Challenges in managing adverse effects of immunotherapy treatment

Challenges in managing adverse effects of immunotherapy treatment

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  Challenges in managing adverseeffects of immunotherapy treatment Julie Teraci Clinical Nurse Consultant / Coordinator WA Melanoma Advisory Service Cancer Nurse Coordinator Melanoma & Skin Cancer WA Cancer and Palliative Care Network
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  Effective Surveillance, Recognition,and Intervention Minimizes the Potential Impact of AEs1,2 Early recognition and reporting Management of AEs 1. Teply BA et al. Oncology (Williston Park). 2014;28 Suppl 3:30–38. 2. Kannan R et al. Clin J Onc Nurs. 2015;18(3):311–317, 326.
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  EDUCATION EDUCATE G.P. ED staff Other key clinical staff Yourself Carer’s Patient
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  Education of patientand carer  Individual education preferable  Need to understand MOA and rationale for early reporting of AEs  No self management of AEs  NOT chemotherapy – medic alert band  Treating hospital preferable for ED  Contact details for reporting AEs Early recognition and reporting
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  Some of thechallenges…  BRAF/MEK & checkpoint inhibitors  No predictable time for developing AEs  Other HCP may not be familiar with new drugs  Patients self manage symptoms  Patients delay reporting AEs –subtle onset  Contact with many staff – inconsistent advice
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  Challenges cont’d  Phoneassessment challenging  Who is assessing patient?  How are they assessed? – no formal tools  If presentation to hospital via ambulance may not go to Rx centre  Patients prefer closest hospital – may not have appropriate expertise  Rural context
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  Case study -Rick  41 YO male with stage IV M1c melanoma.  Rx BRAF/MEK inhibitors for 1 yr – POD with brain mets - Feb 2017  Completed 4 cycles Ipi/Nivo early May 2017  patient emailed CNC (reason not related to AEs)  CNC enquired re side effects in return email “ pretty good, had an upset tummy over past 10 days but managing well with Imodium and good fluid intake” Proactive monitoring
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  Case study cont’d Thereality:-  8-10 watery, orange coloured stools / day  Urgency, bloating and abdo cramps  No blood, obvious mucous in stool  10 day duration
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  Case study cont’d Reported symptoms before final Ipi/Nivo cycle -- CN documented “mild diarrhoea, advised re bowel care, gastro stop and adequate hydration”  Advised to go to ED  “ I followed their advice, they give this treatment all the time so I thought they must know what they’re talking about”  Advised consultant & ward registrar
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  Management issues  Appropriatetreatment sometimes delayed  ED discharge patients without med onc review  Patients admitted under medical team and do not consult with med onc  Other specialties not providing treatment as for immune related AE Appropriate management
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  Solutions????  Regular followup of patients between appointments • Resources – how often?, cost effective?  Education • unaware of significance Aes / apparent knowledge • only reaches those that attend session • rotation of medical staff
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  Solutions?  Formal education- nursing & medical staff  Assessment tools / alert cards  Designated contact with Immuno-oncology experience  Individual responsibility to know about treatment - proper assessment and follow up of symptoms Vigilant follow-up
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  Assessment tool
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  A team approach– Communication is KEY! Patient Medical Oncologist Pharmacist Carer /family Oncology nurse General Practitioner Other Specialists