biologic DS was 55.6% at 50 months. Evidence suggests that IL-17 is a key pathogenic factor involved in tumorigenesis, resulting in a lower risk of malignancies in subjects managed with IL-17 inhibitors. Similarly, IL-23 plays a role in suppressing innate immunity and promoting tumor and metastases development. This is a consistent real-life case series that support the use of biologic drugs in patients with TST. Conclusions: IL-23 and IL-17 inhibitors, being immunomodulators rather than immunosuppressants, may be a safe option for patients in an active oncological setting and for immune-correlated adverse events.

Identification of Hub Genes for Psoriasis and Cancer by Bioinformatic Analysis

Psoriasis increases the risk of developing various cancers, including colon cancer. The pathogenesis of the co-occurrence of psoriasis and cancer is not yet clear. This study is aimed at analyzing the pathogenesis of psoriasis combined with cancer by bioinformatic analysis. Skin tissue data from psoriasis (GSE117239) and intestinal tissue data from colon cancer (GSE44076) were downloaded from the GEO database. One thousand two hundred ninety-six common differentially expressed genes and 688 common shared genes for psoriasis and colon cancer were determined, respectively, using the limma R package and weighted gene coexpression network analysis (WGCNA) methods. The results of the GO and KEGG enrichment analyses were mainly related to the biological processes of the cell cycle. Thirteen hub genes were selected, including AURKA, DLGAP5, NCAPG, CCNB1, NDC80, BUB1B, TTK, CCNB2, AURKB, TOP2A, ASPM, BUB1, and KIF20A. These hub genes have high diagnostic value, and most of them are positively correlated with activated CD4 T cells. Three hub transcription factors (TFs) were also predicted: E2F1, E2F3, and BRCA1. These hub genes and hub TFs are highly expressed in various cancers. Furthermore, 251 drugs were predicted, and some of them overlap with existing therapeutic drugs for psoriasis or colon cancer. This study revealed some genetic mechanisms of psoriasis and cancer by bioinformatic analysis. These hub genes, hub TFs, and predicted drugs may provide new perspectives for further research on the mechanism and treatment.

Psoriasis Comorbidities and Their Treatment Impact

Psoriasis, a systemic inflammatory disease classically presenting with cutaneous lesions, has significant involvement in other organ systems. This article explores the prevalence, clinical manifestations, screening mechanisms, and laboratory testing by which to evaluate these comorbidities. Treatment approach for these comorbidities must combine patient preference with established treatment algorithms while recognizing innovative therapeutics currently under development.

Drug survival, effectiveness, and safety of brodalumab for moderate-to-severe psoriasis up to 3 years

BACKGROUND

Brodalumab is a monoclonal antibody and IL-17 RA inhibitor that is approved for the treatment of moderate-to-severe psoriasis. The present study aims to estimate the drug survival (DS), effectiveness, and safety of brodalumab over a period of 156 weeks.

METHODS

The primary objectives were: (i) to determine the treatment response rate at Weeks 16, 28, 52, 78, 104, and 156 as defined by PASI100, PASI90, and an absolute PASI ≤ 3 and (ii) long-term DS. Secondary objectives included the evaluation of possible predictive factors associated with the achievement of response outcomes, and possible predictive factors associated with lower DS.

RESULTS

The treatment response was rapid, with 80.3% of patients achieving PASI ≤ 3, 66% PASI90, and 54.3% the complete clearance of disease at Week 16. The response improved at Week 28, when a plateau was achieved with mild loss of response at later time points, in particular for PASI100 and PASI90 in 55.2 and 65.5% of patients, respectively, at Week 156. After 156 weeks of treatment, 66.22% of patients were still on therapy, and the previous use of IL-17 inhibitors appeared to be associated with an increased risk of treatment discontinuation (HR: 2.51, CI: 1.06-5.98, P = 0.037), and achievement of PASI ≤ 3 until Week 16 with less risk (HR: 0.27 CI: 0.14-0.51, P < 0.001). Bio-naïve status was favorably associated with treatment response, while high BMI negatively affected the achievement of outcomes.

CONCLUSION

Our study confirms the good effectiveness and favorable safety profile of brodalumab in a real-world setting for up to 3 years of treatment.

The Role of Interleukin 23/17 Axis in Psoriasis Management: A Comprehensive Review of Clinical Trials

Psoriasis pathogenesis is influenced by genetic factors and characterized by a complex interplay between genetic predisposition and various environmental triggers. These triggers set off metabolic processes involving inflammation, cell signaling, immune response dysregulation, and antigen presentation. Several types of innate and adaptive immune cells are involved in psoriasis. Among the cytokine cascade which leads to psoriasis development, the interleukin (IL)-23/Th17 axis, especially IL-17 production, emerges as crucial. Recognizing the pivotal role of this axis has facilitated the development of selective and effective biological drugs, such as anti-IL17 and anti-IL23 monoclonal antibodies. These drugs aim to achieve the complete or near-complete disappearance of psoriatic lesions, as indicated by PASI100 and PASI90 responses, respectively. In this context, the aim of our review was to delve into the functioning of the IL-23/Th17 axis, its dysregulation in psoriasis pathogenesis, and the therapeutic potential of its inhibition. Currently, 4 anti-IL17 (secukinumab, ixekizumab, bimekizumab and brodalumab) and 3 anti-IL23 (guselkumab, risankizumab and tildrakizumab) have been approved. All these drugs showed high levels of effectiveness in both clinical trials and real-life experiences, with an excellent profile in terms of safety. Certainly, furthers studies will allow for better characterization of biologics' profile, in order to administer the right drug for the right patients at the right moment.

Biological Therapy for Psoriasis in Cancer Patients: An 8-Year Retrospective Real-Life Study

Background: It is now recognized that psoriasis plays a key role in the development of several comorbidities, such as cardiovascular disease, and metabolic syndrome. Some authors have hypothesized that patients with psoriasis may have an increased risk of developing certain types of cancer. The efficacy and safety of biologic drugs are well-documented in clinical trials and in real-life studies. However, there is limited evidence on the safety of the use of biologic treatments in cancer patients with psoriasis, and the use of this therapeutic class in patients with a pre-existing or concomitant malignancy is still debated. Methods: We have conducted a retrospective observational study of a group of oncology patients with moderate-to-severe psoriasis treated with biologic therapy at the Dermatology Clinic of the University of Naples Federico II, during the period from 2016 to 2024. We included 20 adult patients; in 15 of them the diagnosis of neoplasm preceded the start of treatment biologic, while four of these patients had been diagnosed with cancer during the course of therapy biologics. Results: The most represented neoplasms in our population were breast carcinoma, prostate carcinoma, thyroid carcinoma, and chronic lymphatic leukemia. Anti-IL17 drugs were the most frequently prescribed (47.7%), followed by anti-IL23p19 (36.8%), anti-IL-12/23 (10.5%) and anti-TNF alpha (5.26%). All patients showed improvement of psoriasis after starting the therapy. Conclusions: Our experience supports the effectiveness and safety of biological therapy for psoriasis in patients with a history of cancer or recent onset neoplasia.

Choosing Systemic Agents for Psoriasis

Treatment options for moderate-to-severe psoriasis depend on drug efficacy and safety, patient preferences, comorbidities, and cost-no drug dominates across all dimensions. Interleukin (IL)-17 inhibitors may be preferred for fast-acting treatment, while the 3-month schedule of risankizumab, ustekinumab, or tildrakizumab may be attractive for patients who prioritize fewer injections. Phototherapy is suitable for patients who wish to avoid systemic agents or when cost is a concern. For patients with poor adherence, infliximab or tildrakizumab may be well suited as they require in-office administration. Dermatologists can educate patients on available therapies to find a regimen best suited to their needs.

Drug survival and clinical effectiveness of secukinumab, ixekizumab, brodalumab, guselkumab, risankizumab, tildrakizumab for psoriasis treatment

BACKGROUND

Biologics targeting IL-23 and IL-17 show efficacy and safety in the treatment of moderate-to-severe psoriasis.

OBJECTIVE

To investigate drug survival in patients with psoriasis treated with biologics.

PATIENTS AND METHODS

We performed a comparative evaluation of the achievement of PASI 90 and PASI ≤ 3 at 16, 28, and 52 weeks along with a DS (drug survival) analysis with IL-17 and IL-23 inhibitors brodalumab, ixekizumab, secukinumab, risankizumab, tildrakizumab, and guselkumab on 1,057 patients.

RESULTS

IL-17 inhibitors showed a faster achievement of PASI 90 and PASI ≤ 3 with significant superiority over IL-23 inhibitors at week 16 (p < 0.001; 56% vs. 42% and 70% vs. 59%, respectively). A difference was shown in favor of IL-23 inhibitors regarding DS (p < 0.001), which was 88% at 24 months vs. 75% for IL-17 inhibitors. In multivariate analysis, IL-23 inhibitors (HR 0.54 CI 0.37-0.78, p = 0.001), and male sex (HR 0.57 CI 0.42-0.76, p < 0.001) were all associated with a lower probability of drug interruption. Risankizumab (HR 0.42 CI 0.26-0.69, p = 0.001), guselkumab (HR 0.49 CI 0.24-0.99, p = 0.046), and male sex (HR 0.57 CI 0.43-0.77, p < 0.001) were associated with a lower probability of drug interruption than secukinumab.

CONCLUSIONS

IL-23 inhibitors showed the best performance on DS. Overall, the most effective class was IL-17 inhibitors considering the short-term effectiveness, but long-term effectiveness is in favor of anti-IL-23.

Drug survival und klinische Wirksamkeit von Secukinumab, Ixekizumab, Brodalumab, Guselkumab, Risankizumab und Tildrakizumab in der Behandlung der Psoriasis: Drug survival and clinical effectiveness of secukinumab, ixekizumab, brodalumab, guselkumab, risankizumab, tildrakizumab for psoriasis treatment

Hintergrund

Biologika, die die Interleukine IL‐23 and IL‐17 hemmen, haben sich in der Behandlung der mittelschweren bis schweren Psoriasis als sicher und wirksam erwiesen.

Studienziel

Medikamenten‐Überleben bei Patienten mit Psoriasis zu untersuchen, die mit Biologika behandelt werden.

Patienten und Methoden

Wir haben die Erreichung des PASI 90 und PASI ≤3 nach 16, 28, and 52 Wochen im Vergleich der IL‐17‐ und IL‐23‐Inhibitoren Brodalumab, Ixekizumab, Secukinumab, Risankizumab, Tildrakizumab und Guselkumab bei insgesamt 1057 Patienten untersucht sowie eine Drug Survival‐Analyse durchgeführt.

Ergebnisse

Unter IL‐17‐Inhibitoren wurden PASI 90 und PASI ≤3 schneller erreicht; nach 16 Wochen waren sie den IL‐23‐Inhibitoren signifikant überlegen (p <0,001; 56% vs. 42% beziehungsweise 70% vs. 59%). Im Drug Survival zeigte sich allerdings ein Vorteil für die IL‐23‐Inhibitoren; dieses betrug nach 24 Monaten 88% im Gegensatz zu 75% für die IL‐17‐Inhibitoren (p <0,001). In der multivariaten Analyse waren die IL‐23‐Inhibitoren (HR 0,54 CI 0,37–0,78, p =  0,001) sowie männliches Geschlecht (HR 0,57 CI 0,42–0,76, p <0,001) mit einer geringeren Wahrscheinlichkeit des Absetzens der Medikation assoziiert. Risankizumab (HR 0,42 CI 0,26‐0,69, p =  0,001), Guselkumab (HR 0,49 CI 0,24–0,99, p =  0,046) und männliches Geschlecht (HR 0,57 CI 0,43–0,77, p <0,001) waren mit geringerer Wahrscheinlichkeit des Absetzens der Medikation assoziiert als Secukinumab.

Schlussfolgerung

IL‐23‐Inhibitoren zeigten bezüglich des Drug Survival die besten Ergebnisse. Auf kürzere Sicht waren die IL‐17‐Inhibitoren wirksamer, aber die Langzeitergebnisse sprechen eher für die IL‐23‐Inhibitoren.

A Multidisciplinary Approach to Patients with Psoriasis and a History of Malignancies or On-Treatment for Solid Tumors: A Narrative Literature Review

Psoriasis is a chronic immune-mediated disease that is linked to an increased risk of cancer. Although numerous studies have explored whether neoplasms are concurrent conditions or are induced by psoriasis, a definitive definition remains elusive. In this study, we conducted a comprehensive narrative literature review to offer practical guidance to oncologists and dermatologists regarding the initiation and discontinuation of biologics for psoriasis. The findings indicate that a customized approach is recommended for each patient, and that a history of malignancies does not constitute an absolute contraindication for biologics. Growing evidence supports the treatment of selected patients, emphasizing a nuanced assessment of benefits and risks. There is a lack of data specifying a safe timeframe to initiate biologics following a neoplasm diagnosis due to influences from cancer-related and patient-specific characteristics impacting prognosis. Some patients may continue anti-psoriasis therapy during cancer treatments. Enhanced comprehension of the biological mechanisms in cancer progression and the immune microenvironment of psoriasis holds promise for refining therapeutic strategies. In conclusion, a personalized treatment approach necessitates collaboration between oncologists and dermatologists, considering factors such as cancer prognosis, psoriasis clinical manifestations, patient characteristics, and preferences when making treatment decisions.

Interclass Switch between IL17 and IL23 Inhibitors in Psoriasis: A Real-Life, Long-Term, Single-Center Experience

BACKGROUND

Interleukin 23 (IL-23) inhibitors, such as guselkumab, risankziumab, and tildrakizumab, have proved to be highly effective and safe for psoriasis treatment either in bio-naïve or bio-experienced patients. A substantial proportion of patients show a primary or secondary inefficacy to IL-17 inhibitors and can benefit from an alternative line of treatment, like IL-23 inhibitors. To date, no sufficient data are available on the effectiveness of IL-23 inhibitors after an anti-IL-17 agent.

METHODS

Our study includes 48 patients with moderate to severe psoriasis undergoing a switch from IL-17 to IL-23 inhibitors. This trial is registered with SS_DERMO_20.

RESULTS

The mean PASI (Psoriasis Area Severity Index) decreases from 11.6 to 3.3 at week 16, with responses maintained at weeks 28 and 52 (2 and 1.4, respectively), and a PASI100 achievement in more than 24% of patients at 16 weeks and 61.9 at 48 weeks, with no occurrence of serious adverse events. However, almost one in six patients interrupted the IL-23 inhibitors mainly due to primary ineffectivenss.

CONCLUSIONS

Our data support the evidence that an interclass switch among IL-17 inhibitors is a safe and effective therapeutic option for these patients.

The Current Advancement in Psoriasis

The study on psoriasis disease helps improve the condition and treatment options day by day in dermatology. In the current scenario, research is ongoing to make the best interventions possible for managing the disease. Psoriasis is one of the most common dermatological conditions wherein chronic inflammation of the skin occurs, characterized by the formation of a rash with scaly, itchy patches over the body surface. The condition is mainly related to the immune system wherein epidermal hyperplasia occurs with infiltration of immune cells. Many factors can trigger psoriasis. Environmental, emotional, hereditary, and personal habits are responsible for the conditions. The current research helps to gain a complete understanding, and the basic knowledge of the state with recent advancements in treatment strategies and characteristic features can also be studied. The main aim is to know the disease's primary root cause and management. It involves the main sites of the body. The most commonly affected parts are the scalp, trunks, knees, elbow, and ankle. It is a chronic long-term disease. Sometimes it may be painful. Itching, bleeding, and disturbed sleep patterns are common symptoms. Most commonly involves the upper epidermal surface. The prevalence of the condition has been increased as it is associated with other comorbidities. The main focus of the treatment is to restrict skin cell multiplication and remove scaly surfaces. This review discusses the advancement in the treatment, its initiation, progression, current symptoms, and disease development. The study also includes basic knowledge about the types of psoriatic disease with its specific features and mechanisms.

Psoriasis and skin cancer - Is there a link?

A chronic auto-immune-mediated disease Psoriasis is associated with manycoexisting or co-occurringconditions, which include a significant risk of malignancies, especiallyskin tumours. Numerous studies were done to understand whether psoriasis itself, comorbidities related to psoriasis, or psoriasis treatment might increase the risk of neoplasms. We reviewed the relation between psoriasis and cancer risk, also the significance of inflammation in cancer The various classes of drugs used to treat psoriasis, including biologics like tumour necrosis factor (TNF) inhibitors; and how they increase cancer risk are deliberated. Literature was collated for the past five years from the data bases like PubMed, Medline, Google Scholar, etc. Literatures discussing the skin cancer linked to psoriasis were reviewed. Possible mechanisms associated between inflammation and psoriasis; skin cancer was explained in the context of the several psoriasis medications that increase the likelihood of skin cancer. The risk of cancer in other cutaneous auto-inflammatory diseases is also elucidated. It is frequently observed that increased doses of PUVA therapy, immunosuppressive medications, and lifestyle changes alter the aetiology of the tumours. This review is conceptualized to shed the light on probable mechanisms involved in these connections as well as the chance of cancer in psoriasis patients.

Integrated Safety Analysis on Skin Cancers among Patients with Psoriasis Receiving Ixekizumab in Clinical Trials

INTRODUCTION

Limited data exist on skin cancer risk in patients with psoriasis using biologics. Here, we report treatment-emergent adverse events (TEAEs) of skin cancer in patients treated with ixekizumab from psoriasis clinical trials.

METHODS

Integrated safety databases from 17 clinical trials of adults with moderate-to-severe psoriasis treated with ≥ 1 dose of ixekizumab for ≤ 5 years were used to analyze exposure-adjusted incidence rates (IRs) per 100 patient-years of exposure (PYE) and clinically characterize dermatologist-adjudicated skin cancer TEAEs.

RESULTS

Of 6892 patients, 58 presented with ≥ 1 skin cancer TEAE (IR 0.3) with IRs remaining stable with longer ixekizumab exposure. Non-melanoma skin cancer (NMSC) was the most common event (IR 0.3) affecting 55 patients; of those, 44 had basal cell carcinoma (IR 0.2) and 16 had squamous cell carcinoma (IR 0.1). Two treatment-emergent melanoma events were identified; neither were classified as serious AEs.

CONCLUSIONS

Incidence of skin neoplasms in patients with psoriasis treated with ixekizumab for ≤ 5 years was low, and among those events, NMSC was most common. Limitations included that longer exposure may be required to confirm risk of skin cancer and that the study exclusion criteria of several studies, which excluded patients with skin cancer events within 5 years prior to baseline, might limit interpretation of skin cancer risk in this cohort. These findings support the safety profile of ixekizumab for patients requiring long-term psoriasis control.

Biologic treatment of psoriasis in oncologic patients

INTRODUCTION

There is a complex interplay between psoriasis and cancer, with therapeutic implications. Patients with psoriasis have an increased risk of developing several types of cancer, and safety concerns have arisen regarding biologic therapies and cancer. On the other hand, biologics can provide adequate control of psoriasis that appears or worsens as an immune-related adverse event following immune enhancing checkpoint inhibitor therapy for cancer, thus allowing prosecution of oncologic treatment without impairing its efficacy.

PATIENTS AND METHODS

We performed a retrospective observational study of patients with moderate-to-severe psoriasis under biological treatment and cancer who were treated at our Department between January 2009 and June 2022.

RESULTS

We included 31 adult patients with psoriasis and cancer; in 16 the diagnosis of cancer preceded the inception of biological treatment, and 9 of those patients were in remission. Most malignancies arose in the genitourinary system, followed by breast, hematologic, colorectal, thyroid, and others. Anti-IL23p19 biologics were most frequently used (36%), followed by anti-TNF (32%), anti-IL-17 (16%) and anti-IL-12/23 (16%) agents. All patients showed improvement of psoriasis after biologic initiation.

CONCLUSIONS

Biologic treatment for moderate-severe psoriasis should be considered in oncologic patients since it is not formally contraindicated and is safe. Moreover, the efficacy and safety profile of IL-23 and IL-17 inhibitors may be advantageous for those patients.

Secukinumab in Patients with Psoriasis and a Personal History of Malignancy: A Multicenter Real-Life Observational Study

Introduction

There is limited evidence to guide clinicians on the treatment of psoriasis with biologics in patients with a history of malignancy who are often excluded from clinical trials investigating biologics. The aim of this work is to report a multicenter real-life experience of secukinumab treatment in patients with psoriasis and a personal history of cancer.

Methods

This retrospective observational study included adult patients with moderate-to-severe plaque psoriasis treated with secukinumab for at least 24 weeks and a previous diagnosis of cancer at 15 Italian referral centers. The primary endpoint of the study was tumor recurrence or progression and new cancer diagnosis during treatment. Secondary outcome assessment of secukinumab effectiveness (reduction of Psoriasis Area and Severity Index [PASI] score, improvement of Dermatology Life Quality Index [DLQI], itch and pain).

Results

Forty-two patients (27 male) were included. Malignancy was diagnosed in the previous 5 years in 21 (56.8%) and in the previous 10 years in 37 (88.1%). The mean interval between cancer diagnosis and the start of secukinumab treatment was 3.5 ± 3.3 years. No tumor recurrence nor progression occurred over a mean of 56 ± 31.7 weeks of treatment. Three patients developed a new malignancy not related to the previous cancer. At week 48, PASI 90 was reached by 64.7% of patients and PASI 100 by 38.2%. Mean DLQI, itch, and pain VAS scores significantly improved during treatment.

Conclusions

Our multicenter real-life experience is the largest reported to date focusing on a specific biologic and adds evidence to the safety of secukinumab in psoriatic patients with a personal history of cancer.