As immunotherapeutic options for cancer treatments continue to grow, oncology nurses need a deeper understanding of the therapies, how they work, and how to manage their side effects, so they can continue to provide the best patient care.

The Clinical Journal of Oncology Nursing published a supplement in April 2017 exploring the facets of immunotherapy as cancer treatment. It provided an overview of the current evidence, discussed the types of available immunotherapy options, and explored certain treatments and side effects in detail. Additionally, it offered ONS’s recommendations for safe handling of immunotherapy agents.

Immunotherapy as Cancer Care

According to Ginex, Brassil, and Ely, immunotherapy has a few key advantages over other cancer treatments such as chemotherapy or radiation therapy. “First, the human immune system can distinguish between healthy and unhealthy cells and, in many cases, can mount a response against the unhealthy cells. Second, immunotherapy treatment can be dynamic and react to cancer cells as they develop, leading to more lasting results.”

But Ginex et al. noted that challenges come with the advantages: less than half of patients undergoing treatment for cancer will benefit from immunotherapy drugs, which is why genetic testing is indicated with some. They called for future research to better identify why some patients respond well to immunotherapy treatment and others do not.

ONS Perspective

Based on ONS guidelines and the anecdotal experiences of professionals at cancer centers with varied experiences in immunotherapy administration, ONS makes the following recommendations for principles surrounding immunotherapy administration.

Education and competencies: ONS recommends that nurses have a fundamental knowledge of the immunotherapy classes of drugs that patients in their care are receiving, as well as specific agents and protocols to follow. Nurses need to understand the highly unique and life-threatening complications associated with immunotherapy, as well as the management of those adverse events, which may differ from how they are managed when caused by traditional, cytotoxic chemotherapy.
Administration principles: ONS recommends treating the administration of immunotherapy agents with the same level of care and vigilance as other antineoplastic agents. The American Society of Clinical Oncology/ONS Chemotherapy Administration Safety Standards should be applied to immunotherapy administration as well and considered in policies and procedures surrounding these agents.

ONS also recommends that oncology nurses have fundamental knowledge of antineoplastic principles in conjunction with immunotherapy, chemotherapy, radiation therapy, and other treatments as multimodality treatment plans become more common.
Safe handling: Because immunotherapies are a newer treatment option, limited research is available on their hazardous potential. ONS recommends that every institution have an ongoing process for drug evaluation through current literature, product information, and safety data sheets. Immunotherapy agents may pose a risk of biohazard exposure, and institutions should collaborate with infection control or biologic safety departments to develop policies and procedures surrounding their use.

For more information on immunotherapy, refer to the Clinical Journal of Oncology Nursing supplement.

Types of Cancer Immunotherapy Treatments

Immunotherapy agents are currently classified into four major categories. As the treatments become even more common and oncology nurses provide care for increasing numbers of patients receiving immunotherapy, they will need a deeper understanding of the agents’ mechanisms of action, administration principles, treatment indications, toxicities or adverse events, and safety concerns.

Checkpoint inhibitors: Some cancer cells thrive by evading the body’s innate checkpoints that would normally attack malignant cells. One of the newer immunotherapies, checkpoint inhibitors prevent cancer cells from using these pathways and flag them for destruction by activated T cells.

Ipilimumab, nivolumab, pembrolizumab, and atezolizumab are the currently approved checkpoint inhibitors; each uses a different mechanism to inhibit different checkpoints. They are primarily indicated for a diverse range of solid tumors. The broad inflammatory response most commonly results in toxicities such as fatigue, colitis, pneumonitis, dermatitis, and hepatitis. Most toxicities can be treated with steroids or antitumor necrosis factor agents.

Patients will need regular laboratory tests during treatment, and oncology nurses should be aware that patients may present with atypical symptoms. Nurses can educate patients about expected toxicities and how to manage them, in addition to general best practices for antineoplastic treatments (e.g., infection control, good hand hygiene, hydration, safe sexual practices, intact skin integrity).

Chimeric antigen receptor (CAR) T-cell therapy: CAR therapies use tumor-specific antigen recognition to attack target cells. Currently, this category is in clinical trials; CART-19 is in phase I and II trials for the treatment of relapsed and refractory acute lymphoblastic leukemia, and a trial studying CAR for CD22 is open and accruing patients.

The most common toxicity for CAR T-cell therapy is cytokine release syndrome; Bayer et al. cited that the majority of patients experience it to some degree. Symptoms include fever, myalgia, and headache in mild or moderate cases to hypotension, capillary leak, or neurotoxicities in more severe cases.

Oncology nurses need to monitor patients for adverse effects and ensure laboratory tests assess for cytopenia and organ toxicities. Nurses are well positioned to notice critical changes in patients and should collaborate with the cancer care team to manage acute and chronic complications.

Monoclonal antibodies: These substances are created to target a specific antigen but have the capability to act as a natural antibody. Some are used in combination with radiation, and others use inflammatory cytokine and tumor invasion as the mechanism of action. Many drugs are approved as monoclonal antibody therapies for a variety of cancers and can usually be recognized by the suffix “-mab” in their generic name. Refer to Bayer et al. for a comprehensive list of drug names, the cancers they treat, and their associated adverse effects.

Acute infusion reactions are rare, and the majority of side effects can be treated with steroids. The symptoms do not normally self-resolve and should be treated promptly to prevent treatment interruption. Because of the immune system involvement, patients should be educated about good hand hygiene and infection prevention.

Oncolytic viral immunotherapy: These live-virus vaccines produce tumor-toxic cytokines or antitumor host immune responses. They involve four mechanisms of action: viral cell receptor response, cytokine release, nuclear replication, or extracellular immune response.

Only talimogene laherparepvec is approved for intralesional injection of metastatic melanoma, but several other vaccines are in clinical trials for a variety of other cancers. Refer to Bayer et al. for a complete list of the vaccines and the cancers they are intended to treat.

Nurses should be aware of the safety considerations for live-virus vaccines, including use of personal protective equipment and proper biohazard disposal. Patient and caregiver education should discuss measures to prevent cross-contamination, and patients should avoid contact with immunocompromised individuals, including small children, older adults, and women who are pregnant or trying to conceive.

This monthly feature offers readers a concise recap of full-length articles published in the Clinical Journal of Oncology Nursing (CJON) or Oncology Nursing Forum. This edition summarizes the immunotherapy supplement to the April 2017 issue of CJON. Questions regarding the information presented in this article should be directed to the CJON editor. Photocopying of this article for educational purposes and group discussion is permitted.

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