Immune‐related Adverse Events in Cancer Patients

Abstract

The U.S. Food and Drug Administration has approved immune checkpoint inhibitors and chimeric antigen receptor T cells (CAR-T cells) as immunotherapy strategies for cancer. These therapies cause a wide variety of adverse events, which mimic other disease states and may emerge months after completion of treatment. This is important because ascertaining a past medical history of cancer treatment within the past year becomes necessary for many presentations. This narrative review summarizes the biology, pathophysiology, and adverse events associated with checkpoint inhibitors and CAR-T cells and provides a rational approach to management. Proper treatment begins with heightened awareness, rapid diagnosis, and discussion with the patient's oncologist. Treatment of these adverse effects requires only corticosteroids, infliximab, tocilizumab, or fluids or vasopressors when clinically indicated.

Immune checkpoint blockade toxicity among patients with cancer presenting to the emergency department

“…Accordingly, when the toxicity grade was mentioned in our study, it was mostly high-grade toxicity (3 or 4). IRAEs are generally more frequent with higher doses of ICB,10 with combination ICB8 and with anti-CTLA-4 rather than anti-PD-1 treatments 6…”

“…However, consideration of an IRAE was documented for only 17.3% of patients receiving ICB, and emergency physicians tended to attribute symptoms to malignant progression or infection. Because IRAEs may have a ‘sepsis-like’ or ‘pseudo-progression’ clinical presentation,8 one could argue that erroneously considering IRAEs as an infection may not be harmful, but confusing some reversible IRAEs with cancer progression might have more serious consequences.…”

Vaccine efficacy against primary and metastatic cancer with in vitro-generated CD103+conventional dendritic cells

“…1 2 Nonetheless, limitations exist with current immunotherapies including non-responsiveness or adverse events. 3 Thus, approaches to improve the specificity, effectiveness, and safety of cancer immunotherapy across patient populations and cancer types are needed.…”

Addressing New Diagnostic and Treatment Challenges Associated With a New Age of Cancer Treatment

“…10 The clinical picture is thus similar to one of autoimmune disease rather than immunosuppression. 11 Additionally, symptoms can manifest weeks to months after treatment is initiated or completed, complicating the identification of treatment-related adverse effects. Identifying immune-related adverse events requires emergency providers to have a high degree of clinical suspicion and to obtain a thorough clinical history that includes current and past oncologic treatments.…”

“…Review articles on immune-related adverse events targeting emergency providers have recently been published and warrant study. 11,12 The article by Majzoub et al 6 provides the first look at patients with specific immune-related adverse events and presenting to the ED of a large cancer center. They found that a quarter of ED patients receiving immune checkpoint inhibitors presented with an immune-related adverse event; the most common were consistent with those found in other settings, including diarrhea or colitis, pneumonitis, and dermatitis.…”