Immunotherapy represents a significant advance in cancer treatment. Immunomodulating agents utilize immunostimulatory monoclonal antibodies as antagonists of immune-repressor molecules or agonists of immune-activating receptors. They target immune checkpoint molecules dysregulated by tumors and promote tumor destruction by augmenting specific CD4-positive and CD8-positive T-cell responses. Clinical studies with immunomodulating therapies, including anti–programmed death ligand 1, anti–cytotoxic T-lymphocyte associated protein 4, anti–PD-1, anti-CD40, anti-CD137, and anti-OX40, stimulate durable and long-lasting antitumor immune response.
The mechanism of action for immunotherapeutic agents is dramatically different from traditional cytotoxic chemotherapy. Likewise, these agents have the potential to induce autoimmune activity, resulting in immune-related adverse events (irAEs) not seen with traditional cytotoxic chemotherapy. To ensure optimal care and patient safety, there is a need for a different approach to the care of patients receiving immunotherapy.
In response, an immunotherapy program was developed by nurses at Oncology Specialists for physicians, other nurses, and patients. This program includes immunotherapy educational materials for patients, families, and nursing staff; policy and procedure guidelines; toxicity-assessment tools; and electronic medical record (EMR) documentation templates. This program was implemented on September 1, 2016.
“What Is Immunotherapy?” is a patient educational tool that uses “Turn on the Light Switch” images to help patients understand immune activation. Additional patient education tools include “When to call the doctor on immune therapy,” “Patient immune-mediated reaction questioner,” and “Incorporate pharmaceutical companies’ wallet cards.” EMR templates included “Weekly check for dual immunotherapy patient,” “Immune-mediated reaction questioner,” and “Treatment plan and documentation for high-dose steroid use in immune therapy patients.”
“Nursing Immune-Mediated Adverse Reaction Checklist” is a tool to assess irAEs at patient visits and a guide for patients to use when calling to report side effects. The nursing staff received training on the immune system; immunotherapy and its effects on the immune system; how to properly assess and evaluate patients receiving immunotherapy; and how to accurately use the EMR tools and templates. They also received an overview of the potential uses of immune therapy in oncology. A “Supportive Care Treatment Plan: Steroids for Immune Oncology Toxicities” was also developed to standardize high-dose steroid use. In addition, a tool was developed to document steroid dose changes in the patient’s EMR. Clinicians with prior immunotherapy treatment experience lead peer-to-peer training on treatment administration, safety, and management guidelines.
Program evaluation will begin 3 months after implementation. Evaluation tools will be developed for medical doctors, registered nurses, and patients. The evaluation process will continue until the medical staff achieves a minimum compliance rate of 90%, and patients clearly understand immunotherapy and its related adverse events. A yearly chart audit will also be implemented. Immunotherapy is a rapidly evolving treatment modality, offering exciting treatment options and unique challenges to the healthcare team. A specific program to address the care of these patients is an effective way to meet this challenge and ensure optimal care and enhanced education.
McGreal A, et al. ONS Abstract 166.