Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses

Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer
Immunotherapies in Everyday Oncology Practice: Need-to-Know Information and
Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40.
Immune Checkpoint Inhibition in the
Treatment of Cancer: Basics and Practicalities
PRACTICE AID
Oncology Nursing
Tumor Microenvironment
Lymphoid Tissue
Immune checkpoint inhibitors modulate T-lymphocyte responses
against cancer by blocking negative regulation of immune responses
PD-1 pathway inhibits
signaling downstream of TCR
• TCR triggered by antigen
presented by tumor cell
• Negative regulatory receptor
PD-1 expressed and PD-L1
reactively expressed
• PD-L1 binds to PD-1
T cell inactivated
T cell inactivated
T cell activated
T cell activated
Anti–PD-1 or anti–PD-L1
monoclonal antibodies
block the interaction and
negative regulation
Anti–CTLA-4 monoclonal
antibodies block negative
regulation by CTLA-4
CTLA-4 is a negative
regulator of costimulation
required for activation of an
antitumor T cell in a lymph
node upon recognition of
tumor antigen
What Are
Immune
Checkpoints?
PD-1/PD-L1
Checkpoint
Inhibition
CTLA-4
Checkpoint
Inhibition
FDA-Approved Therapies
FDA-Approved Therapies
Without
Immunotherapy
With
Immunotherapy
MHC
Antigen
TCR
PD-1
PD-L1
Anti–
PD-L1
Anti–
PD-1
Tumor
cell
Tumor escape
Inactivation
of T Cell
Activation
of T Cell
Elimination of
tumor cells
Without
Immunotherapy
With
Immunotherapy
MHC CD80/86
CTLA-4
Anti–
CTLA-4
antibody
APC
Antigen
TCR
Inactivation
of T Cell
Activation
of T Cell
Tumor escape Elimination of
tumor cells
STOP
STOP
GO
GO
GO
Tumor escape
Tumor escape
Tumor attack
Tumor attack
Anti–PD-1: Nivolumab
Pembrolizumab
Cemiplimab-rwlc
Anti–CTLA-4: Ipilimumab
Anti–PD-L1: Atezolizumab
Avelumab
Durvalumab
• Proteins on T cells or cancer cells that need to be activated/inactivated to start/stop
an immune response, eg, PD-1, PD-L1, CTLA-4
• Serve as “brakes” that help keep immune responses in check; can prevent T-cell
response against cancer cells
• Can be blocked by immune checkpoint inhibitors (the “brakes” on the immune system
are released and T cells are able to attack and kill cancer cells)

PRACTICE AID
Oncology Nursing
FDA-Approved Immune Checkpoint Inhibitors:
Agents and Combination Regimens1
Nivolumab
• Melanomaa
• Squamous cell carcinoma of the head and
neck (SCCHN)
• Non–small cell lung cancer (NSCLC)
• Small cell lung cancer (SCLC)
• Hepatocellular carcinoma (HCC)
• MSI-H/dMMR colorectal cancer (CRC)a
• Renal cell carcinoma (RCC)a
• Urothelial carcinoma (UC)
• Hodgkin lymphoma (HL)
• Melanoma
• Merkel cell carcinoma (MCC)
• SCCHNa
• NSCLCa
• SCLC
• Esophageal cancer
• Gastric cancer
• HCC
• MSI-H/dMMR CRC and solid tumors
• Cervical cancer
• Endometrial carcinomab
• UC, including NMIBC
• RCCb
• HL
• Primary mediastinal B-cell lymphoma (PMBCL)
Cemiplimab-rwlc
• Cutaneous squamous cell carcinoma (CSCC)
Anti–PD-1
Anti–PD-L1
Anti–CTLA-4
Atezolizumab
• NSCLCa
• SCLCb
• Triple-negative breast cancer (TNBC)
• UC
Avelumab
• MCC
• RCCb
• UC
Durvalumab
• NSCLC (stage III)
• UC
Ipilimumab
• Melanomaa
Combination Regimens
Atezolizumab + bevacizumab + chemotherapy
• NSCLC
Atezolizumab + chemotherapy
• NSCLC
• SCLC
• TNBC
Avelumab + axitinib
• RCC
Nivolumab + ipilimumab
• Melanoma
• MSI-H/dMMR CRC
• RCC
Pembrolizumab + axitinib
• RCC
Pembrolizumab + chemotherapy
• SCCHN
• NSCLC
Pembrolizumab + lenvatinib
• Endometrial carcinoma
Pembrolizumab
• RCCb
• MSI-H/dMMR CRCb

PRACTICE AID
a
ICPI indicated as a single agent or as part of a combination regimen. b
ICPI indicated as part of a combination regimen. c
Line of treatment varies by disease. d
SCLC is only indicated at 240 mg Q2W.
APC: antigen-presenting cell; Bev: bevacizumab; CD: cluster of differentiation; CRC: colorectal cancer; CSCC: cutaneous squamous cell carcinoma; CT: chemotherapy; CTLA-4: cytotoxic T-lymphocyte–associated protein 4;
dMMR: mismatch repair deficient; HCC: hepatocellular carcinoma; HL: Hodgkin lymphoma; ICPI: immune checkpoint inhibitor; MCC: Merkel cell carcinoma; MHC: major histocompatibility complex; MSI-H: microsatellite
instability high; NMIBC: nonmuscle invasive urothelial carcinoma; NSCLC: non–small cell lung cancer; PD-1: programmed cell death protein 1; PD-L1: programmed death ligand 1; PMBCL: primary mediastinal B-cell
lymphoma; RCC: renal cell carcinoma; SCCHN: squamous cell carcinoma of the head and neck; SCLC: small cell lung cancer; TCR: T-cell receptor; TNBC: triple-negative breast cancer; UC: urothelial carcinoma.
1. https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm279174.htm. Accessed January 16, 2020.
Oncology Nursing
Anti–PD-L1
NSCLC; urothelial 840 mg Q2W; 1,200 mg Q3W; 1,680 mg Q4W
(IV over 60/30 min)
NSCLC (in combination with
chemotherapy ± bev), SCLC
(in combination with
chemotherapy)
1,200 mg IV over 60/30 min Q3W prior to CT/bev; upon
discontinuation of CT ± bev, continue atezo at 840 mg Q2W,
1,200 mg Q3W, or 1,680 mg Q4W (IV over 60/30 min)
TNBC (in combination with
chemotherapy)
840 mg over 60/30 min Q2W
Anti–PD-1 Indicationd
Dose
MCC, UC, RCC 800 mg Q2W as IV infusion over 60 min
UC and stage III NSCLC 10 mg/kg Q2W as IV infusion over 60 min
Anti–CTLA-4
Melanoma (unresectable/metastatic) 3 mg/kg IV over 90 min Q3W x 4
Melanoma (adjuvant) 10 mg/kg IV over 90 min Q3W x 4 à 10 mg/kg Q12W
up to 3 y
RCC, in combination with nivolumab
MSI-H/dMMR CRC, in combination
with nivolumab
Nivolumab 3 mg/kg over 30 min à ipilimumab 1 mg/kg
on same day Q3W x 4; upon discontinuation of
ipilimumab, continue nivolumab 240 mg Q2W/480 mg
Q4W IV over 30 min
Ipilimumab
Anti–PD-L1
Immune Checkpoint Inhibitors: Dosing and Frequency1,c
IV infusion over 60 min à 30 min if 1st infusion tolerated
CSCC 350 mg Q3W as IV infusion over 30 min
Melanoma (metastatic and adjuvant), NSCLC,
SCLC,d
SCCHN, RCC, UC, MSI-H/dMMR
CRC, HCC, HL
240 mg Q2W or 480 mg Q4W as IV infusion
over 30 min
Melanoma (unresectable/metastatic), in
combination with ipilimumab
Nivolumab 1 mg/kg à ipilimumab 3 mg/kg
on same day Q3W x 4; upon ipilimumab
discontinuation, nivolumab 240 mg Q2W or
280 mg Q4W over 30 min
RCC, in combination with ipilimumab;
MSI-H/dMMR CRC, in combination with
ipilimumab
Nivolumab 3 mg/kg over 30 min à
ipilimumab 1 mg/kg on same day Q3W x 4;
upon ipilimumab discontinuation, nivolumab
240 mg Q2W or 480 mg Q4W over 30 min
Melanoma (metastatic and adjuvant), MCC, NSCLC,
SCLC, SCCHN, HCC, esophageal, gastric, MSI-H
or dMMR CRC or other solid tumors, cervical,
endometrial, RCC, UC, HL, PMBCL
200 mg Q3W
as IV infusion over 30 min
Cemiplimab-rwlc
Pembrolizumab
Nivolumab
Atezolizumab
Avelumab
Durvalumab

Immune-Related Adverse Effects Associated With Immune
Checkpoint Blockade Therapy: Recognition and Management
PRACTICE AID
Access the activity, “Maximizing the Benefits and Minimizing the Risks of Cancer Immunotherapies in Everyday
Oncology Practice: Need-to-Know Information and Practical Guidance for Oncology Nurses,” at PeerView.com/WUA40.
Musculoskeletal
Gastrointestinal
Renal
Hematologic
Neurologic
Pulmonary
Cardiovascular
Ocular
Dermatologic
Endocrine
Spectrum of Potential irAEs
Neuropathy, meningitis,
Guillain–Barré syndrome,
myasthenia gravis, encephalitis,
and transverse myelitis
Myocarditis, pericarditis,
arrhythmias, impaired ventricular
function with heart failure and
vasculitis, and venous
thromboembolism
Pneumonitis
Colitis, hepatitis, and hepatic
transaminases
Inflammatory arthritis, myositis,
and polymyalgia-like syndrome
Uveitis/iritis, episcleritis, and blepharitis
Primary hypothyroidism,
hyperthyroidism, hypophysitis,
primary adrenal insufficiency,
and diabetes
Rash/inflammatory dermatitis,
bullous dermatoses, and severe
cutaneous adverse reactions
Autoimmune hemolytic anemia,
aTTP, hemolytic uremic syndrome,
aplastic anemia, lymphopenia, ITP,
and acquired hemophilia
Nephritis
ü Are autoimmune/inflammatory by nature
ü Are different from toxicities of chemotherapies and other cancer therapies
ü Can affect any organ system
ü Can have unpredictable onset (any time during treatment course or after)
ü Can be difficult to differentiate from other causes (diagnosed by exclusion)
ü Treatment depends on severity and may require corticosteroids + sometimes
other immunosuppressive treatments
NB!
irAEs:
Oncology Nursing

PRACTICE AID
Provides tool to distinguish which patients can be treated at home and which ones
need to come into the clinic
All staff must be educated in the use and updates of the Telephone Triage guidelines
Early identification of symptoms will minimize severity of AEs and keep patients on
beneficial therapy for a longer period of time
Telephone Triage Guidelines
Patient Considerations
Is the patient a reliable and accurate “historian”?
How reliable is the patient to follow telephone instructions? Comprehension of “sense of urgency”?
Language barriers, cognitive deficits, alcohol and drug use, comorbidities?
How far does the patient live from the clinic? Is there available transportation?
What support or resources does the patient have to follow guidelines?
• Any associated abdominal pain,
cramping, nausea, or vomiting?
• Any blood or mucous in the
stool?
• Secretary notifies clinic
practice nurse
• When did it start?
• How many episodes?
• Any recent sick contacts?
• Is the patient able to drink fluids?
Additional IO-specific
symptom questions
RN returns call; triage
questions
Patient calls with complaint
of diarrhea
If mild (increase of 4 stools/day baseline) and not
interfering with ADLs, patient may hydrate by
mouth and take an antidiarrheal agent
If moderate or severe, not able to maintain fluid
intake or associated with any other symptoms,
patient should come into the clinic for evaluation
Oncology Nursing

PRACTICE AID
General Recommendations for Grading, Assessment, and Management of irAEs1
irAEs are often diagnosed by
exclusion; other causes should
be ruled out (including AEs of other
therapies used), but immunotherapy-
related toxicity should always be
included in the differential
There should be a high level of
suspicion that new symptoms are
treatment related; early recognition,
evaluation, and treatment of irAEs
plus patient education are essential
for the best outcome
Depending on the severity of
an irAE, management may
require corticosteroids or other
immunosuppressive treatment and
interruption or discontinuation
of therapy
If appropriate immunosuppressive
treatment is used, patients generally
recover from irAEs
Grade 1 Asymptomatic; diagnostic changes only; continue immunotherapy
Grade 2
Mild-to-moderate symptoms; grade 2 diagnostic abnormalities
• Hold treatment; provide supportive care
• Methylprednisolone 0.5-1.0 mg/kg/d until stable (or oral equivalent)
If improving: transition to oral steroid at start of taper
• Dose suggested: 60 mg prednisone daily x 2 wk
• Taper over 4 wk or more to reduce recurrence of symptoms
• May consider reinitiation of immunotherapy
If progressing: treat as grade 3/4
• Consider hospitalization of patient; multidisciplinary evaluation of toxicity
Grade 3/4
Discontinue immunotherapy (consider organ-specific algorithms; endocrine)
• Hospitalization indicated
• Methylprednisolone 1.0-2.0 mg/kg/d until stable
Refractory
If no improvement or progression, additional immunosuppressant treatment may be needed
• Infliximab 5 mg/kg (except if contraindicated)
• Mycophenolate mofetil 1 g twice daily
• Cyclosporine or IV immunoglobulin
Grade Assessment and Management
Oncology Nursing

PRACTICE AID
Dermatologic—
maculopapular rash
Macule, papule, morbilliform rash, pruritus,
eczema, psoriasis, eosinophilic infiltrates,
lichenoid deposits, alopecia, vitiligo
(correlates with positive outcomes);
consider all mucous membranes
Rule out other causes, such as
cellulitis, contact dermatitis, other
drug reactions, allergies, sun
exposure, and radiation recall;
perform total body exam, including
mucosa; measure distribution;
assess impact on ADLs; assess
for prior inflammatory
dermatologic processes
Dermatologic—
bullous dermatitis
and Stevens-
Johnson syndrome
Drug rash with eosinophilia and
systemic symptoms (DRESS)
cellulitis, contact dermatitis, other
drug reactions, and allergies;
perform total body exam, including
mucosa; measure distribution;
assess impact on ADLs; assess
for prior inflammatory dermatologic
processes
Gastrointestinal Educate patients on potential AEs; onset
3 d to 10 wk or even months after ICPI
initiation; avoid foods that cause loose
stools; consider opioid constipation;
diarrhea is more common with dual ICPI;
earlier with anti–CTLA-4; risk of perforation
and sepsis
Calculate frequency and volume of
diarrhea for 24 h (including ostomy;
incontinence); look for mucous or
blood in stool; do abdominal CT scan
with contrast (look for mesenteric
engorgement, bowel wall thickening,
fluid-filled colonic distention); do
stool evaluation to rule out infectious
etiology (NAATs for GI pathogens/
bacterial culture; Clostridium difficile;
ova and parasite: molecular test for
Giardia lamblia, Cryptosporidium,
and Entamoeba histolytica; consider
microsporidia Cyclospora/Isospora;
do viral pathogens testing
when available
Most Common Organ-Specific irAEs: Presentation, Assessment, and Management1
System Prevent/Anticipate Detect/Monitor Treatment/Management
Mild G1 (10% BSA)
• Continue immunotherapy
• Treat with moderate-potency
topical steroids
• Oral antihistamines
• Topical emollients
Moderate G2 (10%-30% BSA)
• Consider holding immunotherapy
• Treat with high-potency topical
steroids and/or prednisone 0.5-1.0 mg/kg/day
Severe G3-4 (30% BSA)
• Hold immunotherapy
• Treat with high-potency topical
steroids
• Prednisone 0.5-1.0 mg/kg/day
(increase up to 2.0 mg/kg/day
if not responsive)
• Urgent dermatologic consult
Mild G1 (10% BSA)
•
Hold immunotherapy
•
Treat with high-potency topical
steroids
Moderate G2 (10%-30% BSA)
• Prednisone 0.5-1.0 mg/kg/day
Severe/Life-Threatening G3-4
(30% BSA)
• Permanently discontinue
• G3: prednisone 0.5-1.0 mg/kg/day
(increase up to 2.0 mg/kg/day if
not responsive)
• Inpatient care at ICU or burn unit
• Urgent dermatologic and
ophthalmology consult
Mild G1 (4 stools baseline)
• Consider holding
• Antispasmodic
• Antidiarrheal: loperamide,
diphenoxylate/atropine
Moderate G2 (4-6 stools)
• Hold Immunotherapy
• Prednisone 1-2 mg/kg/day (if no
response in 2-3 days, increase to
2-4 mg/kg/day)
• If refractory, consider infliximab;
if infliximab resistant, consider
vedolizumab
Grade 3 (6 stools baseline)
• Discontinue CTLA-4; consider
restarting anti–PD-1/L1 if resolved
Grade 4 (life-threatening)
• Consider inpatient care
• Prednisone 2-4 mg/kg/day
(if no response in 2-3 days,
consider infliximab)
General
supportive care:
sun protection
(sunscreen,
sunglasses);
consider biopsy if
anything unusual
presents
General
supportive care:
educate about
supportive care to
maintain hydration
and dietary changes;
GI consult: consider
colonoscopy
and EGD
General
supportive care:
urgent
dermatologic
consultation
• G4: prednisone 1.0-2.0 mg/kg/day
Oncology Nursing

PRACTICE AID
Most Common Organ-Specific irAEs: Presentation, Assessment, and Management1
(Cont’d)
Pulmonary Prevention: smoking cessation;
vaccinations
Dyspnea; dry cough; wheezing;
tachypnea; tachycardia; hypoxia;
increased oxygen requirements;
chest pain
infection, disease progression,
pulmonary embolism, pleural
effusion, sarcoidosis,
pulmonary fibrosis;
pulmonary function tests
Endocrine—
thyroid
Baseline laboratory
assessment:
fatigue, sluggishness,
anorexia, weight loss/
gain, irritability, palpitations,
feeling hot/cold,
visual disturbances,
headaches, and change
in sexual drive
Close laboratory monitoring;
monitor TSH and free T4
every 4-6 wk
Endocrine—
adrenal and pituitary
Close laboratory monitoring
with: ACTH, cortisol, FSH, LH,
renin, TFTs, estradiol,
testosterone, comprehensive
metabolic panel; monitor TSH
and free T4 every 4-6 wk
Mild G1 (25% lung)
• Reassess in 1-2 wk
• Pulse oximetry rest and ambulation
• Consider chest imaging with CT
(with contrast preferred)
• Repeat in 3-4 wk
Moderate G2 (25%-50% lung)
• Hold immunotherapy; infectious workup:
nasal swab, sputum, blood
• Consider bronchoscopy and BAL
• Chest imaging with CT contrast
• Repeat in 3-4 wk
• Consider empiric antibiotics
• Methylprednisolone 1-2 mg/kg/day
• If no response in 3-4 d, treat as G3
Severe G3-4
immunotherapy
• Inpatient care
• Infectious work up
• Pulmonary and infectious
disease consultation
• Bronchoscopy with BAL
• Empiric antibiotics
• Methylprednisolone
1-2 mg/kg/day (when G1,
taper over 6 weeks)
• If refractory, consider infliximab,
mycophenolate, or IVIG
Asymptomatic hypothyroidism
• TSH 4-10; T4 norm: continue ICPI
• TSH 10; T4 norm: continue;
consider levothyroxine
• TSH low; T4 low/norm: consider central
hypothyroidism
Clinical hypothyroidism
• Monitor TSH and T4 every 4-6 wk
• Levothyroxine replacement to maintain free T4 level at mid-range (typically 1.6 mcg/kg/day)
• Consider endocrine consultation
• Exclude concomitant adrenal insufficiency
Thyrotoxicosis
• Continue ICPI
• Propranolol for palpitations
• Repeat TFTs in 4-6 wk
Adrenal insufficiency
• Endocrine consultation
• Start corticosteroids before other hormone
replacement to prevent adrenal crisis
• Steroid replacement: hydrocortisone 20 mg
AM, 10 mg PM, slowly titrate down according
to symptoms, or prednisone 7.5 mg or 10 mg
and titrate, and fludrocortisone 0.1 mg every other day, then titrate to BP
• May need additional fluids if hypotensive
Hypophysitis
• MRI of brain with pituitary
cuts (sellar cuts)
• Methylprednisolone 1-2 mg/kg/day
• Hormone replacement as
necessary
General
supportive care:
dyspnea
management;
oxygen support;
nebulizer
treatment
General
supportive care:
levothyroxine;
educate patients
that lifetime
hormone
replacement
is likely
General
supportive care:
patient education
about stress and
hormone dosing;
wear alert
bracelet
•
•
Baseline laboratory
assessment:
fatigue, sluggishness,
anorexia, weight loss/
gain, irritability, palpitations,
feeling hot/cold,
visual disturbances,
headaches, and change
in sexual drive
Oncology Nursing

ABX: antibiotics; ACTH: adrenocorticotropic hormone; ADL: activities of daily living; ALK: alkaline phosphatase; ALT: alanine aminotransferase; ANA: antinuclear antibodies; AST: aspartate aminotransferase; aTTP: acquired thrombotic thrombocytopenic purpura; BAL: bronchoalveolar lavage;
BSA: body surface area; CBC: complete blood count; CCP: cyclic citrullinated peptide; CK: creatine kinase; CRF: chronic renal failure; CRP: C-reactive protein; CVA: cerebrovascular accident; CXR: chest x-ray; DMARD: disease-modifying antirheumatic drug; EGD: esophagogastroduodenoscopy;
EMG: electromyography; ESR: erythrocyte sedimentation rate; FSH: follicle-stimulating hormone; ICPI: immune checkpoint inhibitor; IMAR: immune-mediated adverse reaction; IO: immuno-oncology; irAE: immune-related adverse effect; ITP: immune thrombocytopenic purpura; IVIG:
intravenous immunoglobulin; LH: luteinizing hormone; LP: lumbar puncture; MRI: magnetic resonance imaging; NAATs: multiplex nucleic acid amplification tests; OT: occupational therapy; PD-1: programmed cell death protein 1; PD-L1: programmed cell death ligand 1; PT: physical therapy;
RF: rheumatoid factor; RUQ: right upper quadrant; SOB: shortness of breath; TFT: thyroid function test; TSH: thyroid-stimulating hormone; TTP: thrombotic thrombocytopenic purpura; VTE: venous thromboembolism.
1. NCCN Clinical Practice Guidelines in Oncology. Management of Immunotherapy-Related Toxicities. Version 1.2020. https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf. Accessed January 16, 2020.
PRACTICE AID
Other Common Organ-Specific irAEs: Presentation, Assessment, and Management1
Hepatic Nausea; vague abdominal discomfort; RUQ
pain; dehydration; jaundice; bleeding;
bruising; dark skin; drowsiness
Liver enzymes (AST, ALT, ALK, total
and direct bilirubin); liver ultrasound;
GI consult; rule out viral syndrome
• Hold hepatotoxic drugs
• Mycophenolate 2 mg/kg/day if refractory to corticosteroid
• No infliximab
Renal—
nephritis
Elevated serum creatinine; vague nausea;
emesis; decreased urine output; blood in
urine; ankle swelling
Serum creatinine; urinalysis;
nephrology consult; renal
ultrasound; biopsy
• Limit nephrotoxic drugs: ABX, NSAIDS, contrast dye
• Identify high risk patients (CRF)
• Hydration
Cardiac Chest pain; SOB; tachycardia; arrhythmias;
VTE; fluid retention; pericarditis; myocarditis;
effusion; vasculitis
Echocardiogram; CXR; cardiology
consult
• Blood pressure support
• Heart rate regulation
Neurologic Unusual weakness; numbness; peripheral
neuropathy; autonomic neuropathy; altered
gait; memory difficulties; seizures; aseptic
meningitis; myasthenia gravis; Guillain-Barré;
encephalitis; transverse myelitis
Neurology consult; MRI of brain to
rule out CVA; brain metastases;
MRI spine; LP; rule out infection
• Permanent discontinuation
• Rehab services
• IVIG
Ocular Dry, scratchy eyes; vision changes; redness;
inflammation; pain; iritis; uveitis; blepharitis;
episcleritis; conjunctivitis
Rule out infection; ophthalmology
consult
• Lubricating eyedrops
• Topical corticosteroid eyedrops
• Decrease local irritants, such as contact lenses and eye makeup
Musculoskeletal Inflammatory arthritis; myositis;
polymyalgia-like syndrome
Rheumatologic tests/autoimmune
panel (ANA, RF, anti-CCP, ESR,
CK, CRP); imaging; EMG
• NSAID
• Corticosteroid joint injections
• DMARD
• Methotrexate
• PT/OT
Hematologic Autoimmune hemolytic anemia; aTTP;
hemolytic uremic syndrome; aplastic anemia;
lymphopenia; immune thrombocytopenia;
acquired hemophilia
History and physical exam;
rule out drug causes; blood
chemistry tests; imaging;
coagulation panel; autoimmune
serology; viral/infection tests;
hematology consult
• Corticosteroid
• RBC transfusion or IVIG according to guidelines
• Hold/discontinue ICPI
Oncology Nursing

Patient Education and Survivorship in the Era of Immuno-Oncology:
Guidance and Resources for Oncology Nurses
PRACTICE AID
Patients resources are available online!
Nurses and the rest of the clinical team should educate and engage in shared
decision-making with patients and their families/caregivers to determine if
immunotherapy is the right choice for them, develop a treatment and monitoring
plan, and discuss what to expect during and after treatment
Education can help patients become well-informed, engaged participants in their care
Patient communication and education is critical!
What immunotherapies are and how they work
What factors determine if the patient is/is not a good candidate for immunotherapy
What to expect during and after treatment
What irAEs are, when they can occur, and the importance of close monitoring and early
detection, diagnosis, and management
Educate your patients about
Remind your patients to
Carry a wallet card with information on current/prior immunotherapy at all times
Notify their healthcare provider if they develop any new/unusual symptoms or are
admitted to a facility
• Oncology Nursing Society
https://www.ons.org/node/3761
• ASCO
https://www.cancer.net/sites/cancer.net/files/
asco_answers_immunotherapy.pdf
• NCCN
https://www.nccn.org/images/pdf/Immunotherapy_Infographic.pdf
• AIM with Immunotherapy
https://aimwithimmunotherapy.org/patient-action-plans/
• SITC
https://www.sitcancer.org/connectedold/p/patient
Oncology Nursing

PRACTICE AID
Survivorship Care in the Immunotherapy Era1-3
What are the central components of survivorship care?
Prevention strategies for new and recurrent cancers and other late effects
Surveillance for cancer spread or recurrence or second cancers
Assessment of late psychosocial and physical effects
Intervention for consequences of cancer and treatment
Coordination of care between primary care providers and specialists to ensure that all
of the survivor’s health needs are met
What do oncology nurses and nurse navigators need to know about caring for cancer survivors in the IO era?
Important to maintain relationships during and after the conclusion of immunotherapy
Immunotherapy is still a fairly new treatment with little evidence on long-term outcomes and implications à
nurses/navigators should monitor and address anxiety arising in survivors due to uncertainty about their future, eg:
No consensus on optimal duration of immunotherapy and implications of stopping early à can cause anxiety
in patients who worry that their cancer may return if they stop therapy; however, staying on treatment longer
may increase the risk of developing irAEs
irAEs can develop after stopping therapy à important to educate patients about this possibility and need to
continue to monitor and report unusual symptoms
Not clear whether immunotherapy impacts fertility or ability to conceive a healthy child à refer younger patients
to specialists to provide counseling, testing, and guidance
Number of post-immunotherapy cancer survivors will continue to grow as immunotherapy treatments move into earlier
(curable) disease settings à increased need for nurses/navigators to provide survivorship care and education
Oncology Nursing

ASCO: American Society of Clinical Oncology; irAE: immune-related adverse effect; NCCN: National Comprehensive Cancer Network; SITC: Society for Immunotherapy of Cancer.
1. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology: Survivorship. Version 2.2019. https://www.nccn.org/professionals/physician_gls/pdf/survivorship.pdf. Accessed December 27, 2019. 2. Institute of Medicine and National Research
Council. From Cancer Patient to Cancer Survivor: Lost in Transition. Washington, DC: The National Academies Press; 2006. 3. http://www.jons-online.com/issues/2016/august-2016-vol-7-no-7/1471-game-changing-immunotherapy-presents-unique-challenges-for-navigation.
Accessed December 27, 2019. 4. Marcus C. Health Psychol Behav Med. 2014;2:482-495.
PRACTICE AID
Enhance
comprehension
and retention
Deliver
patient-centered
education
Understand
the learner
Communicate
clearly and effectively
Address
health literacy and cultural
competence
Teaching and
Education
goals
Use a question list so that
patients can ask questions, and
providers can answer them
Talk to—not at— people
Find out what patients
already know before
providing information
New communication skills require
practice; structured skill
development exercises may be
helpful for providers
Ask patients, “Do you need help
understanding health information?”
Adequate
preparation for
teaching and
learning
Repeat the most important
information and increase the
frequency of the message
exposure through several
repetitions
Practice empathy,
especially when the
patient’s view differs from
that of the provider
Be aware of nonverbal
messages, including
gestures, body language,
and dress, when
communicating verbally
Present the most important
information first; emphasize one to
three key points; focus on one issue
at a time; present the information in
logical blocks; use concrete
instructions
Supplement verbal education with
simple written and visual
materials; however, the materials
should reinforce and not replace
verbal instructions or directions
Good teaching
methods
Ask patients to repeat
information in their own words
Ask patients about their life
experiences and use them
to teach; use metaphors
comparing patients’ care
and their life situation
Determine patients’ barriers
to health literacy; assessing
the ability to learn may
include interview or
observation
Use easy-to-understand language
(avoid medical jargon)
Use an interpreter if a patient
requires one due to language or
disability; avoid technical
terminology or medical jargon
Overcoming barriers
to learning
Provide information in several
ways to ensure patient
understanding; audiotapes of
patient consultations can help
patient recall of verbal education
Pay attention to and try to
dispel patients’ worries and
fears
Family remembers often
require education (eg, on
pain management)
Give patients an opportunity to ask
questions and time to speak prior to
discharge
Using a scripted tool may help
providers verbalize clearer and
more understandable patient
education
Teaching as an
interactive process
Use the teach-back method
Ask patients to state their
goals of medical care to
begin a discussion
Realize that patients may
not be aware that they do
not understand what is being
communicated to them
Audiotapes of patient consultations
can help patient recall of verbal
education
Do not just ask the patient, “Do
you understand?” Many patients
answer “yes” even when they don’t
understand
Assessment of
learning
Remember: EDUCATE to help patients become
informed and engaged participants in their care!4
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