Immune checkpoint inhibitors (ICPIs) mobilize the body’s own immune system to target cancer cells. However, the resulting immune-related adverse events (irAEs) vary in severity and may persist for months or years following treatment.
Marianne Davies, DNP, ACNP, FAAN, of the Yale Comprehensive Cancer Center, Smilow Cancer Hospital at Yale New Haven Hospital, and the Yale University School of Nursing, and Laura S. Wood, RN, MSN, OCN®, of Cleveland Clinic Cancer Center, discussed how nurses should assess and manage irAEs.
Grading for Immune-Related Adverse Events
Davies and Wood discussed the application of the Common Terminology Criteria for Adverse Events (CTCAE) for irAEs, which grades symptoms for severity on a 1–4 scale:
- Grade 1: Mild or asymptomatic; no treatment needed
- Grade 2: Moderate with limited age-appropriate activities of daily living (ADL); minimal or noninvasive treatment needed
- Grade 3: Severe or medically significant, but not life-threatening, with significant impact on ADL; hospitalization required
- Grade 4: Life-threatening; urgent treatment needed
Using the example of gastrointestinal AEs, they illustrated how CTCAE grading is used in clinical management strategies.
- Grade 1: Monitor patients or follow up within 24–48 hours to assess for changes or progression; if symptoms persist, start routine stool and blood tests and introduce a bland diet.
- Grade 2: Hold therapy and perform stool and blood work; if patients are experiencing diarrhea only, observe for two to three days and start steroids if they show no improvement.
- Grade 3: Consider hospitalization and IV steroids.
Early grading and management “decreases the risk for permanent discontinuation of checkpoint inhibitor therapies due to delays in identification and interventions for irAEs,” Wood said.
Other Nursing Considerations and Strategies
To help patients achieve the best outcomes, oncology nurses should establish a dialogue and engage them in managing their irAEs when they begin ICPI treatment. “Prepare patients for therapy expectations, and teach them about supportive interventions to help minimize the onset of irAEs,” Davies said.
The speakers shared additional management strategies for common irAEs:
- Hold immunotherapy until no longer symptomatic.
- Initiate thyroid replacement therapy.
- Prescribe hydrocortisone 20 mg every morning and 10 mg every evening.
- Consider an endocrinology consultation.
- Use a medical alert bracelet.
- Toxicities from combination VEGF targeted therapy
- Provide supportive care.
- Hold treatment.
- Monitor closely.
- Consider corticosteroids.
Wood added, “Early communication with the oncology team regarding the development of potential irAEs allows further assessment and initiation of appropriate interventions to minimize the severity and duration of irAEs.”
Survivorship Care and Beyond
Follow-up and survivorship care after immunotherapy treatment requires interprofessional management because of unpredictable long-term and late-onset irAEs, including:
- Adrenal insufficiency
Data for long-term effects on psychosocial well-being, neurocognitive function, and quality of life are limited, so this is an area of opportunity for oncology nursing scientists to fill in the gaps. According to Wood, the most important considerations for nurses are “educating patients and caregivers about the importance of continued awareness regarding the potential for new irAEs to develop following discontinuation of immunotherapy, and the need for early communication regarding new symptoms that could be related to their prior treatment.
“Long-term follow up by the oncology or interprofessional team is critical to effectively monitor and manage ongoing irAEs following completion or discontinuation of checkpoint inhibitor treatment,” she added. “Communication between the oncology team, patient, and primary care providers improves long-term outcomes and quality of life.”
Wood closed by discussing how nurses can advocate for patients in survivorship. “Nurses are pivotal in maximizing clinical outcomes through effective patient education, early identification, and management of irAEs. Nurses can lead peer education regarding ICI therapies, application of CTCAE criteria, and best practice strategies for the care of patients receiving immunotherapy,” she said.