Answer:
As noted below in previous Ask the Expert answers there really is no definitive answer to your question. The Practice Parameter on IT does not specifically address this issues either. In my practice, I have approached this on an individual basis considering the patient, the malignancy and the treatment. For example, treat of solid tumors may be "less" immunosuppressive than for example a leukemia (where the goal of therapy may be complete ablation of lymphocytes). This decision will need to be made on a case by case basis.
I hope this has been helpful
Andrew Murphy, MD, FAAAAI
"There is no definitive answer to your question. The therapy for multiple myeloma will impact rapidly dividing cells and result in a likely transient humoral and cellular immunodeficiency. However, plasma cells will be less affected and likely T regulatory cells that have been induced by the immunotherapy will not be as vulnerable to the therapy since they would not be expected to be rapidly dividing. Thus, the treatment of the myeloma may or may not affect the immune response to the immunotherapy. However, the myeloma therapy would also likely reduce specific antibody responses, including IgE. In balance, there is no evidence or specific theoretical arguments that allergen immunotherapy will not be effective while receiving therapy for myeloma.
A second issue would be whether immunotherapy could aggravate the myeloma. Again, there is no specific contraindication for allergen immunotherapy with malignancy. I have copied a question from the Ask the Expert archives that you may find of interest.
In summary, I would recommend you continue the beneficial allergen immune therapy to your patient during her chemotherapy. I would expect continued benefit. I would discuss this with your patient and share the lack of data in providing guidance but also the reassurance that there is no evidence of a negative effect.”
Orbital malignancy and allergen immunotherapy
Q: 1/26/2015
I have a patient which is on immunotherapy in maintenance phase for mite and weed. Recently he developed a tumor in orbit. If it has any relation with immunotherapy and can I continue?
A: The simple answer to your question is no, there is no relationship between malignancy, orbital or otherwise, and allergen immunotherapy. A report of 6 cases of immunotherapy (majority insect allergy) in subjects with known cancer, showed no evidence of increased growth of the cancers due to modification of T cells that may be specific to the tumor (Int Arch Allergy Immunol 2011;156:313-9). This is a theoretical issue but was raised in a European paper (Klein-Tebbe J, Bufe A, Ebner C. Allergo J 2009;18:508-37, German without English translation that I could locate). The conclusion of the review of the literature in theInternational Archives of Allergy Immunology paper was “…the hypothetical risk of influencing an underlying oncologic disease by SIT seems to be rather low. To finally resolve this important issue, studies with large patient cohorts and long postintervention follow-up periods are urgently required. However, we think that at least low stage cancer may not pose a necessary contraindication for SIT.”
Two epidemiologic reports, one from Australia and one from US, described an inverse association with allergic disease and development of malignancy, suggesting that IgE or specific-IgE may have some protective effect on the development of cancer. The argument then would be that immunotherapy, by reducing specific-IgE, may theoretically increase malignancy. There is no evidence to support this argument. The increase in numerical cancers with omalizumab therapy, anti-IgE monoclonal, was of sufficient concern that a 5 year observational safety study was required by the FDA to investigate an association of malignancy with lowering IgE. No association was found.
In summary, I do not think there is any credible evidence to associate allergen immunotherapy with the development of an orbital tumor or malignancy in general.
References:
1. Wöhrl S, Kinaciyan T, Jalili A, Stingl G, Moritz KB. Malignancy and specific allergen immunotherapy: The results of a case series. Int Arch Alelrgy immunol 2011;156:313-9
2. Talbot-Smith A, Fritschi L, Divitini ML, Mallon DFJ, Knuiman MW: Allergy, atopy, and cancer: a prospective study of the 1981 Busselton cohort. Am J Epidemiol 2003;157: 606–612.
3. Turner MC, Chen Y, Krewski D, Ghadirian P, Thun MJ, Calle EE: Cancer mortality among US men and women with asthma and hay fever. Am J Epidemiol 2005;162:212–221.
4. Schabath MB, Gorlova OY, Spitz MR: Reply: ‘Cancer mortalitiy among US men and women with asthma and hay fever’. Am J Epidemiol 2006;163:394–395.
5. Castaing M, Youngson J, Zaridze D, Szeszenia-Dabrowska N, Rudnai P, Lissowska J, et al: Is the risk of lung cancer reduced among eczema patients? Am J Epidemiol 2005;162: 542–547.
6. Wang H, Rothenbacher D, Low M, Stegmaier C, Brenner H, Diepgen TL: Atopic diseases, immunoglobulin E and risk of cancer of the prostate, breast, lung and colorectum. Int J Cancer 2006;119:695–701.
7. Busse, William, et al. "Omalizumab and the risk of malignancy: results from a pooled analysis." Journal of Allergy and Clinical Immunology 129.4 (2012): 983-989.
I hope this information is of help to you and your patient.
All my best.
Dennis K. Ledford, MD, FAAAAI