Cancer in systemic sclerosis: clinical associations and prognostic impact from the EUSTAR registry
Abstract
BACKGROUND: Cancer represents a major cause of mortality in systemic sclerosis (SSc). Established risk factors are limited to specific subsets, particularly early diffuse anti-RNA polymerase III (POLR3)-positive disease, needing further exploration. METHODS: We performed a nested case-control study within EUSTAR: cases were SSc patients developing cancer at any timepoint; controls were cancer-free SSc matched for age and disease duration. Malignancies were classified as synchronous to SSc onset (±3 years), subsequent (>3 years after), or previous (>3 years before). Clinical, serological, treatments associations, and survival were analyzed. RESULTS: 454 SSc patients with cancer (29% synchronous, 51% subsequent, 20% previous), and 454 controls were identified. Mean age was 55±13 years, disease duration 5±2 years; 88% were female, 27.5% diffuse SSc; 30.5% had interstitial lung disease (ILD), 32% anti-topoisomerase, 10% anti-POLR3. Synchronous cancers were associated with anti-POLR3 (OR 2.06, 95%CI 1.13-3.69), U1RNP (OR 3.56, 1.03-12.3), smoking (OR 1.57, 1.01-2.44), but negatively with digital ulcers (OR 0.55, 0.31-0.93). Calcinosis was inversely associated with subsequent cancers (OR 0.42, 0.17-0.93). Breast cancer showed time-dependent associations with anti-POLR3 and anti-PM/Scl; lung cancer was mainly subsequent and associated with ILD (OR 2.00, 1.12-3.54), anti-topoisomerase (OR 2.61, 1.38-5.04), and smoking. Cancers occurred more frequently in cyclophosphamide-treated patients. Malignancy worsened overall survival, particularly when subsequent. Radiation therapy did not impact mortality or new-onset ILD. CONCLUSIONS: Cancer timing and site identify distinct clinical-serological associations in SSc, with different prognostic implications. As cancers diagnosed during follow-up are major determinants of mortality, our findings inform the implementation of stratified cancer surveillance in SSc.
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Authors: Antonio Tonutti, Francesca Motta, Liala Moschetti, Cosimo Bruni, Carina Mihai, Claudia Iannone, Maria Rosa Pellico, Stefano Stano, Stefano Erba, C. Barison, Eleonora Pazzi, Andrea Benini, Beatrice Moccaldi, Kurszán Jász Dávid, Ágnes Ágoston‐Szabó, Barbara Gabrielli, Francesca Nava, Dóra Tari, Francesca Romana Di Ciommo, Yuri Sasaki, Gonçalo Boleto, Radim Bečvář, Alejandro Brigante, Britta Maurer, Massimiliano Limonta, Rahma A. Elziaty, Fabiola Atzeni, L. Núñez, Roberta Foti, Francesco Benvenuti, Brigitte Granel, Elena Rezuş, Leïla Caillault, S. Blaise, C. Sieiro Santos, Fabio Cacciapaglia, Roberto Giacomelli, Rossella De Angelis, Serena Guiducci, Duygu Temiz Karadağ, Gabriella Szűcs, Luca Idolazzi, Gábor Kumánovics, Florenzo Iannone, Maurizio Cutolo, Gianluca Moroncini, Valeria Riccieri, Nicoletta Del Papa, Elisabetta Zanatta, Anastasiia Kozlova, Masataka Kuwana, Carlo Selmi, Maria De Santis
Institutions: University of Bari Aldo Moro, University of Padua, Ospedale San Bortolo, University of Verona, Nippon Medical School, Kocaeli Üniversitesi, Inserm, Université Grenoble Alpes, Azienda Ospedaliero-Universitaria Careggi, Charles University, University of Brescia, Grigore T. Popa University of Medicine and Pharmacy, University of Lisbon, University of Zurich, University Hospital Zurich, Complejo Asistencial Universitario de Palencia, Marche Polytechnic University, University Hospital of Bern, Sapienza University of Rome, Universidad Autónoma de la Ciudad de México, University of Debrecen, Ain Shams University, Humanitas University, IRCCS Humanitas Research Hospital, University of Pecs, Libera Università Maria SS. Assunta, University of Genoa, Aix-Marseille Université, Università Campus Bio-Medico, Campus Bio Medico University Hospital, Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia, Ospedale Papa Giovanni XXIII, Istituto Ortopedico Gaetano Pini, Hôpital Nord, University of Messina, Assistance Publique Hôpitaux de Marseille, Centre Hospitalier Universitaire de Rennes, Policlinico Universitario di Catania, Hospital de Santa Maria, Institute of Rheumatology, Hospital Son Llatzer