Immunotherapy is one of the hottest concepts in oncology care. Also called biologic therapy, this type of cancer treatment boosts the body’s own natural defenses to fight cancers. Ann M. McGreal, RN, OCN, Oncology Nurse Clinician, and Sigrun Hallmeyer, MD, Senior Executive Director, Advocate Medical Group, Park Ridge, IL, shared their experience with immunotherapy at the Association of Community Cancer Centers National Oncology Conference in October 2017 in Nashville, TN.
Their group has been administering immunotherapy since the first immuno-oncology drugs were approved for melanoma. Over the past 6 years, new FDA approvals for immuno-oncology cancer drugs have expanded to many cancer types. With more than 1000 active clinical trials, immunotherapy research is the fastest growing area in cancer drug development, according to Dr Hallmeyer.
Dr Hallmeyer and her group found this growing activity in immunotherapy to be a challenge given the rising patient awareness and demand for these new therapies. The role that immunotherapy played in the treatment of former President Jimmy Carter’s brain cancer in July 2017 moved the public’s awareness of immunotherapy into the mainstream press. The Advocate Medical Group wanted to develop a formal immunotherapy program, but the complexity of the topic presented challenges.
Immunotherapy Side Effects Require New Thinking
The team realized that their nursing and patient education were based on chemotherapy and biologic therapy, and immunotherapy was quite different. Even the focus of their pretreatment evaluation had to change. The evaluation of known symptoms and treatment side effects would have different origins, according to Dr Hallmeyer.
For example, fatigue, which is usually related to anemia, could be related to adrenal insufficiency. Diarrhea, which is a common side effect of chemotherapy and can be treated with conventional interventions, could now possibly be related to colitis, which would be treated with corticosteroids. Immune-mediated adverse events can start and stop at any time and are thus far more unpredictable to manage than chemotherapy-related side effects.
Health status is no longer measured just by a complete blood count; it is now likely to involve carbohydrate mimetic peptides, thyroid-stimulating hormone with free T4, adrenocorticotropic hormone, and cortisol levels assessments.
The Immunotherapy Program
A multidisciplinary team developed policy, education tools, electronic medical record (EMR) tools, and evaluation processes for patients who receive immunotherapy, including:
- Immunotherapy drug information sheet
- Any pertinent information for the drug company(ies)
- Disease-specific booklets
- Psychosocial distress tool
- Psychosocial resources
Patient forms specific to checkpoint inhibitors included the following questions and information:
- When should I call?
- What is immunotherapy?
- Oral steroids information sheet
- Nursing immune-mediated adverse reaction checklist
- Wallet ID card (drug-specific)
They developed new documentation requirements for immunotherapy teaching records, nursing notes, and discharge instruction sheets. With the introduction of checkpoint inhibitors, a new set of immune-mediated adverse events was similarly introduced. Patients receiving combination checkpoint immunotherapies will therefore be evaluated weekly for signs of immune-mediated toxicities, and a weekly EMR evaluation form will be completed.
In addition to patient education, the oncology team developed peer-to-peer education of the medical staff. The topics addressed include:
- “Immune Response to Cancer and the Complex Balance between Continuous Activation and Suppression”
- “Immuno-Oncology: Immune System Inhibitory Pathways”
- “Immuno-Oncology: Immune System Activating Pathways”
A new “pharmacy immunotherapy” flow sheet of FDA-approved drugs and their indications, by drug and by disease—with vial size and dosages—is keeping track of the rapid changes in the market.
An “Evaluation Tool for Immune Oncology–Nursing” is used to track nurse training and understanding of the immuno-oncology process, policies, treatments, and procedures. These tools have already led to useful nurse feedback that has changed checklists and documentation processes.
Patient evaluation tools provide information on how nurses use the available resources to help teach and monitor patients. Physician evaluation tools review the volume of immuno-oncology activity, and how treatment and documentation are working.
Using Illustrations for Patient Education
“Turning on the Light Switch” is an illustration the team uses for its patient education materials. A simple graphic of a light switch was the foundation for the description. The drawing of the light switch turned on demonstrates “activating the immune system: immune therapy medications turn the switch on.” The drawing of a light switch turned off describes the adverse events; “however, it also stops your body’s natural ability to turn the switch off.” A following graphic says: “Eventually without some intervention, the light will burn out. (Can cause damage to your normal healthy tissue.)”
The patient handout goes on to describe possible side effects of keeping the light switch on, encouraging patients to communicate with their nurse and physician when any side effects occur. In this patient education tool, which was adapted from an educational patient resource supplied by Bristol-Myers Squibb, the team presents a diagram of the human body, with pictures of possible organs that may be affected and a list of possible symptoms from each organ.
One of the last patient materials the team distributes, in addition to its “Patient Home Discharge Instructions,” is a detailed “When Should I Call?” for immunotherapy, listing the reasons why, if these events occur, the patient must call the clinic. These materials are distributed in concert with existing wallet cards about individual drugs that are provided by various pharmaceutical companies.
The patient information is gathered through tools adapted from patient education materials from Bristol-Myers Squibb and Merck, which are completed by the patient, reviewed by the nurse, and transcribed into the EMR system for comparison with previous questionnaire responses. Weekly “dual checkpoint immunotherapy” tools are documented from phone calls or office visits at the discretion of the nurse.
Tapering high-dose steroids is an important area to manage. The cancer team has a separate Supportive Care Treatment Plan for steroid tapers and has set up areas in their EMR system to document specific steroid- tapering doses.
Advances in immunotherapy are continuing at a rapid pace. Figuring out how best to educate and prepare patients, as well as physicians, nurses, and other staff, about the latest standards in care is essential for any oncology group. The tools and resources in this program should serve as a useful beginning for discussion and adoption of immuno-oncology programs at other oncology groups.
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Hallmeyer DS. Immuno-Oncology a Revelation in the Field of Oncology. Park Ridge, IL: 2017.
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Worsley A. ASCO 2015 round-up: immunotherapy continues to come of age. Cancer Research UK Science blog. June 5, 2015. http://scienceblog.cancerresearchuk.org/2015/06/05/asco-2015-round-up-immunotherapy-continues-to-come-of-age.