Unlike side effects associated with common cancer treatments like chemotherapy and radiation, side effects from immunotherapy can arise months or even years after treatment is completed and can affect any organ system. Not knowing when or where these symptoms will occur can complicate cancer care, but navigators can prepare patients by deploying strategies for early identification and management of these toxicities, according to Lavinia Dobrea, MS, BSN, RN, OCN, Manager of Oncology Research and the Biospecimen Program at St. Joseph Hospital in Orange, CA.
Recent research has shown that some immunotherapy side effects tend to appear within a few weeks or months of starting treatment. For example, providers should watch for rash and pruritis between 4 and 10 weeks from start of treatment, diarrhea between 5 and 10 weeks, and liver toxicities between 7 and 14 weeks. However, the most severe side effects tend to be linked to uncontrolled inflammation. These are conditions that end in the suffix “-itis,” and they can occur anywhere in the body long after treatment is completed.
Side effects can be common (ie, dermatitis, fatigue, diarrhea), infrequent (ie, hepatitis, adrenal insufficiency), or rare (ie, pneumonitis, encephalitis), but providers should know what to look for and be equipped to prepare patients for their potential onset.
The 5 Pillars of Immunotherapy Toxicity
Knowing the 5 pillars of immunotherapy toxicity can be invaluable to a navigator, Ms Dobrea told attendees at the AONN+ 2019 Midyear Conference. The key is prevention, she said; knowing the immune-toxicity spectrum and informing patients about the potential for immune-related adverse events. Providing them with this education will empower them to reach out if and when they experience a toxicity.
Next, anticipate; understand a patient’s baseline, including factors such as energy levels and bowel habits (frequency and consistency). This baseline evaluation also offers an opportunity to forge a connection with a patient who might not feel comfortable talking with another provider about something as personal as a change in their bowel movements. And without knowing the patient’s baseline, another provider wouldn’t recognize the extent of the change. Encourage patients to recognize and talk about what’s abnormal to them, she advised. After baseline evaluation, conduct on-treatment as well as off-treatment (survivorship phase) follow-ups.
Next, detect; conduct detailed questioning for autoimmune infectious disease, endocrine and organ-specific disease history, and document critical details. (Is the disease currently being managed? Is it stable?) Conduct blood tests and full skin and mucosal exams, and if any lesions are present, take note of the extent and type, “really looking at what’s currently on their body, and what may change once they start immunotherapy,” she noted. Individuals with preexisting organ disease who are at risk of organ-specific toxicity should receive further cardiopulmonary screening.
“But you can’t just forget about the actual cancer itself,” she said. “Is the side effect tumor progression, or is it an immune-related adverse event?” Once progression is eliminated, treat. Provide patient education, and discuss options such as suspension of immunotherapy, referral to an organ specialist, and corticosteroids or other immunosuppressive drugs.
Finally, monitor for relapse or any immunosuppressive complications. According to Ms Dobrea, the National Comprehensive Cancer Network guidelines for the management of immune checkpoint inhibitor–related toxicities can be a helpful guide for conducting baseline assessments, and for indicating how frequently symptoms should be monitored and evaluated.
Developing patient-facing resources, such as wallet cards, can easily identify patients on immunotherapy and lead to fewer complications and adverse events. If complications do arise, particularly when the patient is in the care of another noncancer specialist, knowing a patient is on immunotherapy treatment could mean the difference between life and death.
Managing patients on immunotherapy is still evolving, but according to Ms Dobrea, navigators can and do play a vital role in preparing patients and their caregivers for what might lie ahead.