Cancer Risk for Fingolimod, Natalizumab, and Rituximab in Multiple Sclerosis Patients

Research output: Contribution to journalArticle


Objective: Novel, highly effective disease-modifying therapies have revolutionized multiple sclerosis (MS) care. However, evidence from large comparative studies on important safety outcomes, such as cancer, is still lacking. Methods: In this nationwide register-based cohort study, we linked data from the Swedish MS register to the Swedish Cancer Register and other national health care and census registers. We included 4,187 first-ever initiations of rituximab, 1,620 of fingolimod, and 1,670 of natalizumab in 6,136 MS patients matched for age, sex, and location to 37,801 non-MS general population subjects. Primary outcome was time to first invasive cancer. Results: We identified 78 invasive cancers among treated patients: rituximab 33 (incidence rate [IR] per 10,000 person-years = 34.4, 95% confidence interval [CI] = 23.7–48.3), fingolimod 28 (IR = 44.0, 95% CI = 29.2–63.5), and natalizumab 17 (IR = 26.0, 95% CI = 15.1–41.6). The general population IR was 31.0 (95% CI = 27.8–34.4). Adjusting for baseline characteristics, we found no difference in risk of invasive cancer between rituximab, natalizumab, and the general population but a possibly higher risk with fingolimod compared to the general population (hazard ratio [HR] = 1.53, 95% CI = 0.98–2.38) and rituximab (HR = 1.68, 95% CI = 1.00–2.84). Interpretation: In this first large comparative study of 3 highly effective MS disease-modifying therapies, no increased risk of invasive cancer was seen with rituximab and natalizumab, compared to the general population. However, there was a borderline-significant increased risk with fingolimod, compared to both the general population and rituximab. It was not possible to attribute this increased risk to any specific type of cancer, and further studies are warranted to validate these findings. 


  • Peter Alping
  • Johan Askling
  • Joachim Burman
  • Katharina Fink
  • Anna Fogdell-Hahn
  • Martin Gunnarsson
  • Jan Hillert
  • Annette Langer-Gould
  • Jan Lycke
  • Petra Nilsson
  • Jonatan Salzer
  • Anders Svenningsson
  • Magnus Vrethem
  • Tomas Olsson
  • Fredrik Piehl
  • Thomas Frisell
External organisations
  • Karolinska Institutet
  • Uppsala University
  • Örebro University
  • Karolinska University Hospital
  • Kaiser Permanente Research Institute
  • University of Gothenburg
  • Umeå University
  • Danderyd Hospital
  • Linköping University
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Cancer and Oncology
Original languageEnglish
Pages (from-to)688-699
Number of pages12
JournalAnnals of Neurology
Issue number5
Publication statusPublished - 2020 May
Publication categoryResearch