1. This document discusses the challenges in managing adverse effects from immunotherapy treatments. It notes that early recognition and reporting of adverse effects is important to minimize potential impacts. 2. Some challenges include the unpredictable timing of adverse effects from new drugs like BRAF/MEK inhibitors, other healthcare providers' lack of familiarity with the drugs, patients self-managing symptoms or delaying reporting, and inconsistent advice from different providers. 3. A case study highlights how a patient experienced diarrhea for 10 days from immunotherapy but did not report it as severe until prompted by his nurse, showing how education is needed for patients and providers on taking adverse effects seriously and seeking prompt evaluation.

1. Challenges in managing
adverse effects of
immunotherapy treatment
Julie Teraci
Clinical Nurse Consultant / Coordinator
WA Melanoma Advisory Service
Cancer Nurse Coordinator Melanoma & Skin Cancer
WA Cancer and Palliative Care Network

2. Effective Surveillance, Recognition, and
Intervention Minimizes the Potential
Impact of AEs1,2
Early
recognition
and reporting
Management of AEs
1. Teply BA et al. Oncology (Williston Park). 2014;28 Suppl 3:30–38. 2. Kannan R et al. Clin J Onc Nurs. 2015;18(3):311–317, 326.

3. EDUCATION
EDUCATE
G.P.
ED staff
Other key
clinical
staff
Yourself
Carer’s
Patient

4. Education of patient and carer
 Individual education preferable
 Need to understand MOA and rationale for
early reporting of AEs
 No self management of AEs
 NOT chemotherapy – medic alert band
 Treating hospital preferable for ED
 Contact details for reporting AEs
Early
recognition and
reporting

5. Some of the challenges…
 BRAF/MEK & checkpoint inhibitors
 No predictable time for developing AEs
 Other HCP may not be familiar with new
drugs
 Patients self manage symptoms
 Patients delay reporting AEs –subtle onset
 Contact with many staff – inconsistent
advice

6. Challenges cont’d
 Phone assessment challenging
 Who is assessing patient?
 How are they assessed? – no formal tools
 If presentation to hospital via ambulance
may not go to Rx centre
 Patients prefer closest hospital – may not
have appropriate expertise
 Rural context

7. Case study - Rick
 41 YO male with stage IV M1c melanoma.
 Rx BRAF/MEK inhibitors for 1 yr – POD with
brain mets - Feb 2017
 Completed 4 cycles Ipi/Nivo early May 2017
 patient emailed CNC (reason not related to AEs)
 CNC enquired re side effects in return email
“ pretty good, had an upset tummy over past 10
days but managing well with Imodium and good
fluid intake”
Proactive
monitoring

8. Case study cont’d
The reality:-
 8-10 watery, orange coloured stools / day
 Urgency, bloating and abdo cramps
 No blood, obvious mucous in stool
 10 day duration

9. Case study cont’d
 Reported symptoms before final Ipi/Nivo cycle --
CN documented “mild diarrhoea, advised re
bowel care, gastro stop and adequate hydration”
 Advised to go to ED
 “ I followed their advice, they give this treatment
all the time so I thought they must know what
they’re talking about”
 Advised consultant & ward registrar

11. Management issues
 Appropriate treatment sometimes delayed
 ED discharge patients without med onc
review
 Patients admitted under medical team and
do not consult with med onc
 Other specialties not providing treatment
as for immune related AE
Appropriate
management

12. Solutions????
 Regular follow up of patients between
appointments
• Resources – how often?, cost effective?
 Education
• unaware of significance Aes / apparent
knowledge
• only reaches those that attend session
• rotation of medical staff

13. Solutions?
 Formal education - nursing & medical staff
 Assessment tools / alert cards
 Designated contact with Immuno-oncology
experience
 Individual responsibility to know about
treatment - proper assessment and follow
up of symptoms Vigilant
follow-up

15. Assessment tool

16. A team approach – Communication is KEY!
Patient
Medical
Oncologist
Pharmacist
Carer
/family
Oncology
nurse
General
Practitioner
Other
Specialists