Over 1.8 million Americans have rheumatoid arthritis (RA). Compared to the general population these
patients are at an increased risk of developing cancer, especially lymphoma and lung cancer. There has been
a theoretical concern that use of immunosuppressive agents may impair immune responses to tumors placing
patients at risk for developing new cancers and for recurrence of previously treated cancers. These concerns
have made clinicians reluctant to use standard therapies for RA in patients with an active or recently diagnosed
cancer. Although only a limited number of studies have evaluated their safety, they have in fact not shown any
signal of harm from disease modifying anti-rheumatic drugs (DMARDs) in patients with RA and cancer.
However, these studies have numerous limitations including focus on mostly patients with remote (> 5 years)
history of cancer, small sample sizes, focus on only certain DMARDs, and/or limited information on cancer-
specific mortality and other outcomes that might matter to patients. Also, nothing is known about the
perspectives and experiences of patients with RA who are being treated for a cancer and how this experience
might shape their willingness to use DMARDs. Treatment guidelines for the management of RA support a
shared decision-making (SDM) approach that attempts to leverage the professional expertise of the
rheumatologist to uphold what is most important to each patient. We herein propose a mixed methods
approach to identify the optimal ways to enhance delivery of care for these patients and to provide a foundation
for shared decision making to ensure alignment between treatment decisions and the values, goals, and
preferences of individual patients.
The studies proposed here will build an evidence base to identify the safest DMARD options for patients
with RA who develop cancer (Aim 1); elicit the experiences, perceptions, and most valued outcomes of
patients with RA and an active or recently diagnosed (<5 years) cancer, their family members and clinicians
who care for these patients (Aim 2).
The overall goal of this K23 mentored career development proposal is to support Dr. Namrata Singh’s
development as an independent, patient-oriented researcher whose long-term goal is to develop a research
agenda focused on the identification of factors that contribute to suboptimal treatment and outcomes for
patients with rheumatic diseases, especially those with cancer. The training and research plans proposed here
will allow her to develop critical skills in advanced pharmacoepidemiology and in qualitative research methods.
Combined with an outstanding mentorship team, the University of Washington’s world-class facilities, and a
rigorous training plan, this project will prepare Dr. Singh to successfully obtain future funding to adapt and test
a decision aid for SDM implementation among patients with RA and an active or recent cancer.