Supportive care for patients undergoing immunotherapy

Abstract

Immune checkpoint inhibitors, a new class of cancer therapeutic agents, play an important role in the management of melanoma, NSCLC, and other malignancies. A workshop organized by three MASCC Study Groups: Oral Care, Skin Toxicities, and Neutropenia, Infection, and Myelosuppression during the MASCC Annual Meeting held in Adelaide, Australia on 23-25 June, 2016 focused on the new class of anti-cancer therapeutic agents. Topics in the workshop included the mechanism of action and clinical uses of immune anti-CTL4 and anti-PD1 antibodies, checkpoint inhibitor toxicities, including skin adverse events, gastrointestinal toxicities, oral complications, pulmonary toxicities, and endocrinological and immune-related infections. Checkpoint inhibitors have been approved for use in different malignancies including metastatic melanoma, advanced non-small cell lung cancer, metastatic renal cell carcinoma, refractory Hodgkin's lymphoma, metastatic bladder cancer, and advanced head and neck cancer, and the list continues to grow. In general, these agents seem to be better tolerated in most patients and less toxic compared to conventional chemotherapy. However, the toxicities here, termed immune-related adverse events (irAEs), are unique and different from what we have seen in the past. There is no prospective data on these toxicities, and guidelines or recommendations are currently based on symptomatic management from the ongoing clinical trials. Treating oncologists need to be aware and alert themselves to the subtleties in presentation and the big difference in the way we manage the irAEs. Although most irAEs are low-grade and manageable, they have the potential to be life-threatening and extremely severe if not promptly treated. Additionally, irAEs could even lead to death, if managed incorrectly. The MASCC workshop addressed the various irAEs, per organ system, clinical presentation, management recommendations, and individual toxicities.

Myocarditis Associated with Immune Checkpoint Inhibitors: An Expert Consensus on Data Gaps and a Call to Action

“…Encouraging efficacy outcomes have been observed in a substantial proportion of patients treated with ICIs; however, suppression of important regulators of the immune system can lead to inflammatory reactions, referred to as immune‐related adverse events (irAEs), against normal tissue in multiple organs . Immune‐related AEs are generally low grade and manageable, especially if recognized early, although severe and sometimes fatal complications with ICIs have been reported . Cardiac irAEs appear to occur less frequently than irAEs in other organ systems but can be particularly complex to diagnose and treat .…”

“…Immune‐related AEs are generally low grade and manageable, especially if recognized early, although severe and sometimes fatal complications with ICIs have been reported . Cardiac irAEs appear to occur less frequently than irAEs in other organ systems but can be particularly complex to diagnose and treat .…”

Endocrine complications of cancer immunotherapy

“…assessed according to CTCAE -Common Terminology Criteria for Adverse Events, which will be discussed further below) determines actions needed to be undertaken, including in some cases the cessation of therapy [20][21][22][23].…”

“…There are observations that the appearance of side effects during the immunotherapy (unless, of course, they require the discontinuation of therapy) can indicate greater efficacy of the treatment. The prospective trials on the correlation between AE incidence and the treatment efficacy are still ongoing [20][21][22][23]27].…”

Oral immune‐related adverse events associated with PD‐1 inhibitor therapy: A case series

“…While all organs may be affected, more commonly reported irAEs include dermatological (lichenoid eruptions, vitiligo), gastrointestinal (diarrhea, hepatitis), endocrine (thyroiditis), pulmonary (pneumonitis), and renal (nephritis) (Belli et al, ; De Velasco et al, ; Hofmann et al, ; Michot et al, ; Ohtsuka, Miura, Mori, Ishikawa, & Yamamoto, ; Tetzlaff et al, ). When sufficiently severe, irAEs may require dose modification or suspension of treatment, which may lead to unfavorable outcomes and a negative impact on survival (Rapoport et al, ; Wang et al, ). Although the use of PD‐1 inhibitors in oncology continues to grow at a rapid rate, there have been scarce descriptions of oral irAEs (Tang et al, ).…”