Canadian Rheumatology Association/Canadian Research Group of Rheumatology in Immuno-Oncology Living Guidelines for Baseline Immunosuppression in Individuals With Preexisting Rheumatic Diseases Initiating Immune Checkpoint Inhibitors. Part 2: Preexisting Systemic Autoimmune Rheumatic Diseases
Bibliographic record
Abstract
OBJECTIVE: Although immune checkpoint inhibitors (ICIs) are increasingly used in patients with preexisting systemic autoimmune rheumatic diseases (SARDs), a key concern is whether baseline immunosuppression at the start of ICI treatment might negatively affect cancer outcomes. This risk must be carefully weighed against the potential for a SARD flare. The objective of this study was to develop a living guideline that will provide up-to-date guidance on the management of baseline immunosuppression for preexisting SARDs when initiating cancer immunotherapy with ICIs. METHODS: The Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO) formed a multidisciplinary panel composed of rheumatologists, oncologists, researchers, and a patient representative, with methodological support from the Canadian Rheumatology Association (CRA). We completed a systematic literature review to inform this first installment of our living guideline. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, the panel developed recommendations for the management of baseline immunosuppression in individuals with preexisting SARDs. RESULTS: We identified 67 publications that reported on immunosuppression and cancer outcomes by specific preexisting rheumatic diseases, including 36 on preexisting SARD. Eight best practice statements were developed, highlighting the importance of shared decision making between patients and their care team and careful consideration of risk of SARD flare, risk of organ- or life-threatening manifestations, and potential effect of immunosuppression on cancer outcomes. Seven specific recommendations were made, 1 each for preexisting systemic lupus erythematosus, systemic sclerosis, Sjögren disease, myositis, sarcoidosis, vasculitis, and Behçet disease, considering both the available evidence and expert consensus. The general recommendation for preexisting SARDs was to continue baseline immunosuppression, particularly if there are organ- or life-threatening manifestations. CONCLUSION: This living guideline will provide contemporary baseline immunosuppression recommendations for individuals with cancer and preexisting SARDs when initiating ICI therapy. New recommendations will be added over time and updated, with the latest recommendations, evidence summaries, and Evidence to Decision summaries available through the CRA and CanRIO websites (www.rheum.ca, www.canrio.ca). (PROSPERO registration: CRD42023461024).
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.021 | 0.096 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.004 |
| Bibliometrics | 0.011 | 0.010 |
| Science and technology studies | 0.003 | 0.001 |
| Scholarly communication | 0.003 | 0.002 |
| Open science | 0.005 | 0.002 |
| Research integrity | 0.004 | 0.004 |
| Insufficient payload (model declined to judge) | 0.005 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".