Meeting the Challenge of Immune-Related Adverse Events With Optimized Telephone Triage and Dedicated Oncology Acute Care

Abstract

Immune checkpoint inhibitors (ICIs) have improved outcomes for many patients with advanced cancers. However, managing the immune-related adverse events (irAEs) associated with these agents is challenging. Late recognition and/or inadequate irAE management can result in ICI discontinuation or termination, negatively impacting patient outcomes and increasing unplanned emergency department visits, hospital admissions, and costs of care. Improved clinician training and infrastructure development are needed to adequately address irAEs and maximize the potential benefits of ICIs. Advanced practice providers (APPs) are well positioned to drive these improvements. Two aspects of care may reduce the burden of irAE management: improved telephone triage and the implementation of dedicated oncology acute care services. Evidence-based protocols should be used for telephone triage. Protocol development may benefit from an evaluation of current irAE management guidelines together with resources from the Melanoma Nursing Initiative and Immuno-Oncology Essentials. Patients and their caregivers must be educated to recognize and report early symptoms suggestive of an irAE, thereby supporting triage efforts. Advanced practice providers should also advocate for the development of dedicated oncology acute care facilities staffed with clinicians well trained to recognize, grade, and manage irAEs. This manuscript reviews multiple existing models of telephone triage and dedicated oncology acute care. Oncology APPs are poised to lead the staffing, infrastructure, and educational changes necessary to reduce the burden of irAEs in patients receiving ICI therapy.

Efficiency of Electronic Health Record Assessment of Patient-Reported Outcomes After Cancer Immunotherapy

“…An efficient follow-up process that facilitates the monitoring and reporting of irAEs in a timely manner is important for ensuring patient safety. Previous studies have shown that ePRO follow-up enables timely and continuous collection of information regarding symptoms in a cost-effective manner [9][10][11][12][13][14] and results in an improved QOL, fewer ED visits, longer duration of palliative chemotherapy, and superior quality-adjusted survival. 15,16 However, the efficacy of ePRO follow-up has not been examined in patients treated with…”

“…However, the number of studies, especially large-scale randomized clinical trials, are limited. Hoffner and Rubin reported improvements in telephone triage by using immuno-oncology–essential materials to reduce the burden of irAE follow-up. Le et al evaluated the impact of a pharmacist-led irAE follow-up process that reduced the times required for physicians to manage irAEs and increased physician confidence.…”

Impact of Nutritional Status on Neutrophil-to-Lymphocyte Ratio as a Predictor of Efficacy and Adverse Events of Immune Check-Point Inhibitors

“…While the high therapeutic efficacy of ICIs has been confirmed, serious immune-related adverse events (irAEs) have also been shown to occur [3,4]. irAEs are the side effect caused when this activated immune function is excessive, causing severe damage to various organs throughout the body [5][6][7][8][9]. However, this may contribute to favorable anti-tumor effects and a prolonged prognosis due to a strong immune response [10].…”

Virtual Follow-Up in Patients Initiating Antineoplastic Treatment in the Ambulatory Setting

“…1 Data demonstrate that up to 40%-50% of patients receiving chemotherapy and 25% of patients receiving immunotherapy seek emergency care because of treatment-related side effects. 2 Acute hospital visits affect patient outcomes by delaying treatment, lessening quality of life, burdening caregivers, and increasing overall health care costs. Many emergency visits are avoidable with proper preventative management of key treatment-related conditions that are common causes of emergency visits in patients with cancer receiving antineoplastic therapy: anemia, dehydration, diarrhea, emesis, fever, nausea, neutropenia, pain, pneumonia, and sepsis.…”