Using Immunosuppressive Therapies to Treat Inflammatory Bowel Diseases (IBD) in the Post‑Cancer Setting

Authors

  • Rana Kandel, MD Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, ON
  • Sanjay K. Murthy, MD, MSc, FRCPC Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, ON

DOI:

https://doi.org/10.58931/cibdt.2025.3139

Abstract

Inflammatory bowel diseases (IBD), including Crohn’s disease (CD), and ulcerative colitis (UC), are chronic immune-mediated inflammatory disorders (IMID) affecting both intestinal and extraintestinal organs. Chronic intestinal inflammation causes multifocal DNA damage, increasing the risks of intestinal cancers. While the widespread use of effective biologic and small molecule therapies and intensified immune modulating (IM) regimens in recent years may have contributed toward declining colorectal cancer risks, these treatments could have introduced unexpected cancer risks in organs not directly affected by IBD due to reduced immune surveillance. Among individuals with IBD, the use of thiopurines has been frequently associated with risks of lymphoma, non‑melanoma skin cancer (NMSC), and cervical cancer. Several large studies have also reported increased risks of lymphoma, and melanoma associated with anti-tumour necrosis factor alpha (anti‑TNF) therapies, although other studies have not shown these associations. A randomized controlled trial (RCT) in elderly individuals with rheumatoid arthritis (RA) and cardiovascular risk factors reported a slightly increased all‑cause cancer risk with the non-selective Janus kinase inhibitor (JAKi), tofacitinib. Other immunosuppressive (IS) therapies, including methotrexate, anti-interleukin (IL)‑12/23 or anti‑IL-23 therapies, anti-α4β7 integrin therapy, JAK-1-selective inhibitors (upadacitinib), and sphingosine-1-phosphate receptor agonists, have not been associated with increased cancer risks to date. However, some of these newer therapies have only been available for a few years.   

Given the low absolute risk of treatment‑related cancers, controlling underlying IBD with IS therapies is typically prioritized to improve quality of life and reduce IBD-related complications. However, the decision to start or continue IS therapy in individuals with current or prior malignancy is more complex, as immune surveillance may be more crucial for these patients. Clinical trials generally exclude patients with a cancer history, which limits the available evidence on cancer recurrence risks associated with specific therapies. Additionally, some cytotoxic chemotherapy regimens can control IBD for prolonged periods, suggesting that additional immunomodulation may be unnecessary, and potentially harmful, during cancer treatment. Conversely, hormonal, radiation, and immune checkpoint inhibitor therapies have been associated with increased risks of IBD flares. Therefore, a careful and collaborative approach with oncologists is essential for the optimal management of IBD patients diagnosed with cancer.

Recently, the European Crohn’s and Colitis Organization (ECCO) and the American Gastroenterological Association (AGA) released practice recommendations regarding the use of IS therapies in individuals with IBD in the post‑cancer setting. This review summarizes the evidence regarding cancer risks associated with specific IBD therapies in this context and presents a management approach based on both scientific and practical considerations.

Author Biographies

Rana Kandel, MD , Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, ON

Dr. Kandel is currently a fourth-year Gastroenterology resident at the University of Ottawa. She completed her undergraduate medical degree at the University of Ottawa in 2021 and Core Internal Medicine training at Queen’s University in 2024. Her clinical interests include Inflammatory Bowel Diseases (IBD) in which she intends to pursue an advanced IBD fellowship training.

Sanjay K. Murthy, MD, MSc, FRCPC, Division of Gastroenterology, Department of Medicine, University of Ottawa, Ottawa, ON

Dr. Murthy is an Associate Professor of Medicine at the University of Ottawa, Gastroenterologist at the Ottawa Hospital IBD Centre and Scientist at The Ottawa Hospital Research Institute. He completed his medical degree at the University of Ottawa, Internal Medicine Residency at the University of Manitoba and Gastroenterology Residency at the University of Toronto. He completed advanced clinical and research fellowships in inflammatory bowel diseases (Mount Sinai Hospital, Toronto), clinical nutrition (Toronto General Hospital) and diagnostic endoscopy (University of Mainz, Germany) and an M.Sc. degree in Clinical Epidemiology and Health Care Research (University of Toronto). Dr. Murthy’s research program uses clinical and health administrative data to conduct epidemiological studies, pragmatic trials and clinical prediction models, which he applies to the study of inflammatory bowel diseases (IBD) and gastrointestinal cancers. He is currently leading multiple national studies evaluating cancer epidemiology and prevention in IBD and is supported by a Faculty of Medicine Research Chair in IBD from the University of Ottawa.

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Kandel R, Murthy SK. Using Immunosuppressive Therapies to Treat Inflammatory Bowel Diseases (IBD) in the Post‑Cancer Setting. Can IBD Today [Internet]. 2025 Jun. 23 [cited 2025 Jun. 28];3(1):13–20. Available from: https://canadianibdtoday.com/article/view/3-1-Kandel_et_al

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