Lung cancer treatments are advancing. With these changes come new complications and questions that nurses will have to address with their patients.
At the 14th Annual PER® New York Lung Cancers Symposium, Beth Eaby-Sandy, MSN, CRNP, OCN®, addressed how nurses can provide education and support to patients with lung cancer undergoing immunotherapy, in a presentation on immunotherapy-related adverse events (irAEs) at the CURE® patient-focused sessions held in tandem with the conference.
In a follow-up interview with Oncology Nursing News®, Eaby-Sandy, a nurse practitioner at the Abramson Cancer Center at the University of Pennsylvania in Philadelphia, discussed some of the realities of irAEs that nurses should explain to patients and where they can guide patients for education resources. Eaby-Sandy also had the chance to highlight some of the most important updates in lung cancer treatment that nurses need to be aware of for the foreseeable future.
Oncology Nursing News®: What are the main adverse effects that patients with lung cancer should look out for as they undergo immunotherapy?
Eaby-Sandy: Most patients that are on immunotherapy for their lung cancer don't experience any side effects at all from the immunotherapy. Probably the most common thing that's reported is fatigue, but you never know if it's actually from the immunotherapy or the cancer. And then maybe some arthralgia like some joint aches and pains sometimes but even that is in less than 50% of patients.
The adverse effects are usually things like pneumonitis and colitis, and they're pretty uncommon, but they can be serious, and that's why we pay more attention to them.
Ultimately, the majority of patients tolerate immunotherapy very well, so it's not anything to be afraid of. There is a subset of patients that can develop toxicities that are usually treatable, but we just need to know about them before they become severe.
Are there ways for nurses to help patients manage these irAEs outside of the clinic?
That depends on the toxicity. If it's things like joint aches, if you're able, you can take ibuprofen or Tylenol, things like that. But if it's one of the inflammatory conditions such as pneumonitis, colitis, hepatitis, arthritis, endocrinopathies, they cannot be managed at home because they can get severe very quickly. So, patients need to come in for evaluation. Most side effects of immunotherapy are not something that patients can easily manage at home.
The adverse effects don't happen immediately after you infuse the drug, it's just something that can happen at any time on treatment. The biggest thing is that nurses need to educate patients on what can happen because while they're uncommon, these irAEs happen in about maybe 10 to 15% of patients. So we need to be aware of what to look out for, especially with pneumonitis and colitis which can become severe and even life-threatening if they're not caught soon enough.
How can nurses help patients with immunotherapy education?
You can go to different websites, go to the drug manufacturer website, or you can go to Oncolink is the one that I usually refer to as a trusted website. And it's derived from where I work at the University of Penn. I think the hard thing with immunotherapies is that I can name a few things like hepatitis, pneumonitis, and colitis, but the problem is that really any organ system at all can become inflamed and cause symptoms.
Patients should call us right away if they develop shortness of breath, diarrhea, or nausea and vomiting, but then I go on to say, truthfully, if you develop anything that's wrong with you, you should call us right away because it could be something. This is one of the uncommon toxicities but can become serious very quickly. So, it's important to call us and explain what you're experiencing and then let us determine if it's serious and needs to be evaluated right away.
What is the outlook on the future of immunotherapy?
Right now, the only immunotherapies that are approved in lung cancer are the PD-L1 checkpoint inhibitors but combining them with other immunotherapy pathways such as vaccines, or several other different checkpoints outside of the PD/PD-L1 checkpoint is pretty much where most of the clinical trial research is in lung cancer. And while new toxicities come with it, if it works better there are always ways to manage toxicities.
What is the most exciting update in lung cancer nurses need to know about?
By far the most exciting data that's come out in the past year is the five-year survival from the keynote001 trail. It was pembrolizumab for patients with a high PD-L1 expression and I believe 30% of patients showed a 5-year survival rate. That’s incredible and that’s with metastatic disease.
For patients with metastatic lung cancer, we would have never even entertained the thought that they would live five years. Before immunotherapies, those rates were 2 to 3%. Now patients who have high PDL expression that receive pembrolizumab, 30% of them can live to 5 years. That's a real number. That's a real possibility now. That really changes how we talk to patients.
Before patients would say, "Oh, I really want to be alive in five years to see my son get married, or somebody graduate from high school." You know, a lot of times before we would say "I really hope but that's really unlikely." But now, it's not unlikely. I mean, I wouldn't say "Oh, that would give you a 30% chance," but I would probably not redirect the conversation the way I would have in the past, because now that's not a completely unheard-of goal. The difference between 2 to 3% and 30% is huge.