[blackwell.72]

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• This reply was modified 1 year ago by blackwell.72.

[blackwell.72]

Maria Lowe – thank you for facilitating this club!
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.

[lu-hsu.24]

Hello everyone, I’m Stephanie. I am part of the clinical trial unit at the JOC and James (5 infusion).

What was the knowledge gained from the article?
In clinical trials we administer many immune check-point inhibitors. These patients must meet specific parameters for and during treatment, such as, ECHO, ECGs, and vitals throughout treatment monitoring for cardiac changes. This only emphasizing the possible cardiac impact the drugs can have on our patient’s heart function.
However, I was not aware of the degree of cardiotoxicity that are seen. I also was not aware that there was a link between T cell activity associated with cardiac ischemic events. Unfortunately, many times when patients complain of fatigue and weakness, I attribute that to the other side effects of the treatment such as decrease hemoglobin and not directly to cardiovascular immune-related complications.

What other questions does the article raise about current practice?
I wonder with these findings how can we further identify and assess for cardiotoxicity in our patients? What will the medical team do to manage ICI related cardiotoxicity if steroids are not possible?

Do you agree/disagree with the conclusions of the author, and why?
I agree that further studies and information is needed. I also agree that oncologist and cardiologist need to further collaborate with one another especially since ICI therapies are so prominent now and in the future.

[lu-hsu.24]

Maria,
Thank you for sharing these journals with us.
I agree, I didn’t know about the current statistics of cardiac related toxicities with ICI treatments. I also agree that more research is needed for patients and what we could do if patients do not respond to steroids. I know many times we want to give patients steroids whenever they are having a reaction. In the past, patients typically respond so quickly. However, in some of our clinical trial patients physicians want to avoid giving steroids unless its absolutely necessary and choose to have us administer Benadryl as the first line drug for reactions.

Jeff,
I agree many times with ICIs we concentrate on the side effects that are more prominent such as, pneumonitis, hepatitis, colitis, and skin reactions. Cardiovascular immune-related complications are not an assessment that we are accustomed to doing or recognizing to tell providers about. Our clinical trial patients do get cardiac clearance and monitoring, but it is not always the case outside of clinical trails. I would hope this becomes more of a standard for our patients so that we can get a baseline and then see what the changes are with treatments.

[strohschein.2]

Stephanie,
I agree with you that patient reported fatigue and weakness could stem from a patient’s additional comorbidities, such as anemia. Cardiotoxicity doesn’t immediately come to my mind during these encounters. It makes me wonder how many patients who develop cardiotoxicity from ICI are missed at The James.

Kasey,
I agree, I was not aware that “all patients” who receive ICIs undergo cardiac clearance as the journal article states. Given that cardiotoxicity can be life threatening for the patient, I think it would be more than reasonable to complete a cardiac screen on all patients at The James receiving ICI.

[shawver.25]

Maria, I’ve talked to a few doctors and they said they are seeing more and more people have reactions to immunotherapies since 2020. I think it’ll be a very difficult research follow-up for a variety of reasons whether the immunotherapies are cumulative such as other chemotherapies. I think these long term side effects or toxicities will just have to be addressed when we encounter them in the future vs having a knowledge base to prepare for them.

Thanks again for hosting Maria!

[pauley.18]

Good morning!

1. What I learned from the articles is the that nurses really may be the first line in noticing cardiac toxicities in patients receiving Immune checkpoint inhibitors. I had the knowledge that cardiac side effects could happen and knew that baseline echos were performed for a patient beginining chemotherapay regimens, but didn’t realize the subtle symptoms that could arise and be helpful in lessening the chances of cardiac toxicities causing morbid outcomes for our patients.
2. Will this information change my practice….of course it will. If I know a patient is undergoing an immunotherapy regimen, I will be more likely to ask the patient about any new symptoms they are experiencing, even if they think it is something very small.
3. Questions that I have, not working in chemotherapy, is how in depth are our patients getting the baseline cardiac workup prior to initiating these regimens and are they then given the same testing at certain intervals while on therapy? Are symptoms not being reported by our patients as well due to the lack of knowledge regarding the tendency for these regimens to cause the various cardiac traumas from the regimens. I am hopeful more research is being conducted at The James for these regimens and side effects.

[pauley.18]

Stephanie..your comments were right on point with my post (I made myself not read the other comments until I made my post). I am worried that symptoms patients report could be overlooked by their other diagnoses and could potentially lead to worse outcomes due to the lack of knowledge of the first line evaluators, their nurse.
Jeff and many of the others….I too agree that not all of our patients are getting the in depth cardiac workup that from reading these articles, is absolutely needed to keep our patient as healthy as possible while undergoing these regimens. What is progression free survival if you are not feeling healthy.

Thanks to Renee for coordinating this journal club and Maria for leading…Amoreena.

[monroe.1140]

Hi , My name is Wanda Monroe. I work in BSH Infusion.

1. What was the knowledge gained?
Before reading this article, I had no idea the cardiac toxicities related to immunotherapy. We give a lot of combination treatments with immunotherapy and chemotherapy. It does surprise me that we are not monitoring patients closer for these side effects. It’s also concerning that symptoms can be similar to normal chemo side effects. My knowledge gained is awareness.
2. 2. Will this information change my practice?
Definitely. During my assessment of patients, I will keep in mind symptoms to look for regarding Cardio toxicities. I will also bring these symptoms to attention with the clinic team.
3. 3. What other questions does the article raise about current practice?
The question I have is why are we not scanning these patients for cardiac issues prior to starting treatment? What are we doing to monitor these patients during there treatment. Many of these patients receive immunotherapy for years.

[monroe.1140]

Jeff- I agree with that patients are not being scanned properly prior to starting treatment and during treatment. I think we can do better at monitoring patients before, during and after.

[monroe.1140]

Thanks, Maria, for posting this article. The statistics shocked me. I think patients need to be more aware of long-term risks and what to look for as far as symptoms.

[gabel.164]

What was the knowledge gained from reading these articles?
I was unaware of the potential of cardiac toxicities with patients receiving immune checkpoint inhibitors.
I also was unaware of treatments steroid-refractory immune-related side effects from checkpoint inhibitors.
Will the research in this article change your practice? These articles reiterated the importance of a thorough assessment by the nurse and keeping providers informed of changes.
What other questions does the articles raise?
Like others have mentioned should there be any additional testing for those patients prior to initiating treatment.
I’ve seen provider obtain thyroid labs prior to starting treatment but haven’t seen any cardiac clearance. I know with trastuzumab echocardiograms are required every 3 months.

[gabel.164]

Kasey thank you for sharing a specific patient scenario. It truly reiterated the topics in these journal articles.

[gabel.164]

These articles reinforced the importance of not underestimating the potential of severe adverse side effects from receiving checkpoint inhibitors.

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