The potential for malignancy is a huge issue for patients with RA, particularly in an era when we have so much access to information. Patients often become fearful of these risks, and some are reluctant to start or change therapies. We have solid data indicating that biologics are not associated with an increased risk of solid tumors (eg, breast cancer, lung cancer, colon cancer, prostate cancer); however, RA itself is linked to an increased risk of certain cancers (eg, lung cancer). And tumor necrosis factor inhibitors carry a black box warning for lymphoma.

Skin cancer is a bit more challenging because it is not captured in the large malignancy databases. In fact, the Surveillance, Epidemiology, and End Results database does not include skin cancers. We have evidence demonstrating that virtually all of our RA therapies, including methotrexate, leflunomide, azathioprine, and biologic agents, increase the risk of developing nonmelanoma skin cancer, such as basal cell carcinoma. This makes sense because these cancers are all sun driven, so, if you disrupt tumor surveillance, you will increase the risk that a cell will become cancerous. However, these types of skin cancers are local and quite treatable by a dermatologist and are therefore not as worrisome as a solid malignancy. I am quite comfortable telling my patients with a history of nonmelanoma skin cancer that they can take a biologic as long as they see a dermatologist twice a year for a complete skin check. Melanoma is a more frightening cancer because it can metastasize and can come back years later. But, since the incidence of melanoma is very low, it is difficult to determine whether there is a difference between treatments in clinical trials.

I discuss the risks and benefits of treatment with all of my patients with RA. There is no treatment that has no risk whatsoever, but, given the benefits of these drugs, it is often an appropriate risk to take, even in those with a potentially higher underlying risk (eg, first-degree relative with melanoma). I also remind my patients that untreated RA is associated with many risks, including cardiovascular disease, structural joint damage, and malignancy. So, you need to put the risks and benefits of RA treatment into perspective.