Transcript
Neal Bhatia: Hi, I'm Dr. Neal Bhatia. This is another installment of the Type 2 Journal Club, and I'm here with the captain.
Todd Schlesinger: Todd Schlesinger.
Neal Bhatia: With Todd Schlesinger.
Todd Schlesinger: You remember.
Neal Bhatia: I've seen you before. Up-and-comer, rising star, whatever you want. Even more, we're talking about this article about risk of abdominal nonmelanoma skin cancer in patients with atopic dermatitis, which is something we don't think about. Tell me about this article that you wrote with a bunch of those people.
Todd Schlesinger: So basically, what you're looking at is a population-based study. In the real world, we want to understand, for autoimmune diseases like atopic dermatitis, rheumatoid arthritis being another, is nonmelanoma skin cancer more prevalent? If it is prevalent, why?
A number of studies have come out beforehand. This article is looking at just general prevalence: Is it more common? So this is a big study, almost a million patients in the control cohort group, and then 400,000 patients in the active group with AD and RA. It's a population-based study using Optum data looking at all 50 states, commercial and Medicare. So it's a really nice, big population of patients, right?
Neal Bhatia: Absolutely, yeah.
Todd Schlesinger: And the findings of the study basically showed that atopic dermatitis, whether it's moderate or severe, has a higher risk of nonmelanoma skin cancer than matched controls who do not have AD. There was also a similar risk of getting nonmelanoma skin cancer in the rheumatoid arthritis population of patients.
Neal Bhatia: Which is rare.
Todd Schlesinger: Similar.
Neal Bhatia: And again, all kidding aside, we screen our patients. We look at them head to toe. We think about their nonmelanoma skin cancer risk. We think about anything else that's atypical in their skin. But then, with eczema patients, we really focus on their plaques, and we don't think about the rest of their skin. So what do we do with this data?
Todd Schlesinger: Well, you've got to think about it. It's real-world data. Remember, it's claims-based data, so it has certain limitations. It's not as longitudinal or as in-depth as what you get from EMR data, medical record data. It's claims-based data.
So it looks at people diagnosed with AD versus those who are not. Of course, AD patients are more likely to be in a dermatology office, are more likely to be looked at, and therefore are potentially more likely to be diagnosed. So that's a limitation of the study.
The severe population was basically identified by the fact that they were prescribed dupilumab based on the claims data.
Neal Bhatia: That's right.
Todd Schlesinger: So what do we do with it? It just helps us increase our thought process about why this could be happening. Number one, it could be increased permeability of the skin. Number two, it could be treatments that we do, like UV exposure. UV light treatments could increase the risk as well. Number three, we're looking at these patients more carefully.
But on the other hand, there are also autoimmune factors. Of course, we know that skin cancers are very immune-related, and immune dysregulation may increase the risk as well.
So what do we do with that? We basically just remind ourselves to make sure we're doing full-body skin checks in our AD patients as well. Like you just said, sometimes we don't really do much with them as far as the rest of the body. We're looking for plaques, we're giving them a biologic, whatever we're doing for them, and then we're getting them out the door. We're not remembering to get those full-body checks on them.
Neal Bhatia: No, for sure.
Todd Schlesinger: So that's the learning point. I think the takeaway is: Make sure you also do a full-body check on your AD patients according to standard practice.
Neal Bhatia: So, taking your next JAK inhibitor patient, your next biologic patient, your next patient on anything with systemic therapy, are they at risk, or are we telling them we're just going to watch you like we do anybody else?
Todd Schlesinger: So it's a great question. Prior studies have shown, and even this one, that patients who are on JAKs, other biologics, or whatever, actually don't have that much of an increased risk of skin cancer based on the drug itself. It's more generally the disease state.
Neal Bhatia: Correct.
Todd Schlesinger: The JAKs really haven't shown a great increase in skin cancer compared with normal patients. So that's reassuring for that population.
Neal Bhatia: For sure.
Todd Schlesinger: So it gives us less fear when it comes to using those medications.
Neal Bhatia: Again, we understand the science. We're thinking about dendritic cell surveillance. We're thinking about antigen properties. We know they're not going to have a risk, but these patients are like, "Oh, my immune system, what am I going to do?" So how do we get them off the ledge?
Todd Schlesinger: Basically, we need to talk about the data. I think we just let our patients understand that these are effective treatments and how well they work. Then you just have to talk to them about what's real.
Many patients will go and look stuff up. They're very savvy now. So they're going to go look up things. If I don't tell them what the story is, if I don't tell them about some boxed warning or whatever it's going to be, they're going to look it up. I'd rather have them hear it from me.
Neal Bhatia: They all went to ChatGPT medical school.
Todd Schlesinger: That's it. Unfortunately, we didn't have that. It would've made it a lot easier, right?
Neal Bhatia: For God's sake.
Todd Schlesinger: No, listen. We've got to tell them the straight story: that we don't see an increased risk of skin cancer, and we see an excellent safety profile with the JAKs in our space, and that there's a lot of scare tactics going out there in the world.
Neal Bhatia: Oh, totally.
Todd Schlesinger: And that we need to treat them like they need to be treated and give them the right—
Neal Bhatia: Let's be influenced by people who actually can influence people with intelligence.
Todd Schlesinger: Start with that.
Neal Bhatia: Exactly. So this is another episode of Type 2 Journal Club, and we'll see you next time.
