Cancer immunotherapy for the advanced practice nurse

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Published: 8 May 2019
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Krista Rubin - Massachusetts General Hospital Cancer Center, Boston, USA

Krista Rubin speaks to ecancer at ONS 2019 about cancer immunotherapy for the advanced practice nurse.

In the session she presented information on toxicity management, using case studies that are typical of side effects that advanced practice nurses may have to manage or be vigilant of while monitoring patients.

Krista discusses some of the interesting questions and feedback that she received during the second session on this topic, including the challenges of grading toxicity.

The subject that we discussed in our session yesterday, it was actually a two hour session for advanced practice nurses on an overview of the immune system, in particular with the checkpoint pathways and toxicity management for patients receiving those agents such as the PD-1 inhibitors, anti-CTLA-4 and PD-L1 inhibitors. It was an overview with highlighting the toxicities via case study discussion.

What were some of the case studies that were discussed?

The case studies that we talked about yesterday, there were three case studies that we discussed. One was a case on cardiotoxicity, so toxicity specific to the heart that can evolve through immune checkpoint therapies. We also discussed one on colitis and one on an endocrinopathy, specifically on adrenalitis, or inflammation of the adrenal gland.  We chose those particular case studies because we thought that they would be typical of something that an advanced practice nurse may have to manage. We described the common presenting symptoms, what to look for in terms of testing, what blood tests to obtain, what type of imaging and then we also talked about the role of the advanced practice provider in managing those patients.

The third case that we chose, the one on the adrenal gland inflammation or adrenalitis, we chose because the endocrinopathy toxicities are challenging to many providers because it’s not something that we usually deal with in oncology. Since the evolution of these checkpoint inhibitors we’ve learned that the endocrinopathies, or the toxicities related to the endocrine system, are quite common and advanced practice nurses, nurses, physicians all need to be aware of these and have a high vigilance for looking out for potential symptoms that may be indicative of those particular toxicities.

Were there any interesting questions or discussions during these sessions?

We just had a session now that we followed up with questions. There was much more time and a more informal setting for the audience to ask questions. Many of the questions we got were on how to manage some of the thyroid dysfunction, use of steroids – is that allowed, can you put patients on steroids beforehand to prevent some of these symptoms? So we discussed that in more detail. We talked more about the logistics of managing these patients and it can be challenging for many. Many nurses are not familiar with the common presenting toxicities or symptoms that are indicative of toxicity. So there was a lot of back and forth about practice. I co-presented with Laura Wood, another advanced practice provider, and just among ourselves we managed some of the toxicities differently. We discussed how there’s not necessarily a right or wrong and really went into depth and described the algorithms that are available in public domain to use to guide your assessment and management of these patients.

Was there any interesting feedback that you would like to highlight?

One of the questions that we often… Laura and I give a lot of presentations on this topic and one of the things that we’ve learned is that grading toxicity is not something that’s common to most providers. If you’ve been involved with clinical research you’re familiar with how to grade toxicities. So we described the common toxicity criteria which is known as the CTCAE and we talked about the utility of that in everyday practice and how it’s something that providers caring for these patients receiving immunotherapy should be familiar with because it’s a phenomenal tool that can help with properly diagnosing and steering you to the correct intervention for that particular toxicity.  So there was a lot of discussion about that; there are many nurses not familiar with that and so we provided tools, apps, websites and different resources that they could utilise or access in their everyday practice.

Is there anything else you would like to add?

Laura and I co-presented on behalf of both the Oncology Nursing Society as well as the Society for Immunotherapy in Cancer, or SITC. This was the first time we’ve done this co-sponsored programme. SITC is a wealth of information for immunotherapy specifically and so we’re sharing resources and tools to enhance clinical practice. So this was, we think, a great success, there were a lot of attendees. So it’s a great way to highlight both the resources available to both organisations.

The common toxicity criteria, we recommend that people have that on their smart phone if they have one. That can be downloaded free from the National Cancer Institute, or NCI. They offer the most recent version is 5.0 which just came out in November of 2018 and the version prior to that is 4.03 which was from 2017. The available app right now we think just came out a couple of weeks ago and I do recommend that that is downloaded onto your phone because it’s a terrific resource. Then there’s the ASCO guidelines and the SITC guidelines and the NCCN guidelines, so three different guidelines on managing toxicities are available and providers should be familiar with at least one of those and to be able to access information on proper management.