A single-center program for enhancing patient-provider relationships was able to improve staff member’s understanding of adult education, and in turn, positively effect patient satisfaction scores over time, according to data presented in a poster at the Oncology Nursing Society’s 46th Annual Congress.

This program, developed for the Trinitas Comprehensive Cancer Center in Elizabeth, New Jersey, set out to educate nurses, medical assistants, receptionists, and secretarial staff about patient interactions and to assess their needs. The program will continue to be evaluated through attendance to the program and pre- and post-test intervention assessment; program effectiveness valuation will be conducted by patient-satisfaction surveys.

“In our post program [assessment], our staff showed a better understanding of what adult education is all about and how adults view and learn new knowledge,” Aida Brito, MSN, RN, OCN, lead study author, said in her presentation of the data.

The investigators set out to improve the patients experience based on existing data that indicate health care quality and patient satisfaction go hand in hand. The Ask Me 3 tool and the Oral Exchange Rating Tool, Part 3 were used to educate staff about patient interactions. Pre-program learning-needs assessments and tests were used to determine individual perceptions of the role they play in a patient-provider interaction. All staff then attended the program, and a post-test was given to assess understanding of the content.

Staff members included registered nurses, medical assistants, concierges, patient guides, and medical secretaries. A needs assessment showed that clinicians were interested in learning more about quality of life and critical lab values, symptom management and assessment, and ethical issues.

Themes emerging from the Ask Me 3 pre- and post-tests were education, listening, questioning, understanding, and advocacy. The oral exchange rating summary average scores improved from the pre-program assessment at 29 to 58.4 post-program. Brito pointed out that fewer participants were assessed in the post-program (22 vs 16) due to resignations and medical leave.

Patient satisfaction scores improved from the second quarter (Q2) of 2020 through the first quarter (Q1) of 2021 in areas of emotional support and respect for patient preferences. When asked the question: “How often did you have confidence and trust in the cancer treatment staff treating you?” patient satisfaction scores improved from 76.8% in Q2 2020 to 92.6% in Q1 2021. To the question: “How often did the cancer treatment staff treat you with courtesy and respect” scores improved from 89.3% in Q2 2020 to 93.5% in Q4 2020 but were at 89.3% again in Q1 2021. Scores to: “How often did you have enough input or say in your care at this facility?” scores went from 60.4% in Q2 2020 to 74.1% in Q1 2021.

“Once our patient-provider trusting relationship improves this will in turn enhance health care quality thus improving patient experience and satisfaction,” Brito said. “It is our hope that through proper staff education and the use of the Ask Me 3 communication tool, our cancer patient population will feel confident and supported throughout their cancer experience.”

Brito A, Fryar J, Blecher C. Cultivating a patient-provider relationship of trust while enhancing/improving patient experience and satisfaction. Presented at: Oncology Nursing Society 46th Annual Congress. April 20, 22, 27 & 29, 2021. Virtual.

Articles

A poster presentation from the Oncology Nursing Society’s 46th Annual Congress describes a single-center clinician education program aimed at improving patient satisfaction.

Cancer Center Seeks to Improve Patient Experience, Satisfaction Through Communication Education With Staff

As the impact of the coronavirus disease 2019 (COVID-19) pandemic lingers into the later part of 2020, consideration is needed regarding the lasting effects on patients with cancer who may have experienced delayed care or diagnosis.

Investigators conducted a survey involving health care representatives from the international oncology community to assess the preliminary effects of the pandemic and highlight major concerns regarding patient care. The results of the survey will be covered in detail during the European Society for Medical Oncology (ESMO) 2020 Virtual Congress.

“Our survey confirms that COVID-19 has a major impact on organization of patient care and on the well-being of caregivers,” Guy Jerusalem, MD, PhD, head of the Breast Unit at Centre Hospitalier Universitaire du Sart-Tilman, Liège, Belgium, said during a presentation at the ESMO 2020 Opening Press Conference. “Clinical trial activity [is also affected], as well as continued medical education.”

Although rapid normalization of professional activities of health care workers was hoped for after the COVID-19 lockdown, it is now clear that there will be long-term impacts of the pandemic. Understanding how these resulting effects influence patients with cancer going forward will be crucial in the coming years.

“When you look into the future, the expected problem is the risk of delayed diagnoses of new cancer,” Jerusalem said. “In our hospitals, we see fewer new patients diagnosed, and the risk is that later we will see more patients with advanced-stage [disease] diagnosed with cancer. The economic consequences of COVID-19, which can affect access to health care and cancer treatments, has to be carefully evaluated.”

To assess the impacts of the pandemic on health care workers, a survey of 109 representatives from 18 countries—including Italy, France, Spain, the United States, Mexico, Brazil, and Argentina&mdash;were compiled. The majority of respondents were men (61.5%) who had a median age of 48.5 years. Most of the respondents worked in an academic (62.4%) or community hospital (29.6%), with a median number of years of worked in the oncology field of 20 (interquartile range, 10.5-25). Those specializing in breast cancer represented the majority of respondents at 60.6%, followed by gastrointestinal cancer (10.1%), urogenital cancer (9.2%), and lung cancer (8.3%). Other specialties were included in the survey but represented a low percentage of respondents.

Thirty-four percent of respondents reported that surgery was the treatment modality that was most affected by the pandemic, followed by chemotherapy (22.0%), radiotherapy (13.7%), checkpoint inhibitor therapy (9.1%), monoclonal antibodies (9.0%), and oral targeted therapy (3.7%).

Treatment adaptations were also noted by those from participating centers, including an increased use of both granulocyte colony—stimulating factor in 34.8% and erythropoietin in 6.4%. Therapy modifications that resulted in a reduction of treatment included decreased use of double immunotherapy in 11.1% of centers and a decrease in corticosteroid use in 21.9%.

Regarding a decrease in the use of corticosteroids, Jerusalem stated that there could be several potential reasons for this observation. “One can be that this is an immunosuppressive agent.

Maybe the risk of infection is increased [with its use],” he posited. “In my center, we had considered [decreasing] the dose of steroids during this time. The question was, ‘Do we increase the risk of infection…if we increase the use of steroids?” He noted that this strategy wasn’t based on any data, but rather a rationale that some centers employed based on what is known of steroid use.

ESMO President Solange Peters, MD, PhD, of University of Lausanne in Switzerland, also commented on this finding, stating that prior steroid use, or being on steroids at the time of COVID-19 infection, has now been associated with worse prognosis and increased mortality, based on findings from the TERVAOLT registry.2 She also stated that steroid use at infection baseline differs significantly from administration of these agents to help fight the virus.

Concerning the care of patients with breast cancer specifically, administration of everolimus (Afinitor) was affected in 18% of centers followed by CDK4/6 inhibitors in 8.9%. Only 2.2% of centers reported that endocrine therapy administration was affected.

Notably, Jerusalem stated that early cessation of anticancer palliative care was observed in nearly one-third of participating centers (32.1%), while nearly two-thirds of participants (64.2%) agreed that the risk of undertreatment, such as early lines of treatment in the metastatic setting, is a major concern.

Telemedicine, or teleconsultations as they were referred to in the presentation, were reportedly performed for 94.5% of follow-up visits and for visits related to oral therapy (92.7%), immunotherapy (57.8%), and chemotherapy (55%). In addition, approximately 82% of participants projected that they would continue with the use of telemedicine more frequently in their practices after the pandemic.

According to the survey results, the effects of the pandemic transcend direct patient care and extended to other areas of life for treating clinicians. Most participants (94%) reported more frequent use of virtual platforms for continued medical education, oncological team meetings (92%), and multidisciplinary tumor boards (82%).

Despite some advantages of holding medical meetings in the virtual format, 45% of those surveyed said that they disagreed with the premise that virtual meetings could serve as an acceptable alternative to live international meetings, such as the ESMO Congress or the American Society of Clinical Oncology Annual Meeting.

Regarding meeting attendance, Peters felt that being pushed to a virtual format for major medical meetings has definite advantages and predicts that organizations will hold on to the positive aspects that resulted from this change. “For every meeting that we had to transform to a virtual format, we first saw a huge increase in the number of attendees and an increase in the geographical span, or the reach, of each conference,” she said. “What you realize is that one of the missions of ESMO, which is being able to convey education globally, was better achieved in the virtual format.”

Peters concluded by stating, “We have to think about how we can communicate…these data and education and fulfill needs in a better way. In the future, we have to do more virtual [meetings].”

1. Jerusalem G. Expected medium and long term impact of the COVID-19 outbreak in oncology. Presented at: European Society for Medical Oncology 2020 Opening Press Conference. September 10, 2020. Virtual. Abstract LBA76_PR.

2. Garassino MC, Whisenant JG, Huang LC, et al. COVID-19 in patients with thoracic malignancies (TERAVOLT): first results of an international, registry-based, cohort study. Lancet Oncol. 2020;21(7):914-922. doi:10.1016/S1470-2045(20)30314-4

This article was originally published on OncLive as, "

Experts Consider Long-Term Impact of COVID-19 Pandemic on Oncology Care

COVID-19 Leaves Its Mark on Cancer Care

In patients with bladder cancer treated with cystectomy, neoadjuvant chemotherapy with a dose-dense, or accelerated, course of methotrexate, vinblastine, doxorubicin, and cisplatin (ddMVAC) was more likely to produce a complete pathologic response (pCR) and extend overall survival (OS) than any other chemotherapy regimen, according to 

Despite published reports on the efficacy of MVAC, gemcitabine plus cisplatin has become the standard neoadjuvant chemotherapy regimen for patients with muscle-invasive 

 preceding surgical resection. This is owing, in part, to its favorable toxicity profile and published clinical trial results showing comparable results between the 2 regimens in patients with metastatic disease.

Regular administration of MVAC has been shown to have a serious toxicity profile with more than 50% of patients experiencing myelosuppression and mucositis in some published reports. However, using a dose-dense administration period is well tolerated, considered safe, and has response rates similar to gemcitabine plus cisplatin.

The investigators, led by Charles C. Peyton, MD, a urologic oncology fellow at Moffitt Cancer Center, performed a retrospective analysis of 1113 patients who underwent cystectomy for bladder cancer at the Moffitt Cancer Center in Tampa, Florida to compare neoadjuvant chemotherapy regimens. Patients undergoing cystectomy who did not receive any type of chemotherapy were included as controls.

Primary outcome measures included pathologic downstaging of disease, defined as either any decrease in disease stage or pCR, and OS, defined as date of cystectomy to date of last follow up or death from any cause. Clinical staging was determined mostly by pathologic findings on resection of the bladder tumor and was supplemented with radiographic images. Time to cystectomy was examined as a secondary outcome across chemotherapy subgroups.

Out of a total of 824 patients with advanced or invasive disease (defined as clinical stage ≥T2N0M0), 332 patients were treated with neoadjuvant chemotherapy, 329 received no chemotherapy, and 163 received induction or adjuvant chemotherapy. In the neoadjuvant chemotherapy group, 204 (61.4%) received gemcitabine plus cisplatin, 46 (14%) received ddMVAC, 32 (10%) received gemcitabine plus carboplatin, and 50 (15.1%) received other agents including etoposide, fluorouracil, and paclitaxel regimens. Standard MVAC was included in the other neoadjuvant chemotherapy regimens group and accounted for 3 patients. A 6- to 8-week administration period was used to distinguish dose-dense from standard MVAC regimens.

Patient characteristics based on chemotherapy regimen were similar between groups. The number of cycles of chemotherapy received were similar across regimens with 146 patients (73.7%) receiving gemcitabine plus cisplatin and 42 (91.3%) receiving ddMVAC having 3 or more cycles of chemotherapy. Clinical-stage distributions were similar between the two groups. Median follow-up times for each group were 15 months (95% CI, 12.6-21.0) for gemcitabine plus cisplatin, 12 months (95% CI, 8.2-19.4) for gemcitabine plus carboplatin, 11 months (95% CI, 6.3-18.0) for ddMVAC, and 15.8 months (95% CI, 12.2-23.6) for patients receiving all other regimens.

Downstaging was observed in 52.2% of patients receiving ddMVAC, 41.3% of patients receiving gemcitabine plus cisplatin, and 27% of patients taking carboplatin plus gemcitabine. The rates of pCR were 41.3%, 24.5%, and 9.4% of patients in each group, respectively. Notably, the rate of pCR for patients without neoadjuvant chemotherapy was 10.7% which is similar to the rate observed in patients receiving neoadjuvant carboplatin plus gemcitabine.

Median OS was higher for patients in the ddMVAC group compared with those treated with other regimens. The 2-year Kaplan-Meier survival probability estimates were 73.3% for ddMVAC (95% CI, 48%-89.1%), 62% for gemcitabine plus cisplatin (95% CI, 53.4%-69.9%), and 34.8% for gemcitabine plus carboplatin (95% CI, 18.8%-55.1%; 

Achieving pCR was also a significant predictor of OS regardless of the chemotherapy agent(s) used. Seventy-eight patients (92.8%) who achieved pCR were still alive 2 years following surgery and these results were consistent across neoadjuvant chemotherapy subgroups. All patients receiving both ddMVAC (n = 19) and gemcitabine plus carboplatin (n = 3) who had achieved pCR were still alive at 2 years. Forty-six patients (92%) receiving gemcitabine plus cisplatin and 10 patients (83.3%) on other chemotherapy regimens who had initially achieved pCR were also alive at 2 years.

Median treatment time for patients taking ddMVAC was 35 days (range 28-46). The average time from the start of neoadjuvant chemotherapy to cystectomy in patients taking ddMVAC was 95 days; for patients taking gemcitabine plus cisplatin the average was 119 days versus 134 days for gemcitabine plus carboplatin (

The most common grade 1/2 adverse event (AE) reported was fatigue in 26 patients taking ddMVAC. There were no grade 4 AEs reported and the toxicity profile reported in this study was consistent with those previously published for ddMVAC.

Trial investigators said adjustments to administering MVAC “have led to better tolerability, and as a result, 3 cycles of neoadjuvant MVAC can be safely and effectively delivered over a 6-week period.”

Peyton CC, Tang D, Reich RR, et al. Downstaging and survival outcomes associated with neoadjuvant chemotherapy regimens among patients treated with cystectomy for muscle-invasive bladder cancer. 

. 2018;4(11):1535-1542. doi: 10.1001/jamaoncol.2018.3542.

This article was originally published on 

Neoadjuvant Dose-Dense MVAC Demonstrates Superior Survival Outcomes in Bladder Cancer

Neoadjuvant chemotherapy with dose-dense MVAC extends overall survival compared with other chemo regimens in bladder cancer treated with cystectomy.

Accelerated Chemo Regimen Extends OS in Neoadjuvant Bladder Cancer Treatment

The addition of tumor treating fields (TTF), an antimitotic therapy that delivers continuous low-intensity electrical fields to the tumor region, to weekly paclitaxel (Taxol) appeared safe in the treatment of patients with platinum-resistant ovarian cancer, according to findings published in 

With a primary endpoint of safety, the INNOVATE (NCT02244502), phase II single-arm trial found no serious adverse events (AEs) from TTF, and investigators said the combination with weekly paclitaxel was well tolerated, with encouraging response and survival data.

Based on these results, investigators will move forward with INNOVATE-3, a prospective open-label study that will randomize 540 patients with recurrent, platinum-resistant ovarian cancer to weekly paclitaxel alone or weekly paclitaxel in combination with TTF tuned to 200 kHz until progression.

Trial eligibility in INNOVATE was based on histologically-confirmed recurrent epithelial ovarian, fallopian tube, or primary peritoneal carcinoma. A total of 31 patients were enrolled, median age of 60 years, and 77% (n = 24) had serous histology and stage III disease. All patients had been previously treated with platinum-based chemotherapy, and a majority had also been treated with taxanes (97%), as well as pegylated liposomal doxorubicin (PLD) (58%).

TTF was delivered at 200 kHz in conjunction with paclitaxel administered weekly for 8 weeks and then on days 1, 8, 16 of each subsequent 28 day-cycle, with a starting dose of 80 mg/m

Dermatologic AEs, anticipated from use of TTF, were reported in 28 (90%) patients. Two patients reported grade 3 dermatitis and 1 of those discontinued treatment as a result. Patients experiencing grade 3-4 AEs on the combination therapy numbered 17 or 55%. The most common grade 3-4 AEs were blood and lymphatic system disorders (9), anemia (4), and neutropenia (3).

Median 1-year survival was 61% (95% CI, 37-78). Clinical benefit was reported in 20 (71%) of patients, with 7 partial responses and 13 patients with stable disease. Median progression-free survival (PFS) was 8.9 months (95% CI, 4.3-not reached), which investigators said compared favorably with results of prior studies in similar patient populations. In a meta-analysis of phase III trials that involved 1640 patients with recurrent ovarian cancer after primary taxane/platinum therapy, investigators found that the median PFS of patients at their fourth relapse was 4.4 months and median overall survival was 6.2 months.

“The results of these previous studies, though not directly comparable to the phase II, single arm INNOVATE trial, strengthen the rationale for further evaluating the role of TTFields in the management of platinum resistant ovarian cancer,” investigators wrote.

Ovarian cancer, the second most common gynecologic malignancy, has a poor prognosis. Although most patients achieve a complete remission, 80% to 85% of patients will experience recurrence. Most will develop resistance to platinum therapy.

“A clear unmet need remains for patients with recurrent ovarian cancer, particularly for those patients resistant to platinum-based chemotherapy, with median overall survival of about 13 months post recurrence,” said lead author Ignace Vergote, chair of the Department of Obstetrics and Gynecology and Gynecologic Oncology at the Catholic University of Leuven, Belgium.

 “These phase II pilot data show that tumor treating fields combined with paclitaxel has the potential to increase survival without significantly increasing side effects for recurrent ovarian cancer patients.”

TTF has been tested in a variety of tumor types. The National Comprehensive Cancer Network (NCCN) became the first guideline-setting body to endorse the routine frontline use of TTF when it updated its glioblastoma treatment guidelines in March. That followed a 2011 FDA approval of the Optune TTF system for patients with glioblastoma following tumor recurrence. The system now carries an NCCN category 1 recommendation in combination with radiotherapy and temozolomide for patients with glioblastoma who have undergone surgery.

TTF is self-administered and non-invasive. Transducer arrays are connected to a small, portable medical device, then affixed to the abdomen. In the INNOVATE trial, patients were instructed to wear the device 18 hours per day for continuous delivery throughout the treatment period. Investigators noted median compliance at 3 months of 77% (14 h/day on average).

Patients with recurrent ovarian cancer who progress on paclitaxel following platinum-resistant disease are often treated with PLD, which has response rates below 20%. Gemcitabine and topotecan, 2 alternative treatments, have similarly low response rates, and there is limited data on the efficacy of additional treatments.

The design for INNOVATE-3, NovoCure’s phase III trial of its TTF technology in recurrent ovarian cancer, was disclosed in June at the American Society of Clinical Oncology (ASCO) Annual Meeting 2018.

Vergote I, von Moos R, Manso L, Van Nieuwenhuysen E, Concin N, Sesse C. Tumor treating fields in combination with paclitaxel in recurrent ovarian carcinoma: results of the INNOVATE pilot study [published online July 31, 2018]. 

Novocure to Present INNOVATE-3 Phase 3 Pivotal Trial Design in Recurrent Ovarian Cancer at the American Society of Clinical Oncology Annual Meeting 2018 [press release]. St. Helier, Jersey: NovoCure; June 4, 2018. novocure.com/novocure-to-present-innovate-3-phase-3-pivotal-trial-design-in-recurrent-ovarian-cancer-at-the-american-society-of-clinical-oncology-annual-meeting-2018/. Accessed August 1, 2018.

Gynecologic Oncology Publishes Results of the INNOVATE Phase 2 Pilot Study Demonstrating Combination of Tumor Treating Fields With Paclitaxel May Improve Survival Of Patients With Recurrent Ovarian Cancer [press release]. St. Helier, Jersey: NovoCure; July 31, 2018. novocure.com/gynecologic-oncology-publishes-results-of-the-innovate-phase-2-pilot-study-demonstrating-combination-of-tumor-treating-fields-with-paclitaxel-may-improve-survival-of-patients-with-recurrent-ovarian-ca/. Accessed August 1, 2018.

A version of this article was originally published by 

Tumor Treating Fields Show Promise in Ovarian Cancer

The addition of tumor treating fields (TTF), an antimitotic therapy that delivers continuous low-intensity electrical fields to the tumor region, to weekly paclitaxel (Taxol) appeared safe in the treatment of patients with platinum-resistant ovarian cancer.

Tumor Treating Fields May Address Unmet Need in Ovarian Cancer Treatment

As abemaciclib (Verzenio) has emerged as a promising agent for patients with hormone receptor (HR)-positive, HER2-negative metastatic breast cancer, the oncology nurse is now a key factor for these patients, according to Paula Fulgham, RN, OCN.

“If they leave with (an oral) medication, they don’t know how to take the drug, the side effects and what to expect, and they’re going to be at home (without medical advisement. It’s not like they are coming in every 3 weeks for chemo and we can coach them and guide them as they go along,” said Fulgham, who is chief nursing officer at the Cancer Center of Kansas in Wichita.

“These patients are now going to be in the driver’s seat,” she added. “Understanding how these drugs work and the side effects profile, and what to educate the patients with early on is so important.”

Annual School of Nursing Oncology, held Aug. 3-4 in Chicago, Fulgham offered an overview of abemaciclib regimens, and their associated adverse events (AEs) to review practical considerations for nurses to use.

In the randomized, double-blind phase III MONARCH 2 trial, women who recurred or progressed on or after endocrine therapy received abemaciclib plus fulvestrant (Faslodex). Overall, 86% of patients experienced diarrhea with a median onset occurring 6 days after treatment started.

With this, Fulgham recommended for patients to have an over-the-counter antidiarrheal medication on hand before symptoms begin, and to know who and when to call when symptoms get out of control to ensure treatment continuation. She noted that it is up to the oncology nurse to understand the physiology of these patients and the AE profile of the drug to help determine whether a dose modification is necessary to resolve symptoms.

Additional AEs that occurred in the MONARCH 2 trial were nausea (45%), abdominal pain (35%), vomiting (26%), and stomatitis (15%). Additionally, fatigue (46%), peripheral edema (12%), and pyrexia (11%) of all grades were experienced. 

Nine percent of patients had to discontinue treatment due to an AE compared with 3% of patients who were treated with fulvestrant alone. Of these, 43% of patients required a dose reduction due to an AE. 

All-grade neutropenia occurred in 46% of patients, with death occurring in < 1% of patients due to neutropenia sepsis. Febrile neutropenia occurred in < 1% of patients. Fulgham noted that for patients who develop grade 3/4 AEs, dosage may be reduced, interrupted, or delayed.

Fulgham recommended for oncology nurses to provide patients with appropriate instructions that can be easily referenced at home. A sheet that goes through the basics, such as avoiding foods that interfere with the CYP3 pathway, would be more helpful to patients than a lengthy package insert.

Lastly, she stressed the importance of establishing an action plan that includes specific dosage times with patients before they start taking abemaciclib.

“Looking at the patient overall you want to know where their baseline is and how to monitor these patients as they go through the treatment,” Fulgham said. “We’ve had a great increase in our phone calls because nurses now see patients who are not coming in for chemotherapy regularly. Usually patients would discuss side effects at their follow-up appointments. These patients start these oral oncolytic they do have questions and monitoring. It’s important for nurses to understand when they discuss with the patients.”

Fulgham P. A CDK4&6 inhibitor for women with HR+, HER2-, MBC: Including those with concerning clinical characteristics. Presented at: the 2nd

Annual School of Nursing Oncology; Aug. 3-4, 2018; Chicago.

Managing Adverse Events in Patients Taking Abemaciclib

The favored use of immune checkpoint inhibitors in oncology has led to an increase in immune-related adverse events (IRAEs), which if not managed properly, can be life-threatening. However, this can be addressed if nurses use the 5 pillars of managing IRAEs: prevent, anticipate, detect, treat, and monitor.

At the 2nd Annual School of Nursing Oncology™, held from Aug. 3-4 in Chicago, Marianne Davies DNP, RN, CNS, ACNP-BC, AOCNP, an assistant professor and oncology nurse practitioner at the Yale Comprehensive Cancer Center, presented an overview of IRAEs nurses should look out for, and how to respond to them when they are identified.

“This has been an incredibly active field over the past several years in terms of the approval of several immune checkpoint inhibitors,” said Davies. “What’s import to understand is that the approvals are slightly different across the disease entities. Some of the dosages require modification, [therefore] you really need to understand the dosing schedule and that it might be different for different lines of therapy. Some of these agents are approved in the first-, second- and third-line setting. It’s not just a one-size-fits-all administration.”

IRAEs can include dermatologic, gastrointestinal (GI), pulmonary, and endocrine toxicities, which are unique to immunotherapy agents since adverse events (AEs) in this organ system were not previously seen in targeted therapies or chemotherapy, Davies said.

Treatment of IRAEs depends on the organ system and severity of onset, but usually involves steroids and other immunosuppressant drugs for grade 1 toxicities, treatment dose delays for grade 2 toxicities, or discontinuation of the immunotherapy agent itself for grade 3-4 (Table 1).

Davies says the most common adverse events are dermatologic toxicities. Patients can present with maculopapular rash or an increased manifestation of their eczema or psoriasis.

Jane Arboleda, ARNP from the Miami Cancer Institute in Florida, who presented at the conference on pembrolizumab (Keytruda) and its role in the treatment of metastatic non-small cell lung cancer, said connecting the patient to a dermatologist who has knowledge of immunotherapy-related dermatologic toxicities before beginning therapy may be valuable for patients who are most susceptible to dermatologic AEs. She says trying to procure an initial appointment after symptoms begin could mean weeks of discomfort and dose delay as a result of long wait times. It is essential that the oncology nurse involve the oncologist and patients in treating symptoms to bridge the gap between onset of toxicity and treatment by the specialist.

“It’s important to collaborate with your dermatologist, whether it’s someone within your community or your institution. Where I’m from in Miami, it can take up to 6-8 weeks to see a dermatologist. If you have something very serious, or life-threatening, that’s something the patient cannot afford,” Arboleda stressed.

When discussing pulmonary toxicities, Arboleda further emphasized the potential for pembrolizumab to result in severe cases of pneumonitis. An analysis of 2790 patients selected across numerous KEYNOTE trials, 6.9% of patients taking the anti&shy;&shy;&shy;—PD-1 agent experienced pneumonitis as opposed to 2.9% in the control arms.

“It’s important to note that pneumonitis occurs frequently in patients with history of thoracic radiation,” said Arboleda.

Davies recommends ruling out other causes of pulmonary distress such as disease progression or infection. In all cases of pneumonitis, an infectious workup is recommended to determine if the cause is immune-related and warrants treatment discontinuation.

The onset of gastrointestinal IRAEs can occur anywhere from 3 days to 10 weeks after treatment initiation. Appropriate nursing counseling, including foods to avoid, is important for patients beginning immunotherapy. Colitis and diarrhea are more commonly seen in patients on anti-CTLA4 agents and combination therapies. Risks associated with GI toxicities are bowel perforation and sepsis.

“Patients might have altered bowel patterns if they’re on opioids for pain management [and] they may have significant constipation. If their bowel pattern was such that they were going every two to three days, or maybe even longer, and now they’re going twice per day, that may be a significant toxicity,” said Davies. A baseline assessment is crucial in assessing future bowel dysfunction.

Management of endocrine toxicities is a new consideration for oncology nurses who may not be accustomed to managing AEs related to this organ system with chemotherapy or targeted therapies, Davies noted. Unlike other IRAEs, most events up to grade 4 can be managed with endocrine therapy to avoid dose delay or discontinuation.

Treatment with steroids and immunosuppressant drugs should be managed to mitigate the risk of refractory IRAEs and other medication side effects. Long-term exposure to steroids may require a proton pump inhibitor or beta blocker depending on pre-existing conditions and dose tapering over at least a 30-day period to prevent recurrence. Patients being treated for months at a time will be at risk for osteoporosis and should be treated with Vitamin D and calcium.

IRAEs can occur between 5-12 weeks after treatment has started; however, they can occur months, or even years, after treatment discontinuation. Davies noted that anti-CTLA-4 agents are the most likely to cause toxicities because they initiate activity “upstream” in the immune process. This risk is increased with combination therapies, especially with anti-PD-L1 and anti-PD-1 agents.

The role of the oncology nurse in managing IRAEs starts with a baseline assessment before immunotherapy treatment has started. Having an extensive understanding of the immune system and the likelihood of developing toxicities can be achieved by laboratory evaluations, medication reconciliation, and knowledge about preexisting autoimmune diseases, Davies explained. 

Current research focus is centered on predictive markers in patients that will anticipate IRAEs and their sequencing before immunotherapy is initiated. Davies recommends oncology nurses acquaint themselves with National Comprehensive Cancer Network (NCCN) 

 on IRAEs, as well as resources from the Society for Immunotherapy of Cancer (SITC) and the American Society of Clinical Oncology (ASCO).

Common Immune-Related Adverse Events by Organ System

Grade 1: Continue immunotherapy; treat with topical steroids and antihistamines

Grade 2: Consider holding immunotherapy; treat with high-potency topical steroid or prednisone

Grade 3-4: Hold immunotherapy; urgent dermatology consult

Grade 1: Consider holding immunotherapy; hydration; close monitoring

Grade 2: Hold immunotherapy; IV methylprednisone, consider infliximab if no response

Grade 3: Discontinue anti-CTLA-4, consider resume anti-PD1/anti-PD-L1 after resolution

Grade 4: Permanently discontinue immunotherapy; consider inpatient care   

Grade 1: Hold immunotherapy; reassess after 1-2 weeks; repeat chest imaging after 3-4 weeks if indicated

Grade 2: Assess for infection; monitor every 3-7 days; advance to grade 3 if no improvement in 48-72 hours; methylprednisone

Grade 3-4: Permanently discontinue immunotherapy; inpatient treatment; infectious workup

Continue immunotherapy at all levels ≤ grade 4; consider hormone replacement/supplementation

Suppressed thyroid will need to be treated with levothyroxine indefinitely

The favored use of immune checkpoint inhibitors in oncology has led to an increase in immune-related adverse events (IRAEs), which if not managed properly, can be life-threatening. 