Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses
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The document discusses the role of immune checkpoint inhibitors (ICIs) in cancer immunotherapy, detailing how these therapies, such as anti-PD-1 and anti-CTLA-4 agents, function by modulating T-lymphocyte responses against cancer. It also outlines various FDA-approved ICIs, their indications, combination regimens, and potential immune-related adverse effects, emphasizing the importance of early recognition and management of these effects in oncology nursing practice. Overall, the document serves as a practical guide for oncology nurses to maximize the benefits of cancer immunotherapies while minimizing associated risks.
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Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses
- 1. Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Immune Checkpoint Inhibition in the Treatment of Cancer: Basics and Practicalities PRACTICE AID Oncology Nursing Tumor Microenvironment Lymphoid Tissue Immune checkpoint inhibitors modulate T-lymphocyte responses against cancer by blocking negative regulation of immune responses PD-1 pathway inhibits signaling downstream of TCR • TCR triggered by antigen presented by tumor cell • Negative regulatory receptor PD-1 expressed and PD-L1 reactively expressed • PD-L1 binds to PD-1 T cell inactivated T cell inactivated T cell activated T cell activated Anti–PD-1 or anti–PD-L1 monoclonal antibodies block the interaction and negative regulation Anti–CTLA-4 monoclonal antibodies block negative regulation by CTLA-4 CTLA-4 is a negative regulator of costimulation required for activation of an antitumor T cell in a lymph node upon recognition of tumor antigen What Are Immune Checkpoints? PD-1/PD-L1 Checkpoint Inhibition CTLA-4 Checkpoint Inhibition FDA-Approved Therapies FDA-Approved Therapies Without Immunotherapy With Immunotherapy MHC Antigen TCR PD-1 PD-L1 Anti– PD-L1 Anti– PD-1 Tumor cell Tumor escape Inactivation of T Cell Activation of T Cell Elimination of tumor cells Without Immunotherapy With Immunotherapy MHC CD80/86 CTLA-4 Anti– CTLA-4 antibody APC Antigen TCR Inactivation of T Cell Activation of T Cell Tumor escape Elimination of tumor cells STOP STOP GO GO GO Tumor escape Tumor escape Tumor attack Tumor attack Anti–PD-1: Nivolumab Pembrolizumab Cemiplimab-rwlc Anti–CTLA-4: Ipilimumab Anti–PD-L1: Atezolizumab Avelumab Durvalumab • Proteins on T cells or cancer cells that need to be activated/inactivated to start/stop an immune response, eg, PD-1, PD-L1, CTLA-4 • Serve as “brakes” that help keep immune responses in check; can prevent T-cell response against cancer cells • Can be blocked by immune checkpoint inhibitors (the “brakes” on the immune system are released and T cells are able to attack and kill cancer cells)
- 2. Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Immune Checkpoint Inhibition in the Treatment of Cancer: Basics and Practicalities PRACTICE AID Oncology Nursing FDA-Approved Immune Checkpoint Inhibitors: Agents and Combination Regimens1 Nivolumab • Melanomaa • Squamous cell carcinoma of the head and neck (SCCHN) • Non–small cell lung cancer (NSCLC) • Small cell lung cancer (SCLC) • Hepatocellular carcinoma (HCC) • MSI-H/dMMR colorectal cancer (CRC)a • Renal cell carcinoma (RCC)a • Urothelial carcinoma (UC) • Hodgkin lymphoma (HL) • Melanoma • Merkel cell carcinoma (MCC) • SCCHNa • NSCLCa • SCLC • Esophageal cancer • Gastric cancer • HCC • MSI-H/dMMR CRC and solid tumors • Cervical cancer • Endometrial carcinomab • UC, including NMIBC • RCCb • HL • Primary mediastinal B-cell lymphoma (PMBCL) Cemiplimab-rwlc • Cutaneous squamous cell carcinoma (CSCC) Anti–PD-1 Anti–PD-L1 Anti–CTLA-4 Atezolizumab • NSCLCa • SCLCb • Triple-negative breast cancer (TNBC) • UC Avelumab • MCC • RCCb • UC Durvalumab • NSCLC (stage III) • UC Ipilimumab • Melanomaa Combination Regimens Atezolizumab + bevacizumab + chemotherapy • NSCLC Atezolizumab + chemotherapy • NSCLC • SCLC • TNBC Avelumab + axitinib • RCC Nivolumab + ipilimumab • Melanoma • MSI-H/dMMR CRC • RCC Pembrolizumab + axitinib • RCC Pembrolizumab + chemotherapy • SCCHN • NSCLC Pembrolizumab + lenvatinib • Endometrial carcinoma Pembrolizumab • RCCb • MSI-H/dMMR CRCb
- 3. Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Immune Checkpoint Inhibition in the Treatment of Cancer: Basics and Practicalities PRACTICE AID a ICPI indicated as a single agent or as part of a combination regimen. b ICPI indicated as part of a combination regimen. c Line of treatment varies by disease. d SCLC is only indicated at 240 mg Q2W. APC: antigen-presenting cell; Bev: bevacizumab; CD: cluster of differentiation; CRC: colorectal cancer; CSCC: cutaneous squamous cell carcinoma; CT: chemotherapy; CTLA-4: cytotoxic T-lymphocyte–associated protein 4; dMMR: mismatch repair deficient; HCC: hepatocellular carcinoma; HL: Hodgkin lymphoma; ICPI: immune checkpoint inhibitor; MCC: Merkel cell carcinoma; MHC: major histocompatibility complex; MSI-H: microsatellite instability high; NMIBC: nonmuscle invasive urothelial carcinoma; NSCLC: non–small cell lung cancer; PD-1: programmed cell death protein 1; PD-L1: programmed death ligand 1; PMBCL: primary mediastinal B-cell lymphoma; RCC: renal cell carcinoma; SCCHN: squamous cell carcinoma of the head and neck; SCLC: small cell lung cancer; TCR: T-cell receptor; TNBC: triple-negative breast cancer; UC: urothelial carcinoma. 1. https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm279174.htm. Accessed January 16, 2020. Oncology Nursing Anti–PD-L1 NSCLC; urothelial 840 mg Q2W; 1,200 mg Q3W; 1,680 mg Q4W (IV over 60/30 min) NSCLC (in combination with chemotherapy ± bev), SCLC (in combination with chemotherapy) 1,200 mg IV over 60/30 min Q3W prior to CT/bev; upon discontinuation of CT ± bev, continue atezo at 840 mg Q2W, 1,200 mg Q3W, or 1,680 mg Q4W (IV over 60/30 min) TNBC (in combination with chemotherapy) 840 mg over 60/30 min Q2W Anti–PD-1 Indicationd Dose MCC, UC, RCC 800 mg Q2W as IV infusion over 60 min UC and stage III NSCLC 10 mg/kg Q2W as IV infusion over 60 min Anti–CTLA-4 Melanoma (unresectable/metastatic) 3 mg/kg IV over 90 min Q3W x 4 Melanoma (adjuvant) 10 mg/kg IV over 90 min Q3W x 4 à 10 mg/kg Q12W up to 3 y RCC, in combination with nivolumab MSI-H/dMMR CRC, in combination with nivolumab Nivolumab 3 mg/kg over 30 min à ipilimumab 1 mg/kg on same day Q3W x 4; upon discontinuation of ipilimumab, continue nivolumab 240 mg Q2W/480 mg Q4W IV over 30 min Ipilimumab Anti–PD-L1 Immune Checkpoint Inhibitors: Dosing and Frequency1,c IV infusion over 60 min à 30 min if 1st infusion tolerated CSCC 350 mg Q3W as IV infusion over 30 min Melanoma (metastatic and adjuvant), NSCLC, SCLC,d SCCHN, RCC, UC, MSI-H/dMMR CRC, HCC, HL 240 mg Q2W or 480 mg Q4W as IV infusion over 30 min Melanoma (unresectable/metastatic), in combination with ipilimumab Nivolumab 1 mg/kg à ipilimumab 3 mg/kg on same day Q3W x 4; upon ipilimumab discontinuation, nivolumab 240 mg Q2W or 280 mg Q4W over 30 min RCC, in combination with ipilimumab; MSI-H/dMMR CRC, in combination with ipilimumab Nivolumab 3 mg/kg over 30 min à ipilimumab 1 mg/kg on same day Q3W x 4; upon ipilimumab discontinuation, nivolumab 240 mg Q2W or 480 mg Q4W over 30 min Melanoma (metastatic and adjuvant), MCC, NSCLC, SCLC, SCCHN, HCC, esophageal, gastric, MSI-H or dMMR CRC or other solid tumors, cervical, endometrial, RCC, UC, HL, PMBCL 200 mg Q3W as IV infusion over 30 min Cemiplimab-rwlc Pembrolizumab Nivolumab Atezolizumab Avelumab Durvalumab
- 4. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Musculoskeletal Gastrointestinal Renal Hematologic Neurologic Pulmonary Cardiovascular Ocular Dermatologic Endocrine Spectrum of Potential irAEs Neuropathy, meningitis, Guillain–Barré syndrome, myasthenia gravis, encephalitis, and transverse myelitis Myocarditis, pericarditis, arrhythmias, impaired ventricular function with heart failure and vasculitis, and venous thromboembolism Pneumonitis Colitis, hepatitis, and hepatic transaminases Inflammatory arthritis, myositis, and polymyalgia-like syndrome Uveitis/iritis, episcleritis, and blepharitis Primary hypothyroidism, hyperthyroidism, hypophysitis, primary adrenal insufficiency, and diabetes Rash/inflammatory dermatitis, bullous dermatoses, and severe cutaneous adverse reactions Autoimmune hemolytic anemia, aTTP, hemolytic uremic syndrome, aplastic anemia, lymphopenia, ITP, and acquired hemophilia Nephritis ü Are autoimmune/inflammatory by nature ü Are different from toxicities of chemotherapies and other cancer therapies ü Can affect any organ system ü Can have unpredictable onset (any time during treatment course or after) ü Can be difficult to differentiate from other causes (diagnosed by exclusion) ü Treatment depends on severity and may require corticosteroids + sometimes other immunosuppressive treatments NB! irAEs: Oncology Nursing
- 5. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Provides tool to distinguish which patients can be treated at home and which ones need to come into the clinic All staff must be educated in the use and updates of the Telephone Triage guidelines Early identification of symptoms will minimize severity of AEs and keep patients on beneficial therapy for a longer period of time Telephone Triage Guidelines Patient Considerations Is the patient a reliable and accurate “historian”? How reliable is the patient to follow telephone instructions? Comprehension of “sense of urgency”? Language barriers, cognitive deficits, alcohol and drug use, comorbidities? How far does the patient live from the clinic? Is there available transportation? What support or resources does the patient have to follow guidelines? • Any associated abdominal pain, cramping, nausea, or vomiting? • Any blood or mucous in the stool? • Secretary notifies clinic practice nurse • When did it start? • How many episodes? • Any recent sick contacts? • Is the patient able to drink fluids? Additional IO-specific symptom questions RN returns call; triage questions Patient calls with complaint of diarrhea If mild (increase of 4 stools/day baseline) and not interfering with ADLs, patient may hydrate by mouth and take an antidiarrheal agent If moderate or severe, not able to maintain fluid intake or associated with any other symptoms, patient should come into the clinic for evaluation Oncology Nursing
- 6. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. General Recommendations for Grading, Assessment, and Management of irAEs1 irAEs are often diagnosed by exclusion; other causes should be ruled out (including AEs of other therapies used), but immunotherapy- related toxicity should always be included in the differential There should be a high level of suspicion that new symptoms are treatment related; early recognition, evaluation, and treatment of irAEs plus patient education are essential for the best outcome Depending on the severity of an irAE, management may require corticosteroids or other immunosuppressive treatment and interruption or discontinuation of therapy If appropriate immunosuppressive treatment is used, patients generally recover from irAEs Grade 1 Asymptomatic; diagnostic changes only; continue immunotherapy Grade 2 Mild-to-moderate symptoms; grade 2 diagnostic abnormalities • Hold treatment; provide supportive care • Methylprednisolone 0.5-1.0 mg/kg/d until stable (or oral equivalent) If improving: transition to oral steroid at start of taper • Dose suggested: 60 mg prednisone daily x 2 wk • Taper over 4 wk or more to reduce recurrence of symptoms • May consider reinitiation of immunotherapy If progressing: treat as grade 3/4 • Consider hospitalization of patient; multidisciplinary evaluation of toxicity Grade 3/4 Discontinue immunotherapy (consider organ-specific algorithms; endocrine) • Hospitalization indicated • Methylprednisolone 1.0-2.0 mg/kg/d until stable Refractory If no improvement or progression, additional immunosuppressant treatment may be needed • Infliximab 5 mg/kg (except if contraindicated) • Mycophenolate mofetil 1 g twice daily • Cyclosporine or IV immunoglobulin Grade Assessment and Management Oncology Nursing
- 7. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Dermatologic— maculopapular rash Macule, papule, morbilliform rash, pruritus, eczema, psoriasis, eosinophilic infiltrates, lichenoid deposits, alopecia, vitiligo (correlates with positive outcomes); consider all mucous membranes Rule out other causes, such as cellulitis, contact dermatitis, other drug reactions, allergies, sun exposure, and radiation recall; perform total body exam, including mucosa; measure distribution; assess impact on ADLs; assess for prior inflammatory dermatologic processes Dermatologic— bullous dermatitis and Stevens- Johnson syndrome Drug rash with eosinophilia and systemic symptoms (DRESS) Rule out other causes, such as cellulitis, contact dermatitis, other drug reactions, and allergies; perform total body exam, including mucosa; measure distribution; assess impact on ADLs; assess for prior inflammatory dermatologic processes Gastrointestinal Educate patients on potential AEs; onset 3 d to 10 wk or even months after ICPI initiation; avoid foods that cause loose stools; consider opioid constipation; diarrhea is more common with dual ICPI; earlier with anti–CTLA-4; risk of perforation and sepsis Calculate frequency and volume of diarrhea for 24 h (including ostomy; incontinence); look for mucous or blood in stool; do abdominal CT scan with contrast (look for mesenteric engorgement, bowel wall thickening, fluid-filled colonic distention); do stool evaluation to rule out infectious etiology (NAATs for GI pathogens/ bacterial culture; Clostridium difficile; ova and parasite: molecular test for Giardia lamblia, Cryptosporidium, and Entamoeba histolytica; consider microsporidia Cyclospora/Isospora; do viral pathogens testing when available Most Common Organ-Specific irAEs: Presentation, Assessment, and Management1 System Prevent/Anticipate Detect/Monitor Treatment/Management Mild G1 (10% BSA) • Continue immunotherapy • Treat with moderate-potency topical steroids • Oral antihistamines • Topical emollients Moderate G2 (10%-30% BSA) • Consider holding immunotherapy • Treat with high-potency topical steroids and/or prednisone 0.5-1.0 mg/kg/day • Oral antihistamines • Topical emollients Severe G3-4 (30% BSA) • Hold immunotherapy • Treat with high-potency topical steroids • Prednisone 0.5-1.0 mg/kg/day (increase up to 2.0 mg/kg/day if not responsive) • Urgent dermatologic consult Mild G1 (10% BSA) • Hold immunotherapy • Treat with high-potency topical steroids Moderate G2 (10%-30% BSA) • Hold immunotherapy • Prednisone 0.5-1.0 mg/kg/day • Oral antihistamines • Topical emollients Severe/Life-Threatening G3-4 (30% BSA) • Permanently discontinue • G3: prednisone 0.5-1.0 mg/kg/day (increase up to 2.0 mg/kg/day if not responsive) • Inpatient care at ICU or burn unit • Urgent dermatologic and ophthalmology consult Mild G1 (4 stools baseline) • Consider holding • Antispasmodic • Antidiarrheal: loperamide, diphenoxylate/atropine Moderate G2 (4-6 stools) • Hold Immunotherapy • Prednisone 1-2 mg/kg/day (if no response in 2-3 days, increase to 2-4 mg/kg/day) • If refractory, consider infliximab; if infliximab resistant, consider vedolizumab Grade 3 (6 stools baseline) • Discontinue CTLA-4; consider restarting anti–PD-1/L1 if resolved Grade 4 (life-threatening) • Permanently discontinue • Consider inpatient care • Prednisone 2-4 mg/kg/day (if no response in 2-3 days, consider infliximab) General supportive care: sun protection (sunscreen, sunglasses); consider biopsy if anything unusual presents General supportive care: educate about supportive care to maintain hydration and dietary changes; GI consult: consider colonoscopy and EGD General supportive care: urgent dermatologic consultation • G4: prednisone 1.0-2.0 mg/kg/day Oncology Nursing
- 8. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Most Common Organ-Specific irAEs: Presentation, Assessment, and Management1 (Cont’d) Pulmonary Prevention: smoking cessation; vaccinations Dyspnea; dry cough; wheezing; tachypnea; tachycardia; hypoxia; increased oxygen requirements; chest pain Rule out other causes, such as infection, disease progression, pulmonary embolism, pleural effusion, sarcoidosis, pulmonary fibrosis; pulmonary function tests Endocrine— thyroid Baseline laboratory assessment: fatigue, sluggishness, anorexia, weight loss/ gain, irritability, palpitations, feeling hot/cold, visual disturbances, headaches, and change in sexual drive Close laboratory monitoring; monitor TSH and free T4 every 4-6 wk Endocrine— adrenal and pituitary Close laboratory monitoring with: ACTH, cortisol, FSH, LH, renin, TFTs, estradiol, testosterone, comprehensive metabolic panel; monitor TSH and free T4 every 4-6 wk System Prevent/Anticipate Detect/Monitor Treatment/Management Mild G1 (25% lung) • Hold immunotherapy • Reassess in 1-2 wk • Pulse oximetry rest and ambulation • Consider chest imaging with CT (with contrast preferred) • Repeat in 3-4 wk Moderate G2 (25%-50% lung) • Hold immunotherapy; infectious workup: nasal swab, sputum, blood • Consider bronchoscopy and BAL • Chest imaging with CT contrast • Repeat in 3-4 wk • Consider empiric antibiotics • Methylprednisolone 1-2 mg/kg/day • If no response in 3-4 d, treat as G3 Severe G3-4 • Permanently discontinue immunotherapy • Inpatient care • Infectious work up • Pulmonary and infectious disease consultation • Bronchoscopy with BAL • Empiric antibiotics • Methylprednisolone 1-2 mg/kg/day (when G1, taper over 6 weeks) • If refractory, consider infliximab, mycophenolate, or IVIG Asymptomatic hypothyroidism • TSH 4-10; T4 norm: continue ICPI • TSH 10; T4 norm: continue; consider levothyroxine • TSH low; T4 low/norm: consider central hypothyroidism Clinical hypothyroidism • Monitor TSH and T4 every 4-6 wk • Levothyroxine replacement to maintain free T4 level at mid-range (typically 1.6 mcg/kg/day) • Consider endocrine consultation • Exclude concomitant adrenal insufficiency Thyrotoxicosis • Continue ICPI • Propranolol for palpitations • Repeat TFTs in 4-6 wk Adrenal insufficiency • Endocrine consultation • Hold immunotherapy • Start corticosteroids before other hormone replacement to prevent adrenal crisis • Steroid replacement: hydrocortisone 20 mg AM, 10 mg PM, slowly titrate down according to symptoms, or prednisone 7.5 mg or 10 mg and titrate, and fludrocortisone 0.1 mg every other day, then titrate to BP • May need additional fluids if hypotensive Hypophysitis • MRI of brain with pituitary cuts (sellar cuts) • Hold immunotherapy • Methylprednisolone 1-2 mg/kg/day • Hormone replacement as necessary General supportive care: dyspnea management; oxygen support; nebulizer treatment General supportive care: levothyroxine; educate patients that lifetime hormone replacement is likely General supportive care: patient education about stress and hormone dosing; wear alert bracelet • • Baseline laboratory assessment: fatigue, sluggishness, anorexia, weight loss/ gain, irritability, palpitations, feeling hot/cold, visual disturbances, headaches, and change in sexual drive Oncology Nursing
- 9. Immune-Related Adverse Effects Associated With Immune Checkpoint Blockade Therapy: Recognition and Management ABX: antibiotics; ACTH: adrenocorticotropic hormone; ADL: activities of daily living; ALK: alkaline phosphatase; ALT: alanine aminotransferase; ANA: antinuclear antibodies; AST: aspartate aminotransferase; aTTP: acquired thrombotic thrombocytopenic purpura; BAL: bronchoalveolar lavage; BSA: body surface area; CBC: complete blood count; CCP: cyclic citrullinated peptide; CK: creatine kinase; CRF: chronic renal failure; CRP: C-reactive protein; CVA: cerebrovascular accident; CXR: chest x-ray; DMARD: disease-modifying antirheumatic drug; EGD: esophagogastroduodenoscopy; EMG: electromyography; ESR: erythrocyte sedimentation rate; FSH: follicle-stimulating hormone; ICPI: immune checkpoint inhibitor; IMAR: immune-mediated adverse reaction; IO: immuno-oncology; irAE: immune-related adverse effect; ITP: immune thrombocytopenic purpura; IVIG: intravenous immunoglobulin; LH: luteinizing hormone; LP: lumbar puncture; MRI: magnetic resonance imaging; NAATs: multiplex nucleic acid amplification tests; OT: occupational therapy; PD-1: programmed cell death protein 1; PD-L1: programmed cell death ligand 1; PT: physical therapy; RF: rheumatoid factor; RUQ: right upper quadrant; SOB: shortness of breath; TFT: thyroid function test; TSH: thyroid-stimulating hormone; TTP: thrombotic thrombocytopenic purpura; VTE: venous thromboembolism. 1. NCCN Clinical Practice Guidelines in Oncology. Management of Immunotherapy-Related Toxicities. Version 1.2020. https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf. Accessed January 16, 2020. PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Other Common Organ-Specific irAEs: Presentation, Assessment, and Management1 Hepatic Nausea; vague abdominal discomfort; RUQ pain; dehydration; jaundice; bleeding; bruising; dark skin; drowsiness Liver enzymes (AST, ALT, ALK, total and direct bilirubin); liver ultrasound; GI consult; rule out viral syndrome • Hold hepatotoxic drugs • Mycophenolate 2 mg/kg/day if refractory to corticosteroid • No infliximab Renal— nephritis Elevated serum creatinine; vague nausea; emesis; decreased urine output; blood in urine; ankle swelling Serum creatinine; urinalysis; nephrology consult; renal ultrasound; biopsy • Limit nephrotoxic drugs: ABX, NSAIDS, contrast dye • Identify high risk patients (CRF) • Hydration Cardiac Chest pain; SOB; tachycardia; arrhythmias; VTE; fluid retention; pericarditis; myocarditis; effusion; vasculitis Echocardiogram; CXR; cardiology consult • Blood pressure support • Heart rate regulation Neurologic Unusual weakness; numbness; peripheral neuropathy; autonomic neuropathy; altered gait; memory difficulties; seizures; aseptic meningitis; myasthenia gravis; Guillain-Barré; encephalitis; transverse myelitis Neurology consult; MRI of brain to rule out CVA; brain metastases; MRI spine; LP; rule out infection • Permanent discontinuation • Rehab services • IVIG Ocular Dry, scratchy eyes; vision changes; redness; inflammation; pain; iritis; uveitis; blepharitis; episcleritis; conjunctivitis Rule out infection; ophthalmology consult • Lubricating eyedrops • Topical corticosteroid eyedrops • Decrease local irritants, such as contact lenses and eye makeup Musculoskeletal Inflammatory arthritis; myositis; polymyalgia-like syndrome Rheumatologic tests/autoimmune panel (ANA, RF, anti-CCP, ESR, CK, CRP); imaging; EMG • NSAID • Corticosteroid joint injections • DMARD • Methotrexate • PT/OT Hematologic Autoimmune hemolytic anemia; aTTP; hemolytic uremic syndrome; aplastic anemia; lymphopenia; immune thrombocytopenia; acquired hemophilia History and physical exam; rule out drug causes; blood chemistry tests; imaging; coagulation panel; autoimmune serology; viral/infection tests; hematology consult • Corticosteroid • RBC transfusion or IVIG according to guidelines • Hold/discontinue ICPI System Prevent/Anticipate Detect/Monitor Treatment/Management Oncology Nursing
- 10. Patient Education and Survivorship in the Era of Immuno-Oncology: Guidance and Resources for Oncology Nurses PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Patients resources are available online! Nurses and the rest of the clinical team should educate and engage in shared decision-making with patients and their families/caregivers to determine if immunotherapy is the right choice for them, develop a treatment and monitoring plan, and discuss what to expect during and after treatment Education can help patients become well-informed, engaged participants in their care Patient communication and education is critical! What immunotherapies are and how they work What factors determine if the patient is/is not a good candidate for immunotherapy What to expect during and after treatment What irAEs are, when they can occur, and the importance of close monitoring and early detection, diagnosis, and management Educate your patients about Remind your patients to Carry a wallet card with information on current/prior immunotherapy at all times Notify their healthcare provider if they develop any new/unusual symptoms or are admitted to a facility • Oncology Nursing Society https://www.ons.org/node/3761 • ASCO https://www.cancer.net/sites/cancer.net/files/ asco_answers_immunotherapy.pdf • NCCN https://www.nccn.org/images/pdf/Immunotherapy_Infographic.pdf • AIM with Immunotherapy https://aimwithimmunotherapy.org/patient-action-plans/ • SITC https://www.sitcancer.org/connectedold/p/patient Oncology Nursing
- 11. Patient Education and Survivorship in the Era of Immuno-Oncology: Guidance and Resources for Oncology Nurses PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Survivorship Care in the Immunotherapy Era1-3 What are the central components of survivorship care? Prevention strategies for new and recurrent cancers and other late effects Surveillance for cancer spread or recurrence or second cancers Assessment of late psychosocial and physical effects Intervention for consequences of cancer and treatment Coordination of care between primary care providers and specialists to ensure that all of the survivor’s health needs are met What do oncology nurses and nurse navigators need to know about caring for cancer survivors in the IO era? Important to maintain relationships during and after the conclusion of immunotherapy Immunotherapy is still a fairly new treatment with little evidence on long-term outcomes and implications à nurses/navigators should monitor and address anxiety arising in survivors due to uncertainty about their future, eg: No consensus on optimal duration of immunotherapy and implications of stopping early à can cause anxiety in patients who worry that their cancer may return if they stop therapy; however, staying on treatment longer may increase the risk of developing irAEs irAEs can develop after stopping therapy à important to educate patients about this possibility and need to continue to monitor and report unusual symptoms Not clear whether immunotherapy impacts fertility or ability to conceive a healthy child à refer younger patients to specialists to provide counseling, testing, and guidance Number of post-immunotherapy cancer survivors will continue to grow as immunotherapy treatments move into earlier (curable) disease settings à increased need for nurses/navigators to provide survivorship care and education Oncology Nursing
- 12. Patient Education and Survivorship in the Era of Immuno-Oncology: Guidance and Resources for Oncology Nurses ASCO: American Society of Clinical Oncology; irAE: immune-related adverse effect; NCCN: National Comprehensive Cancer Network; SITC: Society for Immunotherapy of Cancer. 1. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Survivorship. Version 2.2019. https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed December 27, 2019. 2. Institute of Medicine and National Research Council. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006. 3. http://www.jons-online.com/issues/2016/august-2016-vol-7-no-7/1471-game-changing-immunotherapy-presents-unique-challenges-for-navigation. Accessed December 27, 2019. 4. Marcus C. Health Psychol Behav Med. 2014;2:482-495. PRACTICE AID Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40. Enhance comprehension and retention Deliver patient-centered education Understand the learner Communicate clearly and effectively Address health literacy and cultural competence Teaching and Education goals Use a question list so that patients can ask questions, and providers can answer them Talk to—not at— people Find out what patients already know before providing information New communication skills require practice; structured skill development exercises may be helpful for providers Ask patients, “Do you need help understanding health information?” Adequate preparation for teaching and learning Repeat the most important information and increase the frequency of the message exposure through several repetitions Practice empathy, especially when the patient’s view differs from that of the provider Be aware of nonverbal messages, including gestures, body language, and dress, when communicating verbally Present the most important information first; emphasize one to three key points; focus on one issue at a time; present the information in logical blocks; use concrete instructions Supplement verbal education with simple written and visual materials; however, the materials should reinforce and not replace verbal instructions or directions Good teaching methods Ask patients to repeat information in their own words Ask patients about their life experiences and use them to teach; use metaphors comparing patients’ care and their life situation Determine patients’ barriers to health literacy; assessing the ability to learn may include interview or observation Use easy-to-understand language (avoid medical jargon) Use an interpreter if a patient requires one due to language or disability; avoid technical terminology or medical jargon Overcoming barriers to learning Provide information in several ways to ensure patient understanding; audiotapes of patient consultations can help patient recall of verbal education Pay attention to and try to dispel patients’ worries and fears Family remembers often require education (eg, on pain management) Give patients an opportunity to ask questions and time to speak prior to discharge Using a scripted tool may help providers verbalize clearer and more understandable patient education Teaching as an interactive process Use the teach-back method Ask patients to state their goals of medical care to begin a discussion Realize that patients may not be aware that they do not understand what is being communicated to them Audiotapes of patient consultations can help patient recall of verbal education Do not just ask the patient, “Do you understand?” Many patients answer “yes” even when they don’t understand Assessment of learning Remember: EDUCATE to help patients become informed and engaged participants in their care!4 Oncology Nursing