Evidence Defines Nursing Implications for Combination Cancer Treatment Side Effects
Immune checkpoint inhibitors (ICIs) enhance immune response against foreign antigens, such as cancer, by manipulating checkpoints that have stopped the body from fighting them. In doing so, they also increase risk of the immune system attacking healthy cells and producing inflammatory side effects, resulting in immune-related adverse events (irAEs).
As a nurse scientist, I’ve participated in and collaborated with interprofessional panels to develop management guidelines for irAEs. Initially, we formed them based on expert consensus extrapolated from patients with autoimmune disease. However, results from ongoing research (https://ascopubs.org/doi/10.1200/JCO.21.01440) into ICI irAEs are defining the guidelines’ latest updates (https://www.nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf).
My research (https://link.springer.com/chapter/10.1007%2F978-3-030-74028-3_7) and clinical experiences have contributed to management guidelines for the following ICI irAEs:
- Pneumonitis
- Rash and pruritis
- Diarrhea and colitis
- Nephritis
- Elevated liver enzymes
- Peripheral neuropathy, myasthenia gravis, and Guillain-Barré syndrome
- Uveitis, iritis, and scleritis
- Elevated lipase, pancreatitis, and type 1 diabetes
Our studies support the understanding that ICI side effects present differently than those from radiation, cytotoxic chemotherapy, and other treatments they may be combined with. ICI irAEs typically occur after weeks of therapy, although some develop after one to two cycles, months of therapy, or discontinuation of therapy.
I’ve found that managing side effects and irAEs for patients on combination therapies can be challenging because of the variety of combination options and disease types, and the landscape is always changing with the expansion of approvals. An important implication for oncology nurses when caring for patients receiving combination treatments is to educate them about all possible side effects and presenting symptoms and the importance of contacting their care team immediately with all new or progressing symptoms. Patients should also understand the mechanism of action of the drugs involved in combination therapies.
Based on the evidence (https://link.springer.com/chapter/10.1007%2F978-3-030-16550-5_7), I advise (https://www.sciencedirect.com/science/article/abs/pii/S0749208119301081) nurses to:
- Review the signs and symptoms of all potential toxicities and the parameters for which a patient should report to the treatment team.
- Understand the ICI administration schedule and any variations based on dosing and combinations versus single agents.
- Help patients and families set expectations about potential responses to therapy and treatment.
- Advise patients of childbearing age to use effective birth control during and for at least five months after the initial dose of immunotherapy.
- Inform patients to carry a card in their wallet with their care team’s contact information and the type of immunotherapy they are receiving.
- Educate patients about using corticosteroids and supporting interventions to prevent side effects from the steroids.
- Ensure patients understand their survivorship care plan and latent effects.
Nurses are at the forefront of patient evaluation and must understand ICIs’ mechanism of actions, side effects, presenting signs and symptoms, assessment parameters, and management. Education and access to the tools and algorithms enables nurses to monitor, track, document, assess, and provide safe care.