New research from the Johns Hopkins Kimmel Cancer Center, published in the June 2019 issue of JNCCN—Journal of the National Comprehensive Cancer Network, suggests that institutions and networks that utilize immunotherapy as a treatment for cancer should consider establishing multidisciplinary teams for providing central, coordinated service for diagnosis and management of immunotherapy-related adverse events (irAEs). The researchers compiled a team of subspecialists across a variety of disciplines, who agreed to be contacted through a password-protected e-mail system. Team members replied to questions within 24 hours to provide the necessary feedback and referrals for the treatment of various irAEs.
“This service helped us identify the relevant specialists that providers can contact when needed, and may also potentially help coordinate the sharing of irAE data for research purposes,” said lead researcher Jarushka Naidoo, MBBCh, The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. “We identified which toxicities are most likely to require subspecialty input based on the breakdown of referrals for suspected and subsequently confirmed irAES. We found that the most commonly needed medical specialists were in pulmonary medicine, gastroenterology, endocrinology, and dermatology.”
The researchers were surprised by just how successful the program was. During the eight-month pilot period, there were 117 referrals regarding 102 different patients, with all providers receiving toxicity management recommendations within 24 hours. The team was comprised of eight medical oncologists, four oncology nurses, four specialists in rheumatology, three in pulmonology, two each in neurology, endocrinology, dermatology, and ophthalmology, and one each in cardiology, hematology, and infectious disease. The time commitment was approximately four-to-six hours per week for central members, and two-to-four for the other specialists.
The service was so effective that referrals continued well beyond the pilot period. All of the 57 providers who responded to a post-pilot survey reported using all or some of the recommendations they received. 73.5% of referring providers said they changed their diagnostic evaluation or management of an immune-related toxicity as a result of the recommendations from the team.
“The immune checkpoint inhibitors (ICIs) have revolutionized medical oncology; ICI therapy induces objective responses and brings improved survival to patients with a variety of cancers. However, ICI therapy may trigger autoimmune side effects that bring inflammation and damage to virtually any tissue or organ,” commented John A. Thompson, MD, Seattle Cancer Care Alliance, Chair of the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) Panel for Management of Immunotherapy-Related Toxicity, who was not involved in the JNCCN study. “Healthcare providers in all specialties are now encountering patients with these toxicities for the first time and are looking for expert, actionable advice in real time. The Multidisciplinary ICI-Toxicity Consult Service described in this paper is an important new resource to support education and best-practice care, and to study these treatment-related concerns.”
The researchers found that the establishment of the multidisciplinary toxicity team was feasible and effective for addressing the urgency and unexpected timing for irAEs. However, they stressed that in the most urgent cases, patients should continue to be treated by emergency departments.