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Klionsky Y, Simon Meara A, Reid P. Immunotherapy Toxicity Management in Clinical Practice: Building the Clinical Infrastructure for Immune-related Adverse Event Evaluation and Care. Rheum Dis Clin North Am 2024; 50:229-239. [PMID: 38670722 DOI: 10.1016/j.rdc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
Abstract
Cancer immunotherapy is revolutionary for survival but has complications due to immunogenicity with unpredictable and potentially long-lasting autoimmune side effects known as immune-related adverse events (irAEs). Currently, treatment beyond corticosteroids can be complicated by the diversity of providers who are needed across a variety of clinical settings to manage irAEs. We outline the role of critical players in the management of irAEs, discuss the current limitations that exist, and propose various methodologies that can be adapted across clinical settings to tackle these needs. We aim to better understand who can be affected by irAEs and tailor diagnostics and therapeutics appropriately.
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Affiliation(s)
- Yael Klionsky
- Division of Rheumatology, Department of Medicine, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston Salem, NC 27157, USA.
| | - Alexa Simon Meara
- Division of Oncology, Department of Medicine, The Ohio State University Wexner Medical Center, 460 West 10th Avenue, Columbus, OH 43210, USA
| | - Pankti Reid
- Division of Rheumatology, Department of Medicine, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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2
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Vanumu DS, Kodisharapu PK, Suvvari P, Rayani BK, Pathi N, Tewani R, Rajappa SJ. Optimizing quality of life: integrating palliative care for patients with hand-foot syndrome in oncology practice. BMJ Support Palliat Care 2024:spcare-2024-004786. [PMID: 38302255 DOI: 10.1136/spcare-2024-004786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
Hand-foot syndrome (HFS) emerges as one of the common dermatological side effects associated with anticancer medications such as 5-fluorouracil (5-FU), capecitabine and docetaxel. This condition can be notably debilitating, exerting a predominant impact on the clinical, functional and psychosocial domains of health. With prevalence rates of HFS, ranging from 43% to 71%, there exists an unmet need among palliative care physicians to comprehend this syndrome in addressing physical, psychological dimensions and its integrated management within healthcare. This understanding enables them to adopt diverse approaches aimed at preserving the quality of life for patients, by enhancing the overall healthcare experience. Our primary objective is to underscore the imperative for the high-quality integration of palliative care with respect to HFS in contemporary oncology practices. We aim to achieve this by providing evidence-based insights to enhance patient outcomes.The intent of this study: (1) The article delves into the range of symptoms linked to HFS, and stresses the necessity of a holistic strategy and the difference that a palliative physician can contribute during cancer treatment-in picking up certain intricate aspects of patient care and addressing them. (2) The article also highlights the comprehensive approach through the incorporation of quality-of-life assessments, with the goal of enhancing patient outcomes, overall care experience within an integrated healthcare framework.
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Affiliation(s)
- Divya Sai Vanumu
- Pain & Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Praveen Kumar Kodisharapu
- Pain & Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Praneeth Suvvari
- Pain & Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Basanth Kumar Rayani
- Onco-Anaesthesiology, Pain & Palliative Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Nikhil Pathi
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Rohan Tewani
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
| | - Senthil J Rajappa
- Department of Medical Oncology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India
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Sabaté Ortega J, Fort Culillas R, Escoda Garcia M, Vásquez-Dongo CA, Sala González N. Case Report: A Presentation of Early-Onset Immune-Mediated Bullous Pemphigoid in a Patient with Urothelial Cancer. Curr Oncol 2023; 30:7802-7809. [PMID: 37754481 PMCID: PMC10529691 DOI: 10.3390/curroncol30090566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/18/2023] [Accepted: 08/20/2023] [Indexed: 09/28/2023] Open
Abstract
Cutaneous immune-related adverse events (cirAEs) are the most common side effects of immune checkpoint inhibitor (ICI) therapy (30-50% for all grades). The vast majority of them are low or mild and can be treated without ICI interruption. Autoimmune blistering disorders, such as immune-mediated bullous pemphigoid (IBP), are rare (<1%) but potentially serious conditions that must be early detected. The onset generally occurs within the first months of the treatment, and it appears to be more common with antiprogrammed death-1 or antiprogrammed ligand 1 (anti-PD1/PDL1) than with anticytotoxic T-lymphocyte-associated protein 4 (anti-CTLA4). We present a case of a three-day severe IBP onset after receiving the first cycle of atezolizumab. This exceptional early presentation could suggest the presence of some predisposing condition and demonstrates the need to better understand predictive toxicity-related biomarkers in candidate patients for immunotherapy.
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Affiliation(s)
- Josep Sabaté Ortega
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Roser Fort Culillas
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | - Marina Escoda Garcia
- Dermatology Department, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
| | | | - Núria Sala González
- Oncology Department, Catalan Institute of Oncology, Hospital Universitari Doctor Josep Trueta, 17007 Girona, Spain;
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Lai-Kwon J, Cohen JE, Lisy K, Rutherford C, Girgis A, Basch E, Jefford M. The Feasibility, Acceptability, and Effectiveness of Electronic Patient-Reported Outcome Symptom Monitoring for Immune Checkpoint Inhibitor Toxicities: A Systematic Review. JCO Clin Cancer Inform 2023; 7:e2200185. [PMID: 37220322 DOI: 10.1200/cci.22.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/07/2023] [Accepted: 03/30/2023] [Indexed: 05/25/2023] Open
Abstract
PURPOSE Increasing use of immune checkpoint inhibitors (ICIs) in routine cancer care will increase the incidence of immune-related adverse events (irAEs). Systems are needed to support remote monitoring for irAEs. Electronic patient-reported outcome (ePRO) symptom monitoring systems can help monitor and manage symptoms and side effects. We assessed the content and features of ePRO symptom monitoring systems for irAEs, and their feasibility, acceptability, and impact on patient outcomes and health care utilization. METHODS A systematic literature search was conducted in May 2022 on MEDLINE, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials. Quantitative and qualitative data relevant to the review questions were extracted and synthesized in tables. RESULTS Seven papers describing five ePRO systems were included. All systems collected PROs between clinic visits. Two of five used validated symptom questionnaires, 3/5 provided prompts to complete questionnaires, 4/5 provided reminders to self-report, and 3/5 provided clinician alerts for severe/worsening side effects. Four of five provided coverage of ≥26/30 irAEs in the ASCO irAE guideline. Feasibility and acceptability were demonstrated with consent rates of 54%-100%, 17%-27% of questionnaires generating alerts, and adherence rates of 74%-75%. One paper showed a reduction in grade 3-4 irAEs, treatment discontinuation, clinic visit duration, and emergency department presentations, while another showed no difference in these outcomes or the rate of steroid use. CONCLUSION There is preliminary evidence of the feasibility and acceptability of ePRO symptom monitoring for irAEs. However, further studies are needed to confirm the impact on ICI-specific outcomes, such as the frequency of grade 3-4 irAEs and duration of immunosuppression. Suggestions for the content and features of future ePRO systems for irAEs are provided.
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Affiliation(s)
- Julia Lai-Kwon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jordan E Cohen
- Liverpool Hospital, South-Western Sydney Local Health District, Sydney, NSW, Australia
| | - Karolina Lisy
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Australian Cancer Survivorship Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Claudia Rutherford
- Sydney Quality of Life Office, School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
- Cancer Care Research Unit (CCRU), Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Afaf Girgis
- South-West Sydney Clinical Campuses, University of New South Wales Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Ethan Basch
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Michael Jefford
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Australian Cancer Survivorship Centre, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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Guinan TJ, Garbutt N, Olsson-Brown A. The impact of an immuno-oncology service at a regional cancer centre based in the north west of the UK. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2022; 31:414-420. [PMID: 35439076 DOI: 10.12968/bjon.2022.31.8.414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This article discusses the implementation and development of a centralised immuno-oncology service. As the indications and licensing of oncological immune checkpoint inhibitors (ICIs) expanded rapidly, they brought with them increasing challenges. The article evaluates the impact of an immuno-oncology service, focusing on the following areas: admission rates due to immune-related adverse events (irAEs), number of bed days occupied due to immunotherapy toxicity and the incidence of Grade 3 and 4 (severe and life-threatening) irAEs. The article will also give an overview of patients requiring acute and subsequent management of toxicity as a percentage of the overall patients commenced on immunotherapy. The ultimate aim of the article is to highlight the importance of toxicity management and the overall benefits of a immuno-oncology service. The article will also discuss the impact of COVID-19 on the immuno-oncology service, highlighting the ways in which the team has adapted to the current environment to ensure high standards of patient care have been maintained.
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Affiliation(s)
- Trudy-Jane Guinan
- Immunotherapy Lead Nurse, Immunotherapy Team, The Clatterbridge Cancer Centre, Liverpool
| | - Nick Garbutt
- Immunotherapy Project Support Manager, Immunotherapy Team, The Clatterbridge Cancer Centre, Liverpool
| | - Anna Olsson-Brown
- Consultant Medical Oncologist, Immunotherapy Team, The Clatterbridge Cancer Centre, Liverpool
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Aso S, Kawamura N, Yanagida H, Nakajima K, Ishikawa H, Omori S, Murakami H, Takahashi T, Naito T. Exploring the educational needs for severe immune-related adverse events of PD-1/PD-L1 inhibitors in advanced lung cancer : A single-center observational study. Asia Pac J Oncol Nurs 2022; 9:100076. [PMID: 36065289 PMCID: PMC9440266 DOI: 10.1016/j.apjon.2022.100076] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/20/2022] [Indexed: 11/26/2022] Open
Abstract
Objective With the expanded use of immunotherapy in medical oncology, effective patient education regarding immune-related adverse events (irAEs) is crucial for oncology nursing. Therefore, this study aimed to identify educational needs for preventing unscheduled hospitalizations due to severe irAEs. Methods We retrospectively reviewed the medical records of 159 consecutive patients with lung cancer who received programmed cell death-1 (PD-1)/programmed death-ligand 1 (PD-L1) inhibitors in 2020. We evaluated the frequency, severity, and unscheduled hospitalization due to irAEs based on the PD-1/PD-L1 inhibitor use. Educational needs were assessed based on initial symptoms, reporters, telephone consultation, and the time lag between symptom onset and hospital visit. Results Among 159 patients evaluable for irAEs, 73 (45.9%) experienced 91 irAEs during the study period. Seventeen patients (10.7%) required unscheduled hospitalization due to severe irAEs after a median duration of 4.1 days from symptom onset, and 52.9% visited hospitals after telephone consultations from caregivers. Pneumonitis (10 events) was the most frequent irAE requiring hospitalization, followed by adrenal insufficiency (three events). The type and severity of irAEs varied based on PD-1/PD-L1 inhibitor use. Conclusions The frequency of severe irAEs requiring hospitalization was high in patients who received PD-1/PD-L1 inhibitors for advanced lung cancer. The early detection of severe irAEs may be possible through education focusing on common irAEs that are potentially severe. Patients and caregivers should be aware of the importance of reporting slight changes in symptoms after PD-1/PD-L1 therapy initiation in a timely manner. Healthcare professionals need to acknowledge common irAEs and be qualified to implement systematic telephone triage of irAEs.
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Affiliation(s)
- Sakiko Aso
- Division of Nursing, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nao Kawamura
- Division of Nursing, Shizuoka Cancer Center, Shizuoka, Japan
| | - Hideki Yanagida
- Division of Nursing, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kazuko Nakajima
- Division of Nursing, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Shota Omori
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Haruyasu Murakami
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
| | | | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center, Shizuoka, Japan
- Corresponding author.
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A Guide to Implementing Immune Checkpoint Inhibitors within a Cancer Program: Experience from a Large Canadian Community Centre. Curr Oncol 2022; 29:869-880. [PMID: 35200573 PMCID: PMC8870472 DOI: 10.3390/curroncol29020074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/25/2022] Open
Abstract
The increased use of immune checkpoint inhibitors across cancer programs has created the need for standardized patient assessment, education, monitoring, and management of immune-related adverse events (irAEs). At William Osler Health System in Brampton, Ontario, a practical step-wise approach detailing the implementation of cancer immunotherapy in routine practice was developed. The approach focuses on four key steps: (1) identification of patient educators; (2) development of patient education materials; (3) development of patient monitoring tools; (4) involvement and education of multidisciplinary teams. Here, we provide an in-depth description of what was included in each step and how we integrated the different elements of the program. For each step, resources, tools, and materials that may be useful for patients, healthcare providers, and multidisciplinary teams were developed or modified based on existing materials. At our centre, the program led to improved patient comprehension of irAEs, the ability to act on symptoms (patient self-efficacy), and low rates of emergency room visits at first presentation for irAEs. We recognize that centres may need to tailor the approaches to their institutional policies and encourage centres to adapt and modify the forms and tools according to their needs and requirements.
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Castillo RM, Sandefur BJ, Finch AS, Richter MD, Thanarajasingam U. Clinical Presentations and Outcomes of Patients Receiving Immune Checkpoint Inhibitors Presenting to the Emergency Department. Mayo Clin Proc Innov Qual Outcomes 2021; 5:1029-1035. [PMID: 34765885 PMCID: PMC8569628 DOI: 10.1016/j.mayocpiqo.2021.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) are increasingly used in the treatment of cancer. Immune checkpoint inhibitors may cause a wide-range of autoimmune toxicities referred to as immune-related adverse events (irAEs). There is a paucity of data regarding the presentations and outcomes of patients receiving ICIs who seek care in an emergency department (ED). We performed a retrospective review of patients receiving an ICI who presented to a tertiary care ED between May 1, 2017, and April 30, 2018. Data including ED chief complaint, diagnosis, treatment, and disposition were collected along with baseline characteristics and diagnosis at the time of outpatient oncology follow-up. We report descriptive statistics summarizing the characteristics of the cohort. There were 98 ED visits identified among 67 unique patients. Immune-related adverse events were diagnosed in 16 (16.3%) cases. The most common chief complaints within the irAE group were gastrointestinal symptoms 10 (62.5%). Among the 16 confirmed irAE cases, the most common irAE diagnosed was colitis 9 (56.3%). Two (12.5%) patients with irAEs received corticosteroids during their stay in the ED, and 10 (62.5%) patients with irAEs required hospital admission. Emergency medicine providers documented consideration of an irAE in the differential diagnosis in 14.3% of all ED visits and in 43.8% of visits in which an irAE was ultimately diagnosed. Emergency providers should be familiar with ICIs given their expanding use and potential adverse effects to improve early recognition and patient outcomes in ED settings.
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Affiliation(s)
- Richmond M. Castillo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | | | | | - Uma Thanarajasingam
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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Shankar A, Wallbridge IG, Yau C, Saini D, Roy S, Bharati SJ, Mishra S, Singh P, Seth T. Development of Management Strategies for Immune Related Adverse Effects of Immunotherapies used in Oncological Treatment. Asia Pac J Oncol Nurs 2021; 9:7-11. [PMID: 35528796 PMCID: PMC9072166 DOI: 10.1016/j.apjon.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 08/14/2021] [Indexed: 11/25/2022] Open
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Gulati N, Celen A, Johannet P, Mehnert JM, Weber J, Krogsgaard M, Osman I, Zhong J. Preexisting immune-mediated inflammatory disease is associated with improved survival and increased toxicity in melanoma patients who receive immune checkpoint inhibitors. Cancer Med 2021; 10:7457-7465. [PMID: 34647433 PMCID: PMC8559502 DOI: 10.1002/cam4.4239] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/27/2021] [Accepted: 08/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Immune-related adverse events (irAEs) are common, clinically significant autoinflammatory toxicities observed with immune checkpoint inhibitors (ICI). Preexisting immune-mediated inflammatory disease (pre-IMID) is considered a relative contraindication to ICI due to the risk of inciting flares. Improved understanding of the risks and benefits of treating pre-IMID patients with ICI is needed. METHODS We studied melanoma patients treated with ICI and enrolled in a prospective clinicopathological database. We compiled a list of 23 immune-mediated inflammatory diseases and evaluated their presence prior to ICI. We tested the associations between pre-IMID and progression-free survival (PFS), overall survival (OS), and irAEs. RESULTS In total, 483 melanoma patients were included in the study; 74 had pre-IMID and 409 did not. In patients receiving ICI as a standard of care (SoC), pre-IMID was significantly associated with irAEs (p = 0.04) as well as improved PFS (p = 0.024) and OS (p = 0.007). There was no significant association between pre-IMID and irAEs (p = 0.54), PFS (p = 0.197), or OS (p = 0.746) in patients treated through a clinical trial. Pre-IMID was significantly associated with improved OS in females (p = 0.012), but not in males (p = 0.35). CONCLUSIONS The dichotomy of the impact of pre-IMID on survival and irAEs in SoC versus clinical trial patients may reflect the inherit selection bias in patients accrued in clinical trials. Future mechanistic work is required to better understand the differences in outcomes between female and male pre-IMID patients. Our data challenge the notion that clinicians should avoid ICI in pre-IMID patients, although close monitoring and prospective clinical trials evaluating ICI in this population are warranted.
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Affiliation(s)
- Nicholas Gulati
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Arda Celen
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Paul Johannet
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Janice M Mehnert
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Jeffrey Weber
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Michelle Krogsgaard
- Department of Pathology, New York University Grossman School of Medicine, New York, NY, USA
| | - Iman Osman
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Judy Zhong
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Zubiri L, Molina GE, Mooradian MJ, Cohen J, Durbin SM, Petrillo L, Boland GM, Juric D, Dougan M, Thomas MF, Faje AT, Rengarajan M, Guidon AC, Chen ST, Okin D, Medoff BD, Nasrallah M, Kohler MJ, Schoenfeld SR, Karp-Leaf RS, Sise ME, Neilan TG, Zlotoff DA, Farmer JR, Bardia A, Sullivan RJ, Blum SM, Semenov YR, Villani AC, Reynolds KL. Effect of a multidisciplinary Severe Immunotherapy Complications Service on outcomes for patients receiving immune checkpoint inhibitor therapy for cancer. J Immunother Cancer 2021; 9:e002886. [PMID: 34544895 PMCID: PMC8454442 DOI: 10.1136/jitc-2021-002886] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND In 2017, Massachusetts General Hospital implemented the Severe Immunotherapy Complications (SIC) Service, a multidisciplinary care team for patients hospitalized with immune-related adverse events (irAEs), a unique spectrum of toxicities associated with immune checkpoint inhibitors (ICIs). This study's objectives were to evaluate the intervention's (1) effect on patient outcomes and healthcare utilization, and (2) ability to collect biological samples via a central infrastructure, in order to study the mechanisms responsible for irAEs. METHODS A hospital database was used to identify patients who received ICIs for a malignancy and were hospitalized with severe irAEs, before (April 2, 2016-October 3, 2017) and after (October 3, 2017-October 24, 2018) SIC Service initiation. The primary outcome was readmission rate after index hospitalization. Secondary outcomes included length of stay (LOS) for admissions, corticosteroid and non-steroidal second-line immunosuppression use, ICI discontinuation, and inpatient mortality. RESULTS In the pre-SIC period, 127 of 1169 patients treated with ICIs were hospitalized for irAEs; in the post-SIC period, 122 of 1159. After SIC service initiation, reductions were observed in irAE readmission rate (14.8% post-SIC vs 25.9% pre-SIC; OR 0.46; 95% CI 0.22 to 0.95; p=0.036) and readmission LOS (median 6 days post-SIC vs 7 days pre-SIC; 95% CI -16.03 to -0.14; p=0.046). No significant pre-initiation and post-initiation differences were detected in corticosteroid use, second-line immunosuppression, ICI discontinuation, or inpatient mortality rates. The SIC Service collected 789 blood and tissue samples from 234 patients with suspected irAEs. CONCLUSIONS This is the first study to report that establishing a highly subspecialized care team focused on irAEs is associated with improved patient outcomes and reduced healthcare utilization. Furthermore, the SIC Service successfully integrated blood and tissue collection safety into routine care.
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Affiliation(s)
- Leyre Zubiri
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gabriel E Molina
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan J Mooradian
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Justine Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sienna M Durbin
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Petrillo
- Division of Palliative Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Genevieve M Boland
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Dejan Juric
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael Dougan
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Molly F Thomas
- Division of Gastroenterology, Department of Medicine, Mass General Center for Cancer Research, Division of Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex T Faje
- Neuroendocrine Unit, Division of Endocrinology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michelle Rengarajan
- Division of Endocrinology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amanda C Guidon
- Division of Neuromuscular Disorders, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven T Chen
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Okin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin D Medoff
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mazen Nasrallah
- Division of Rheumatology, Allergy, Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Minna J Kohler
- Division of Rheumatology, Allergy, Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara R Schoenfeld
- Division of Rheumatology, Allergy, Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rebecca S Karp-Leaf
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meghan E Sise
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tomas G Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel A Zlotoff
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jocelyn R Farmer
- Division of Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aditya Bardia
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ryan J Sullivan
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven M Blum
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yevgeniy R Semenov
- Department of Dermatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexandra-Chloé Villani
- Massachusetts General Hospital Center for Immunology and Inflammatory Diseases, Mass General Center for Cancer Research, Division of Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kerry L Reynolds
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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12
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Lodde G, Forschner A, Hassel J, Wulfken LM, Meier F, Mohr P, Kähler K, Schilling B, Loquai C, Berking C, Hüning S, Schatton K, Gebhardt C, Eckardt J, Gutzmer R, Reinhardt L, Glutsch V, Nikfarjam U, Erdmann M, Stang A, Kowall B, Roesch A, Ugurel S, Zimmer L, Schadendorf D, Livingstone E. Factors Influencing the Adjuvant Therapy Decision: Results of a Real-World Multicenter Data Analysis of 904 Melanoma Patients. Cancers (Basel) 2021; 13:2319. [PMID: 34065995 PMCID: PMC8151445 DOI: 10.3390/cancers13102319] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 11/16/2022] Open
Abstract
Adjuvant treatment of melanoma patients with immune-checkpoint inhibition (ICI) and targeted therapy (TT) significantly improved recurrence-free survival. This study investigates the real-world situation of 904 patients from 13 German skin cancer centers with an indication for adjuvant treatment since the approval of adjuvant ICI and TT. From adjusted log-binomial regression models, we estimated relative risks for associations between various influence factors and treatment decisions (adjuvant therapy yes/no, TT vs. ICI in BRAF mutant patients). Of these patients, 76.9% (95% CI 74-80) opted for a systemic adjuvant treatment. The probability of starting an adjuvant treatment was 26% lower in patients >65 years (RR 0.74, 95% CI 68-80). The most common reasons against adjuvant treatment given by patients were age (29.4%, 95% CI 24-38), and fear of adverse events (21.1%, 95% CI 16-28) and impaired quality of life (11.9%, 95% CI 7-16). Of all BRAF-mutated patients who opted for adjuvant treatment, 52.9% (95% CI 47-59) decided for ICI. Treatment decision for TT or ICI was barely associated with age, gender and tumor stage, but with comorbidities and affiliated center. Shortly after their approval, adjuvant treatments have been well accepted by physicians and patients. Age plays a decisive role in the decision for adjuvant treatment, while pre-existing autoimmune disease and regional differences influence the choice between TT or ICI.
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Affiliation(s)
- Georg Lodde
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Andrea Forschner
- Department of Dermatology, University Hospital Tuebingen, 72076 Tuebingen, Germany; (A.F.); (J.E.)
| | - Jessica Hassel
- Department of Dermatology, University Hospital Heidelberg, 69120 Heidelberg, Germany;
| | - Lena M. Wulfken
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Venereology and Allergology, University Hospital Hannover Medical School, 30625 Hannover, Germany; (L.M.W.); (R.G.)
| | - Friedegund Meier
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, 01307 Dresden, Germany; (F.M.); (L.R.)
| | - Peter Mohr
- Department of Dermatology, Elbe Kliniken Stade-Buxtehude, 21614 Buxtehude, Germany;
| | - Katharina Kähler
- Department of Dermatology, Venereology and Allergology, University Hospital Kiel, 24105 Kiel, Germany;
| | - Bastian Schilling
- Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (V.G.)
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, 55131 Mainz, Germany; (C.L.); (U.N.)
| | - Carola Berking
- Department of Dermatology, University Hospital Erlangen, CCC-Comprehensive Cancer Center Erlangen-EMN, Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Deutsches Zentrum Immuntherapie (DZI), 91054 Erlangen, Germany; (C.B.); (M.E.)
| | - Svea Hüning
- Department of Dermatology, Klinikum Dortmund gGmbH, 44137 Dortmund, Germany;
| | - Kerstin Schatton
- Department of Dermatology, Medical Faculty, Heinrich Heine University, 40225 Düsseldorf, Germany;
| | - Christoffer Gebhardt
- Department of Dermatology, Venereology and Allergology, University Hospital Hamburg, 20246 Hamburg, Germany;
| | - Julia Eckardt
- Department of Dermatology, University Hospital Tuebingen, 72076 Tuebingen, Germany; (A.F.); (J.E.)
| | - Ralf Gutzmer
- Skin Cancer Center Hannover, Department of Dermatology and Allergy, Venereology and Allergology, University Hospital Hannover Medical School, 30625 Hannover, Germany; (L.M.W.); (R.G.)
| | - Lydia Reinhardt
- Skin Cancer Center at the University Cancer Centre Dresden and National Center for Tumor Diseases, 01307 Dresden, Germany; (F.M.); (L.R.)
| | - Valerie Glutsch
- Department of Dermatology, Venereology and Allergology, University Hospital Wuerzburg, 97080 Wuerzburg, Germany; (B.S.); (V.G.)
| | - Ulrike Nikfarjam
- Department of Dermatology, University Hospital Mainz, 55131 Mainz, Germany; (C.L.); (U.N.)
| | - Michael Erdmann
- Department of Dermatology, University Hospital Erlangen, CCC-Comprehensive Cancer Center Erlangen-EMN, Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Deutsches Zentrum Immuntherapie (DZI), 91054 Erlangen, Germany; (C.B.); (M.E.)
| | - Andreas Stang
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, 45122 Essen, Germany; (A.S.); (B.K.)
| | - Bernd Kowall
- Institute for Medical Informatics, Biometry and Epidemiology, University Hospital Essen, 45122 Essen, Germany; (A.S.); (B.K.)
| | - Alexander Roesch
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen and German Cancer Research Center (DKFZ), 45147 Essen, Germany
| | - Selma Ugurel
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Lisa Zimmer
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
| | - Dirk Schadendorf
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
- German Consortium for Translational Cancer Research (DKTK), Partner Site Essen and German Cancer Research Center (DKFZ), 45147 Essen, Germany
| | - Elisabeth Livingstone
- Department of Dermatology, Venereology and Allergology, University Hospital Essen, 45147 Essen, Germany; (G.L.); (A.R.); (S.U.); (L.Z.); (D.S.)
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13
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Holstead R, Kartolo A, Baetz T. Emergency Department Utilization for Patients Receiving Immune Checkpoint Inhibitors: A Retrospective Analysis of Identification and Outcomes for Those Presenting for Immune-Related Adverse Events. Curr Oncol 2020; 28:52-59. [PMID: 33704174 PMCID: PMC7816173 DOI: 10.3390/curroncol28010007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/17/2020] [Accepted: 11/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Immune-related adverse events (iRAEs) are known complications of immune checkpoint inhibitors (ICIs). Early identification and management leads to improved morbidity and mortality. This study seeks to address our center's experience with iRAEs in the emergency department (ED). METHODS We performed a retrospective review of patients treated with ICIs in 2018 and 2019 for any indication. All diagnoses of iRAEs were recorded. For all patients who presented to the ED following administration of an ICI, we assessed whether the presenting symptoms were eventually diagnosed as an iRAE. We assessed disposition, time to initiation of corticosteroids and outcomes in these patients. RESULTS 351 evaluable patients were treated with an ICI, 129 patients (37%) had at least one presentation to the ED, 17 of whom presented with symptoms due to a new iRAE. New iRAE diagnoses were broad, occurred after median 2 cycles, majority irAEs were grade 3 or higher (70.6%), and two patients died due to toxicity. Twelve patients were admitted to the hospital during initial presentation or at follow-up, four required ICU care. All patients required immunosuppressive therapy, and only three were later re-challenged with an ICI. Of the patients who were admitted to the hospital, median time to first dose of corticosteroid was 30.5 h (range 1-269 h). CONCLUSIONS Patients on ICI have a significant risk of requiring an ED visit. A notable proportion of iRAEs have their first presentation at the ED and often can present in a very nonspecific manner. A standardized approach in the ED at the time of presentation may lead to improved identification and management of these patients.
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Affiliation(s)
| | | | - Tara Baetz
- Cancer Centre of Southeastern Ontario, Department of Oncology, Queen’s University, Kingston, ON K7L 2V7, Canada; (R.H.); (A.K.)
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14
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Naing A, Hajjar J, Gulley JL, Atkins MB, Ciliberto G, Meric-Bernstam F, Hwu P. Strategies for improving the management of immune-related adverse events. J Immunother Cancer 2020; 8:e001754. [PMID: 33310772 PMCID: PMC7735083 DOI: 10.1136/jitc-2020-001754] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 02/07/2023] Open
Abstract
With the advent of immunotherapeutic agents, durable and dramatic responses have been observed in several hard-to-treat malignancies, outlining a roadmap to conquering cancer. Immune checkpoint inhibitors (ICPi) are a class of immunotherapeutic agents that attack the tumor cells by reinvigorating the suppressed immune system. However, the unbridled T-cell activity disrupts the immune homeostasis and induces a unique spectrum of side effects called immune-related adverse events (irAEs) in a significant proportion of patients. These irAEs are distinct from the side effects produced by traditional chemotherapeutic agents. Although majority of irAEs are manageable with corticosteroids and other immunosuppressive agents, life-threatening and fatal events have been reported. In the absence of predictive biomarkers to identify patients at risk for irAEs and standardized approach to detect, report, and treat irAEs, management of irAEs has been challenging to the patients, caregivers and the healthcare providers alike. With increasing use of ICPis for treatment of various cancers, the incidence of irAEs will undoubtedly increase. There is a compelling need to develop measures to effectively manage irAEs, both in the community settings and in cancer centers alike. To this end, in this paper, we propose several strategies, such as providing patient education, harmonizing irAE management guidelines, standardizing reporting of irAEs, optimizing the choice of immunosuppressive agents, conducting preclinical, clinical and translational studies to better understand irAEs, including high-risk patients, incorporating diagnostic tools to personalize irAE management using wireless technology and digital health, providing a platform to hear the missing patient's voice, and sharing evolving data to improve the management of irAEs.
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Affiliation(s)
- Aung Naing
- Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joud Hajjar
- William T Shearer Center for Human Immunobiology, Section of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Texas, USA
| | - James L Gulley
- NCI, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Gennaro Ciliberto
- Scientific Directorate, Istituti Fisioterapici Ospedalieri, Roma, Italy
| | - Funda Meric-Bernstam
- Investigational Cancer Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Patrick Hwu
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Kamta J, Magruder B, Hymel L. Implementation of a pharmacy consult service for evaluation of immune checkpoint inhibitor related adverse events at a large community hospital. J Oncol Pharm Pract 2020; 27:1821-1828. [PMID: 33176559 DOI: 10.1177/1078155220970266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Immune checkpoint inhibitors (ICI) are novel oncolytic therapies associated with various immune related adverse events (irAEs) affecting multiple organ systems, which may have a delayed presentation. Identification of irAEs and prompt initiation of appropriate treatment represents a challenge to clinicians. The purpose of this study was to evaluate the effectiveness of a pharmacy consult service in identification and management of irAEs.Methodology: This was a single center, retrospective study. Patients included were: ≥18 years old, admitted as inpatients, and reported a history of cancer treatment within the last year. A pharmacy consult was developed and implemented for patients who reported a history of ICI therapy within the last year. Education regarding the consult service was provided to select physicians, nurses, and all pharmacists. Primary outcome: percent of admitted patients reporting ICI therapy within the last year, who required pharmacist intervention for an irAE. Secondary outcomes: types of interventions performed, percentage of recommendation acceptance, pharmacist time spent. RESULTS Fifty-one patients received a pharmacy immunotherapy consult. Seventeen patients (33%) met the primary outcome. Thirty-three separate recommendations were made by pharmacists for these 17 patients. The secondary outcomes of interventions made and percentage accepted (n; % accepted): Initiation/adjustment of steroid therapy (20; 40%), placement of a consult for oncology or other specialist (10; 70%), other therapeutic interventions (3; 67%). Average time spent by pharmacist on initial consultations (SD): 29 minutes (15). CONCLUSION A pharmacy consult service may help to increase identification of patients receiving immune checkpoint inhibitors and initiate timely interventions.
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Affiliation(s)
- Jeff Kamta
- Sarasota Memorial Hospital, Sarasota, FL, USA
| | | | - Lisa Hymel
- Sarasota Memorial Hospital, Sarasota, FL, USA
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16
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Johnson DB, Reynolds KL, Sullivan RJ, Balko JM, Patrinely JR, Cappelli LC, Naidoo J, Moslehi JJ. Immune checkpoint inhibitor toxicities: systems-based approaches to improve patient care and research. Lancet Oncol 2020; 21:e398-e404. [PMID: 32758477 DOI: 10.1016/s1470-2045(20)30107-8] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 01/24/2020] [Accepted: 02/11/2020] [Indexed: 02/06/2023]
Abstract
Immune checkpoint inhibitors (ICIs) have now been approved in numerous and diverse cancer types and combination regimens. Effective recognition and treatment of ICI toxicities, which might occur acutely, affect any organ system, and produce many distinct clinical syndromes, have emerged as essential goals of ICI management. Thus, developing robust diagnostic and management approaches for ICI toxicity across the health-care system is an urgent and unmet clinical need. In this Personal View, we describe barriers to high-quality care that have constrained the most effective management of patients with cancer receiving ICI treatment. We review education initiatives to enhance patient and physician awareness, which is necessary given the broad spectrum of ICI toxicities often experienced by patients, and assess various systems-based approaches that maximise the chances of appropriate management. In addition, we describe research pipelines that broaden evidence-based approaches and the pathobiology of these novel events. Developing effective, systematic approaches for the recognition and treatment of ICI toxicities will continue to grow in importance as these agents proliferate in cancer care.
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Affiliation(s)
- Douglas B Johnson
- Department of Medicine, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | | | - Ryan J Sullivan
- Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Justin M Balko
- Department of Medicine, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Laura C Cappelli
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jarushka Naidoo
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, Bloomberg-Kimmel Institute for Cancer Immunotherapy, Baltimore, MD, USA
| | - Javid J Moslehi
- Department of Medicine, Vanderbilt Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Kennedy LC, Wong KM, Kamat NV, Khaki AR, Bhatia S, Thompson JA, Grivas P. Untangling the Multidisciplinary Care Web: Streamlining Care Through an Immune-Related Adverse Events (IRAE) Tumor Board. Target Oncol 2020; 15:541-548. [PMID: 32710246 DOI: 10.1007/s11523-020-00739-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Immune-related adverse events (IRAEs) are becoming increasingly common as the use of immune checkpoint inhibitors expands into more tumor types and treatment settings. Although the majority of IRAEs are mild and can be managed in the outpatient setting by the medical oncologist, severe IRAEs can be life threatening and often require complex care coordination among multiple providers. These providers include a variety of non-oncology specialists who have interest and expertise in managing IRAEs. Multiple systems-based solutions have been proposed in the literature, but these need to be tailored to the needs and resources of each practice setting. In this article, we highlight the challenges of IRAE care by presenting an illustrative case from our institution. We then describe the format and structure of the IRAE Tumor Board established at the University of Washington/Seattle Cancer Care Alliance/Fred Hutchinson Cancer Research Center. Finally, we discuss how this tumor board attempts to address clinical issues related to complex IRAE presentations and provide IRAE education.
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Affiliation(s)
- Laura C Kennedy
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Kit Man Wong
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Nikhil V Kamat
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Ali Raza Khaki
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Shailender Bhatia
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - John A Thompson
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Petros Grivas
- Department of Medicine, Division of Oncology, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, 1144 Eastlake Ave E, LG-465, Seattle Cancer Care Alliance, Seattle, WA, 98109, USA. .,Seattle Cancer Care Alliance, Seattle, WA, USA.
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18
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Ruggiero R, Fraenza F, Scavone C, di Mauro G, Piscitelli R, Mascolo A, Ferrajolo C, Rafaniello C, Sportiello L, Rossi F, Capuano A. Immune Checkpoint Inhibitors and Immune-Related Adverse Drug Reactions: Data From Italian Pharmacovigilance Database. Front Pharmacol 2020; 11:830. [PMID: 32581796 PMCID: PMC7295943 DOI: 10.3389/fphar.2020.00830] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/20/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The introduction of immune checkpoint inhibitors (ICIs) in clinical practice has brought significant benefits for patients. Seven ICIs are available in Europe: nivolumab, pembrolizumab, atezolizumab, avelumab, durvalumab, cemiplimab, and ipilimumab. Despite their proven clinical efficacy, these innovative drugs may cause serious immune-related adverse drugs reactions (irADRs). Given the significance of these ADRs for patients' health, we analyzed individual case safety reports (ICSRs) related to ICIs, focusing on those reporting irADRs, collected in the Italian spontaneous reporting database. METHODS We analyzed ICI-induced irADRs collected in the Italian Pharmacovigilance database (Rete Nazionale di Farmacovigilanza [RNF]) from January 1, 2002, to February 28, 2019, focusing on those reported in the Campania Region. We retrieved from an open-access Italian pharmacovigilance system, the RAM system (for national safety data), and from the RNF (for Campania safety data) all ICSRs reporting ADRs related to ICIs authorized until the analysis date. Focusing on irADRs, we performed descriptive and disproportionality analyses through the reporting odds ratio (ROR) with 95% confidence interval. RESULTS National results. Among 2,088 ICI-related ICSRs, 801 reported irADRs. The majority of such ADRs occurred in male patients reporting gastrointestinal and skin toxicities. Nivolumab and pembrolizumab were drugs most commonly reported as suspect drugs. Compared to other ICIs, ROR was statistically significant for pembrolizumab and ipilimumab.Campania Region results. Out of 253 ICI-related ICSRs sent to Regional Pharmacovigilance Center of Campania Region, 121 reported at least one ICI-induced irADR. These were serious in 37.2% of cases and had an unfavorable outcome in 32.2% of cases. Overall, out of 8 ICSRs reported ADR with a fatal outcome, four reported irADRs. From disproportionality analyses on Campania Region ICSRs, statistically significant ROR emerged only for ipilimumab. CONCLUSIONS Our results showed that during the study period several serious irADRs were reported, some of which had fatal outcome. Given the clinical relevance of irADRs, further investigations in real-life context are necessary for a better characterization of ICIs safety profiles. Oncologists should be trained to early recognize and adequately manage irADRs. Patients should also be educated to immediately report any new symptom or worsening of pre-existed ones during the ICI treatment.
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Affiliation(s)
| | | | - Cristina Scavone
- Campania Regional Centre for Pharmacovigilance and Pharmacoepidemiology, Department of Experimental Medicine, Section of Pharmacology “L. Donatelli”, University of Campania “Luigi Vanvitelli”, Naples, Italy
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19
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Boland P, Pavlick AC, Weber J, Sandigursky S. Immunotherapy to treat malignancy in patients with pre-existing autoimmunity. J Immunother Cancer 2020; 8:e000356. [PMID: 32303614 PMCID: PMC7204615 DOI: 10.1136/jitc-2019-000356] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2020] [Indexed: 12/12/2022] Open
Abstract
In the past 10 years, immune checkpoint inhibitors (ICIs) have become an additional pillar of cancer therapy by activating the immune system to treat a number of different malignancies. Many patients receiving ICIs develop immune-related adverse events (irAEs) that mimic some features of classical autoimmune diseases. Unfortunately, patients with underlying autoimmune conditions, many of whom have an increased risk for malignancy, have been excluded from clinical trials of ICIs due to a concern that they will have an increased risk of irAEs. Retrospective data from patients with autoimmune diseases and concomitant malignancy treated with ICIs are encouraging and suggest that ICIs may be tolerated safely in patients with specific autoimmune diseases, but there are no prospective data to guide management. In this manuscript, we review the relationship between pre-existing autoimmune disease and irAEs from checkpoint inhibitors. In addition, we assess the likelihood of autoimmune disease exacerbations in patients with pre-existing autoimmunity receiving ICI.
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Affiliation(s)
- Patrick Boland
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Anna C Pavlick
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Jeffrey Weber
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
| | - Sabina Sandigursky
- Perlmutter Cancer Center, NYU Langone Medical Center, New York, New York, USA
- Department of Internal Medicine, Division of Rheumatology, NYU Langone Health, New York, New York, USA
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20
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Dubey D, David WS, Reynolds KL, Chute DF, Clement NF, Cohen JV, Lawrence DP, Mooradian MJ, Sullivan RJ, Guidon AC. Severe Neurological Toxicity of Immune Checkpoint Inhibitors: Growing Spectrum. Ann Neurol 2020; 87:659-669. [PMID: 32086972 DOI: 10.1002/ana.25708] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Expanding use of immune-checkpoint inhibitors (ICIs) underscores the importance of accurate diagnosis and timely management of neurological immune-related adverse events (irAE-N). We evaluate the real-world frequency, phenotypes, co-occurring immune-related adverse events (irAEs), and long-term outcomes of severe, grade III to V irAE-N at a tertiary care center over 6 years. We analyze how our experience supports published literature and professional society guidelines. We also discuss these data with regard to common clinical scenarios, such as combination therapy, ICI rechallenge and risk of relapse of irAE-N, and corticosteroid taper, which are not specifically addressed by current guidelines and/or have limited data. Recommendations for management and future irAE-N reporting are outlined. ANN NEUROL 2020;87:659-669.
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Affiliation(s)
- Divyanshu Dubey
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neurology, Brigham and Women's Hospital, Boston, MA.,Department of Neurology, and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - William S David
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Kerry L Reynolds
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Donald F Chute
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Nathan F Clement
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Justine V Cohen
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | | | - Ryan J Sullivan
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Amanda C Guidon
- Department of Neurology, Massachusetts General Hospital, Boston, MA
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21
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Yan Y. Immuno-Oncology Essentials: Applications in Clinical Scenarios—Introduction. JCO Oncol Pract 2020; 16:1s-3s. [DOI: 10.1200/jop.19.00715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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