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Cancer is not a risk factor for Bullous Pemphigoid: A ten-year population-based cohort study

This study aims to determine if cancer is associated with an increased risk of subsequently developing Bullous Pemphigoid (BP) and which types of cancer are most strongly associated with developing BP. The study concludes that there was no increased risk of BP seen in cancer patients, with age, diabetes mellitus, and cerebrovascular disease being identified as independent risk factors for BP.

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Cancer is not a risk factor for Bullous Pemphigoid: A ten-year population-based cohort study

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  1. Cancer is not a risk factor for bullous pemphigoid. A ten-year population-based cohort study CT Chen, MD,1,2 HY Hu, PhD,3,4 YT Chang, MD, PhD,1,2 CP Li, MD, PhD 2,5 and CY Wu, MD, PhD1,2,3* 1 Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan 2 National Yang-Ming University School of Medicine, Taipei, Taiwan 3 Institute of Public Health and Department of Public Health, National Yang-Ming University, Taipei, Taiwan 4 Department of Education and Research, Taipei City Hospital, Taipei, Taiwan 5 Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan British Journal of Dermatology. DOI: 10.111/bjd.17197

  2. Lead researcher Chen-Yi Wu M.D., Ph.D. Attending Physician Department of Dermatology, Taipei Veterans General Hospital No. 201, Section 2, Shih-Pai Road, Taipei, 11217, Taiwan Associate Professor National Yang-Ming University School of Medicine No. 155, Sec.2, Li-Nong Street, Taipei, 11221, Taiwan

  3. IntroductionWhat’s already known about this subject ? • Patients with cerebrovascular or neurologic diseases (e.g. dementia, Parkinson’s disease) have a higher risk of developing bullous pemphigoid (BP) • Whether cancer is also a risk factor for BP remains unclear

  4. Objective • Is cancer associated with an increased risk of subsequently developing BP? • Which types of cancer are most strongly associated with developing BP?

  5. Methods (I) • Design • Retrospective cohort study • Data sources • Longitudinal Health Insurance Database 2000, a subset of Taiwan’s National Health Insurance Research Database containing medical records from 1 million randomly sampled beneficiaries • Defining incident cases of cancer • Subjects required a diagnosis of cancer (ICD-9 codes 140–239) + Catastrophic Illness Card (issued for pathology proven cancers), from 2002-2011 • Patients with cancer diagnosis before 2002 were excluded • Index date was the date of the first diagnosis of cancer • Analysis included 36,838 cancer patients

  6. Methods(II) • Control group • Each cancer patient was matched to 4 age-, sex- and index date-matched controls without cancer • Subjects with BP diagnosed before the index date were excluded • Defining incident cases of bullous pemphigoid • ICD-9 code 694.5 • At least three diagnosis codes in outpatient clinic records or at least one in admission records • Covariates • Socioeconomic status, urbanity, and comorbidities (hypertension, diabetes mellitus, hyperlipidaemia, renal disease, chronic liver diseases and cirrhosis, cerebrovascular disease, dementia, and coronary artery disease)

  7. Methods(III) • Statistical analyses • Incidence rate ratio • Hazard ratio • Fine-Gray competing risk regression model (with mortality as the competing event) to eliminate the influence of higher mortality rates in the cancer group • P-value <0.05 considered statistically significant

  8. Results (I) Risk of BP stratified by age The average observation time was 3.48 years for the cancer group and 5.87 years for the control group.

  9. Results (II) Multivariate analysis for prediction of bullous pemphigoid development

  10. Results (III) Incidence for BP stratified by cancer type

  11. Discussion (I) • No increased risk for BP among cancer patients (HR 0.47) • The average observation time of BP development in cancer group was shorter than for the control group (likely due to the high mortality rate in cancer patients) • Analysed by Fine-Gray competing risk regression model, which describes the direction of the effect, but not the magnitude of the effect • The interpretation should be that cancer is not a risk factor for BP (rather than that cancer is a protective factor for BP)

  12. Discussion (II) • The authors observed a high risk for subsequent BP in patients with brain or other nervous system tumours • The main target antigen in BP is BpAg1, with three major forms in the nervous system, epidermis and muscles • A damaged blood brain barrier due to the presence of a brain tumour, or associated treatment e.g. surgery or radiation, could result in the exposure and cross-reactivity of the nervous system antigen to the epidermal antigen • Age, diabetes mellitus, and cerebrovascular disease were independent risk factors for BP, similar to findings from other studies

  13. ConclusionsWhat does this study add? • In this population-based study, there was no increased risk of BP seen in cancer patients • Age, diabetes mellitus, and cerebrovascular disease were independent risk factors for BP

  14. Research team HY Hu CY Wu CP Li YT Chang CT Chen

  15. Call for correspondence • Why not join the debate on this article through our correspondence section? • Rapid responses should not exceed 350 words, four references and one figure. • Further details can be found here.

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