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Jeff, I totally agree. We need more education and so do our patients, especially since so many have comorbidities coinciding with their cancer which can predispose them to adverse events/reactions.
Holly- you make a good point. How often do we have patients on immunotherapy that have cardiovascular changes that we attribute to anything other than cardiac toxicity. So many of our patient have tachycardia and we assume they are dehydrated and/or anemic. You also mention fatigue and SOB- unfortunately those are two of our most common side effects for almost any treatment. We must be diligent to rule out cardiac problems in these situations. I wonder how many of our providers are aware of this?
I completely agree with all of you about the surprising risk of cardiotoxicity with ICIs, and I am concerned for all our patient’s that come in with generalized complaints of fatigue, mild tachycardia, SOB, ect, that we have been attributing to some other problem. I would love to see if there is any data that has been collected on our patients on ICIs and the incidence of cardiotoxicity or even how many have been admitted for what I previously assumed was an unrelated cardiac event, but now to find out was a toxicity from an ICI.
1. What was the knowledge gained from the article?
In the first article, I was surprised by how high the incidences of immunotherapy related side effects are as high as 56-74%. Especially the cardiac side effects. In the second article, the results of the study show that 6.2% of skin ca patients on are steroid-refractory or steroid dependent side effects. I take calls in the After-Hours Clinical Call Center from patients from many areas at the James. These patients have many different cancer diagnoses and have a variety of treatment plans. Many of them are taking checkpoint inhibitors. In the first article, I learned about that the cardiac side effects associated with these drugs, which was something I was not aware of. I also thought that the immunotherapy was less toxic than chemotherapy. Because my job is when all the clinics are closed, it would be important for me to make the appropriate level of care referral depending on the severity of the patient’s symptoms and the fact that the patient must be seen in either our ICC or an emergency room if they have serious cardiac side effects.
2. Will the research/information in this article change or influence your practice? If so, how?
My responsibility is to refer the patient to the most appropriate level of care until the clinic is open. Whether it be home care advise, the ICC (oncology urgent care at the James) or the emergency department. Many of our patients live too far to be able to come to OSU for urgent unscheduled needs but having the knowledge of the side effects and the urgency of getting the patient the right care can often encourage a reluctant patient to report to their local medical facilities. Even when they have been educated on side effects and when to seek care, the patients often don’t want to go to the local facilities or just want a prescription called in so they don’t have to go anywhere. Re-educating them on the side effects and dangers of not seeking care can often persuade them to seek care.
3. What other questions does the article raise about current practice?
We just started taking calls and covering for the oncology cardiology team. I am wondering how these services will grow with the increased use of checkpoint inhibitors in more types of cancer treatment.
4. Do you agree/disagree with the conclusions of the author, why? Yes, I agree that our patient need to be screened for cardiac side effects especially as the use of these medications is expanding. We need more research regarding how to manage and screen for the side effects of these treatment plans.Hi Kasey (karafa-4), I agree that the more we use these treatments the better we should be in screening for cardiac issues that can develop with these treatments and for those patient that are already have a cardiac co-morbidity. I know in our department that we started receiving calls for the oncology cardiac team so at least now we have a resource to check with for patients that we have concerns relating to cardiac side-effects. Your example of the patient with jaundice is very eye opening to see that sometime the swiss cheese effects can occur even with checks and balances and the devastation that missing that can cause. the more we learn, the more we see we didn’t know what we didn’t know. Thanks to Marla for these articles to educate us on these concerns.
Holly,
I agree that fatigue and shortness of breath are very common complaints among cancer patient receiving treatment of any kind, chemotherapy, radiation and immunotherapy. It is important for us as nurses to report these symptoms so that they can be evaluated and rule out any cardiac toxicities sooner.
As a few have mentioned, we seem to brush off complaints of fatigue or tachycardia. So many of our patients are getting chemo in addition to immunotherapies. The chemo can and often will cause fatigue so it’s hard for us to confirm if the immunotherapy is causing it or the chemotherapy.
Hello! My name is Katie Conrad and I am a nurse in the JCRU. Wow! I found these journals interesting to read!
1. What was the knowledge gained from the article?
Both articles are very insightful. Generally, when administering an immunotherapy I assess for inflammatory symptoms or adrenal fatigue. Now I realized I shouldn’t limit my assessment to the typical thyroid, pneumonitis, or colitis. Cardio myocarditis should be a concern as well. I also learned that ICI-associated myocarditis frequently fails to respond to steroids and other immunosuppressants. Which is pretty frighting. More importantly I learned generally myocarditis from ICI generally occurs within the first 3 months of therapy initiation and most prominently 2-4 weeks after the start of therapy. Being primarily an oncology nurse, I sometimes forget how life altering other diseases like mycocarditis can be. Myocarditis can lead to cardiomyopathy, arrhythmias, heart blocks and much more.
2. Will the research/information in this article change or influence your practice? If so, how?
Yes, I will now be more mindful of toxicities related to immunotherapies. To be honest I generally feel like patient’s tolerate immunotherapies pretty well but what I am learning is that rarely when the treatment is not tolerated well it can be pretty life altering. An example of this is adrenal fatigue. I also learned that patients with autoimmune disorders are more at risk for developing adverse effects. Because of this I will be more aware during nursing check ins and notify providers when risk factors are present. Also, I will brush up on my knowledge regarding myocarditis and things I can look for to help patients who might be experiencing that.3. What other questions does the article raise about current practice?
I am more curious now about future research on immunotherapy and adverse effects. Could things that cause inflammation be avoided resulting in better tolerance of the treatments? Would an anti-inflammatory diet help decrease the chances of adverse problems?
4. Do you agree/disagree with the conclusions of the author, why?
I agree with the authors that more research is needed regarding toxicities related to immunotherapy. As with any new treatment time will tell what things we can expect regarding patients who are on these therapies for a longer period. Also, I agree cardiac clearance should be something considered especially with patients who has a history of autoimmune disorders.
@ Strickland- You mentioned oncology cardiac team. Hearing we added this clinic to The James several years ago made me really want to delve deeper into cardiac related issues in Oncology. Now after reading these journals I realize that there’s more to oncology cardiology than what I thought. I would love to spend a day in that clinic and pick their brains.
Kasey thanks for sharing that story regarding your CTU patient. Hearing how good the patient looked verses how sick she really was is an eye opener. I recently had a patient at the Breast Center that experienced pretty significant adrenal fatigue. The patient was refusing her immunotherapy and the team discussed with her that due to her severity of adrenal fatigue, she will live with adrenal fatigue for the rest of her life. The patient was refusing her immunotherapy but the team shared with her that the damage was already done and they encouraged her to continue with the treatment. Ultimately she refused.
Mindy Blackwell – gyn/onc
. What was the knowledge gained from the article?I think what made the biggest impression was the cardiotoxicity because that is not what I first think of when assessing a patient on ICI. I also don’t see many symptoms at all w/ ICI patients compared to what I remember when Pembro first came out or even 5years ago. I just thought the dosing and or frequency was changed to decrease those symptoms because I saw a change in both.
2. Will the research/information in this article change or influence your practice? If so, how? This was a good reminder to focus on cardio a little closer since a lot of times the patients minimize symptoms and farther out from treatment to continue that assessment since side effects can happen farther out treatment.
3. What other questions does the article raise about current practice?
If we know they will be more sensitive, then what would we do different? Can we do some pre-testing to determine how sensitive they will be and if they may need to be on steroids long term etc,. I remember studying for my OCN and reading that those that grew up around mouse droppings like on a farm etc,. were often more sensitive “mab” drugs. I don’t ever remember any assessment asking if they grew up on a farm around mice habitat!
4. Do you agree/disagree with the conclusions of the author, why?
As always, more research is needed. How many more years of research and billions of dollars must be spent?
Jeff – I wonder also about the build up of frequent exposure to ICI’s and their cardiotoxicities. I wonder in further research if we might find that there is a tipping point as to how much is tolerable.
I think everyone agrees that we may overlook cardiotoxicities related to ICIs. I find it very eye opening considering how many I administer and how many new ICI therapies are available!
Could a simple EKG prior to administration be an easy fix to help support patients and take a deeper look at their heart health? We monitor QtCs for other drugs like Zofran. Could a simple comparison from baseline tell us anything is changing?
Is there any additional education that we should be including in our pt teaching?
100% agree with everyone that MORE research is needed! And should there be a prescreening tool to better identify pts at risk? How can Nurses help change the trajectory for better outcomes?
Maria Lowe – thank you for facilitating this club and can you tell me how you get your font to be bold? I have copied and pasted and tried everything to make it easier to read and it doesn’t work!
I was just realizing that maybe I have not given vague symptoms the attention they should have. It is easy to do when we get so focused on certain things. I do think w/ cardio our NP’s are really quick to address and monitor if they are changing from baseline.Jeff- I agree, I think some patients don’t get cardio assessed close enough for ICI’s. I am going to pay closer attention to new starts as to what pre-testing is going to be done.
Katie Conrad – I think these articles have been an eye opener for all of us and in reading the comments it seems most of us are going to start assessing or start are more focused assessment on cardio. It is definitely frightening to read that some don’t respond to immunosuppressants so if they start having symptoms then what?I don’t know about the rest of you but my experience has been that all patients assume immunotherapy is much better than chemo and it is not doing to cause any adverse effects or long term damage. I am sure it has been from how they were first marketed but they really are no safer than standard chemo. We have been doing standard chemo so much longer it is possible that the management is better than w/ ICI too.
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