Care coordination, appropriate adverse event assessment and treatment, and rapid, continuous learning are essential priorities for oncology nurses to care for patients receiving immunotherapy, according to the experts who participated in ONS’s immunotherapy summit in March 2018.
In the June 2019 issue of the Clinical Journal of Oncology Nursing, Galioto, Mucenski, and Wiley reported on the findings from the summit, which brought together experts in clinical immunotherapy to identify critical resource needs to support oncology nurses who administer immunotherapies for cancer and care for patients receiving the treatments. ONS members from advanced practice, clinical trials, nurse navigation, and staff nursing participated, and they identified nomenclature, combination treatments, immune-related adverse events (irAEs), and cellular therapies as key areas in which ONS can provide resources and education.
New treatment classes mean new terms, and as new words are introduced to the lexicon, variation can ensue. In many cases, patients and providers refer to any treatment as “chemotherapy,” although five distinct treatment pillars exist:
- Radiation therapy
- Targeted therapy
Summit participants recommended that medicine embraces a “more versatile yet descriptive approach to referencing cancer therapies” and specifically identified the terms anticancer therapy or cancer therapy as the overarching name for treatments.
Additionally, patients may use confusing terminology when they see non-oncology providers, saying that they are receiving chemotherapy when they actually mean immunotherapy. Summit participants recommended the use of therapy identification cards; since that time, ONS created the Immunotherapy Patient Wallet Card for patients to carry and show other providers.
As researchers and scientists identify the most effective ways to treat cancer, immunotherapies are being combined with other treatment modalities. Patients can receive combinations of immune checkpoint inhibitors, immunotherapy plus chemotherapy, or immunotherapy plus radiation therapy. With the addition of a concurrent treatment modality, patients may be more likely to experience side effects, and summit participants said it was critical for providers to identify which treatment is causing a given side effect to ensure it is managed properly. Other concerns included electronic health records’ inability to accommodate combination treatments, new terminology, or care coordination between treatment settings.
Combination immune checkpoint inhibitors: Summit participants prioritized the need to identify which inhibitor is causing the irAE, how to resume treatment if the inhibitor was held to manage the irAE, and determining the best sequence of therapies.
Chemotherapy plus immunotherapy: Most toxicities are associated with the chemotherapy drug, summit participants said, and occur at the same rate as chemotherapy alone. For sequencing, pembrolizumab is typically administered prior to chemotherapy.
Radiation plus immunotherapy: Data are limited regarding use of immune checkpoint inhibitors and linear accelerator radiation therapy. Summit participants emphasized the need to differentiate between true disease progression and pseudoprogression from tumor inflammation from radiation. They also noted the challenge of care coordination in sequencing, when immune checkpoint inhibitor administration can take as long as five hours before patients are moved to radiation treatment.
Immune-Related Adverse Events
Two priorities emerged from the summit: the need to report suspected irAEs to the U.S. Food and Drug Administration’s MedWatch program and the need for a single, consistent set of irAE-focused guidelines, particularly in terms of long-term follow-up.
Because of the nature of irAEs, patients may need to see a variety of interprofessional disciplines, including endocrinology, cardiology, nephrology, neurology, pulmonology, and rheumatology. Summit participants recommended that cancer centers establish relationships with providers in those disciplines to expedite irAE treatment when required. Smaller practices with less access to those providers may need to use telehealth consultations.
CAR T-cell therapy was in its infancy at the time of the immunotherapy summit, but participants anticipated many of today’s needs. They recommended educating the current nursing workforce to facilitate patient follow-up after CAR T-cell administration, training to recognize severe toxicities like cytokine release syndrome, and exploring the high cost of CAR T-cell therapy and what that means for shared decision making and treatment choices.
See the sidebar for more information on the summit participants’ recommendations, and refer to the article by Galioto et al. for the full report.