Today, the focus of many groundbreaking cancer therapies has turned inward—to the body’s own immune system. Although using the immune system to fight cancer isn’t a new theory, huge advances in the field of immunotherapy have started to change the landscape of cancer treatment as we know it.
These new treatments have increased the survival rates of patients with diseases that typically have high mortality rates, including advanced forms of melanoma, bladder cancer, lung cancer, Hodgkin lymphoma, head and neck cancers, and kidney cancer.
Benefits and Challenges of Immunotherapy
As immunotherapy is increasingly used in clinical trials and as standard of care, clinicians continue to realize the benefits and potential anticancer effects of these agents but also encounter new challenges in management.
Benefits
- Immunotherapy agents are mostly well tolerated.
- Immunotherapy seeks out tumor-specific antigens so that only cancerous cells are targeted and destroyed, leaving healthy cells intact.
- Immunotherapy sometimes results in immunologic memory of cancerous cells, so that they may be detected should additional cells mutate over time.
- Positive effects seem to be universal to multiple cancer sites; clinical trial data for one disease seems to extrapolate to others.
Challenges
- Optimal outcomes may come in early stages of disease prior to being heavily pretreated.
- Questions remain surrounding long-term side effects.
- Additionally, financial burden plays a role in the feasibility of using the agents.
Most immunotherapies bolster the immune system to combat tumor cells. The immune system has a way of monitoring and destroying cancer cells on its own, typically referred to as immune surveillance, but in many cases, tumor cells adapt and disguise themselves from the body’s natural defenses. In such situations, immunotherapies call for checkpoint inhibitors that prevent a cancerous cell’s ability to disguise itself from the immune system. For example, “the interaction between the programmed death 1 receptor and its ligand 1 and 2 is a key pathway hijacked by tumors to suppress immune control." By inhibiting this pathway, the immune system is able to recognize the tumor and attack it accordingly.
Using the Immune System to Fight Back
According to ONS member Jill Weberding, MPH, BSN, RN, OCN®, nurse consultant for Nurse Advocates in Seymour, TN, “Immunotherapy doesn’t target the tumor itself, but it enhances our response to recognize the tumor as a bad guy and attack it. Our immune system is adaptive, so in theory we hope to see less resistance and more durable responses. This has held true for some of the current U.S. Food and Drug Administration-approved checkpoint inhibitors.”
Priming the immune system to recognize and attack cancer cells takes many different agents that can be employed for different types of cancers. “Immunotherapies include cytokines (e.g., interleukins, interferons, granulocyte-colony stimulating factor), monoclonal antibodies (e.g., rituximab, elotuzumab, trastuzumab), cell therapy (e.g., sipuleucel-T), vaccines (e.g., recombinant human papillomavirus vaccine), oncolytic viruses (e.g., talimogene laherparepvec), and checkpoint inhibitors (e.g., ipilimumab, pembrolizumab, nivolumab),” Weberding says. “They all work differently; however, the goal is the same—stimulate or elicit an immune response to attack the cancer in the patient’s body.”
New treatments call for a greater level of knowledge among nursing staff and caregivers. “These drugs are nursing intense from an education and triage standpoint,” Weberding says. “It’s critical that we educate our patients on what side effects to expect, how they are different from typical chemo side effects, and how critical it is to report side effects immediately so we can manage them appropriately.”
Approaching Immunotherapy With Your Patients
Covering the gap between medical explanations and making the information relatable to patients can be tricky, especially when a new treatment is under consideration. “I explain to my patients that this treatment is not your conventional therapy offered to treat cancer,” says ONS member Kristine Mykulowycz, RN, BSN, lead clinical research nurse and educational specialist for the clinical research unit at Abramson Cancer Center in Philadelphia. “I tell them how immunotherapy is a new way to trick the immune system into fighting or disabling the cancer cells from surviving and growing.”
According to Mykulowycz, illustrating the differences between traditional chemotherapy and immunotherapy treatments helps create a clearer picture for patients. “With traditional treatments, such as chemotherapy and radiation, the main purpose is to kill the cancer cell. The unfortunate side effect is that they also have the potential to kill healthy, good cells as well. Immunotherapy is specified to trigger a particular part of the immune system to attack a specific part of the cancer cell, so there are fewer side effects.”
Weberding explains, “The side effect profile is very different from chemotherapy. This first thing I always address with patients is to alleviate the fears of every TV drama they’ve seen. ‘You are not going to lose your hair. You are not going to be puking your guts up, unable to get out of bed or off the couch.’”
However, that doesn’t mean immunotherapies aren’t without side effects. “Once you have taken their greatest fear off the table (intense nausea with vomiting and complete hair loss), they are more equipped to listen to the actual side effects we do expect with these drugs. We have unleashed the immune system, which can sometimes turn into a runaway train. So patients can’t blow off symptoms. Early intervention is the key to successful management of toxicities,” Weberding says.
Although a variety of immunotherapy agents are available, they aren’t all guaranteed to work on all patients. According to Mykulowycz, some immunotherapy vaccines can cause discomfort when being administered.
“The preparation time for the majority of immunotherapies is currently longer than traditional chemotherapy,” Mykulowycz adds. “This causes patients a much longer wait time during the course of their treatment day.”
ONS Immunotherapy Online Course
ONS is introducing the first immunotherapy course for oncology nurses. Hailed as one of the most promising new forms of cancer treatment since chemotherapy, Immunotherapy stands to change the way we treat cancer.
The ONS Immunotherapy online course is the first of its kind. Designed from a clinical perspective, the program educates oncology nurses and other healthcare providers how immunotherapy drugs reprogram the immune system to identify and target cancer cells.
Learn more about this on-demand, online immunotherapy course.
The Promise of Immunotherapy
“We’re finally seeing responses in historically, very difficult diagnoses to treat like advanced melanoma and lung cancer. Squamous cell lung cancer had not seen an improvement in second-line treatment for 15 years prior to nivolumab’s approval. And that’s not for a lack of trying,” Weberding says.
Before the advent of immunotherapies, metastatic melanoma had an average survival timeline of six months. Low survival rates and a lack of treatment options didn’t provide patients with much hope. “Then the immunotherapy gate opened when ipilimumab was approved in 2011. Since then, we’ve had eight new treatments approved for melanoma,” Weberding notes. “We’ve seen patients come out of hospice. We have patients with advanced melanoma who are years out from treatment with no evidence of disease. Think about what that means—all the birthdays, anniversaries, graduations, weddings, holidays, births, and all the wonderfully mundane moments in between. That is real. That is changing lives—not just the patient’s but everyone’s surrounding them.”
The oncology field is excited about immunotherapy, and these treatments are just getting started. With the hope for increased research funding in the near future, immunotherapy will likely benefit as it is applied to a wider spectrum of cancers and more treatment options are developed.
“It’s not a silver bullet and doesn’t work for everyone or in every diagnosis,” Weberding says. “But we are definitely seeing more people responding and that’s equating to longer lasting responses. What’s not to get excited about?”