Immuno-Oncology: Essentials for Nurses in Cancer Care

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Hugh Cannon
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1 Immuno-Oncology: Essentials for Nurses in Cancer Care BERNADINE O LEARY RN, MN, CON (C) CLINICAL EDUCATOR, EASTERN HEALTH CANCER CARE PROGRAM COURSE FACILITATOR- EASTERN HEALTH ADULT CHEMOTHERAPY COURSE

2 Acknowledgements Adapted from: The Complete Immuno-Oncology Essentials for Oncology Nurses Educational Series (2017)

3 Objectives Review immune system and it s functioning Describe the differences between immuno-oncology and traditional cancer therapies Review current and pending immuno-oncology agents Outline the Nurses role in Immuno-oncology practice: Patient assessment: hx, medications, treatment side effects Early identification and management of toxicities Patient education Review Immune Related Adverse Events

5 Why Immuno-oncology?

6 Immuno-Oncology- How it s different?

12 Types of Immunotherapy

13 Cancer and the Immune System 1. Cancer Immuno-editing: not all cancer cells are detected and/or eliminated by immune system. Some persist, enter a dormant phase, avoid immune detection and then later escape as clinically apparent disease. 2. Cancer cells will create an immunosuppressive environment that prevents anti-tumor response from immune system: 1) will release their own immunosuppressive factors 2) try to de-regulate the activity of the T-cells 3) reduce or alter their own cancer antigens

Immune Checkpoints The immune response is very complex and is highly regulated by the T- cells at checkpoints Immune checkpoints sense when it is to turn down

14 Immune Checkpoints The immune response is very complex and is highly regulated by the T- cells at checkpoints Immune checkpoints sense when it is to turn down or turn off the immune response Checkpoint inhibitors are designed to prevent this from occurring, thus allowing enhanced t-cell activation against a cancer cell.

15 Immune Checkpoint Inhibitors CTLA-4 Inhibitors: Cytotoxic T-lymphocyte associated antigen CTLA-4 is a checkpoint protein on T-cells Cancer cell proteins will bind to this to prevent it from working CTLA- inhibitors prevent or block this process PD-1 and PD-L1: Programmed Death and Programmed Death Ligand 1 PD-1 present on T-cells, PD-L1 exist on the tumor cells PD-L1 tries to block PD-1 from functioning PD-1 and PD-L1 inhibitors are designed to prevent this process from occurring

17 Checkpoint Inhibitors:? In the pipeline

18 PD-L1 Testing NSCLCs tested for PD-L1 If known metastasis at time of diagnosis, testing automatically completed Local testing sent to ON % of NSCLCs will have > 50% PD- L1 expression > 50 % eligible for immuno-oncology agent up-front

19 Some more differences

20 Pseudo Progression Tumor growth noted before the tumor actually shrinks This occurs as a result of early, proliferative immune activity on the tumor: t cell proliferation and stimulation Noted early with treatment and monitoring: within first 3-6 months of treatment or 1 st or 2 nd CT scans for monitoring Patient status, clinical exam, toxicity assessment key Continue therapy if patient tolerating well

22 Immune Related Adverse Events

23 Immune Related Adverse Events

24 Adverse Events- Where?

25 Most Common Adverse Events Anti-CDL4: Ipilimumab (All Grades) Anti PD-1/PD-L1: Nivolumab & Pembrolizumab (All Grades) Combination Therapy (All Grades) Skin: Rash, Pruritis 19%, 24% 21%, 23% 28%, 33% Gastrointestinal: diarrhea, colitis, nausea 28%, 8% 20%, 2%, 26% 37%, 12% 22% Fatigue 19% 25% 30% Hepatic 3% 4% 16% Endocrine 6% 5% 7%

26 Adverse Events When?

27 Implications for Nursing

28 Nursing Assessment - Baseline

29 Nursing Assessment: Follow-up

30 Grading Adverse Events

37 Immune Related Adverse Events

52 Patient and Family Education - Adverse events are common, but are usually mold to moderate in severity - Severe adverse events are not frequent but are treatable - Early recognition of adverse events is essential : report ALL symptoms, even if they appear to be mild, it can quickly become something serious - Timing of symptoms: typically peak between 4 12 weeks; however may occur anytime during treatment; earlier with combination treatment and can even occur after treatment discontinuation/completion - Reinforce teaching with every clinic visit

53 Review: Key take home messages Side effects for immuno-oncology agents may not present for a number of weeks or may present after therapy has been discontinued or completed Uniques toxicities with i-o agents are common, but are ususally mild, serious adverse events are rare Nurses responsible to obtain good history, BPMH, assess with each treatment and identify problems early Most adverse events are easily manageable with early identification and treatment Educate patients to monitor and report ALL symptoms Corticosteroids work extremely well for management of side effects.

54 References Amos. S.M. et al. (2011). Blood. 118: Brody, J. et al (2011). Journal of Clinical Oncology 29: Canadian Association of Nurses in Oncology (2017). Immuno-Oncology Essentials for Oncology Nurses. Webinar. December Champiat, S. (2016) Annals of Oncology 27: DeVita, D.B, Rosenberg S.A. (2012). New England Journal of Medicine 62: Elert, E. (2013) Nature 504: S2-S3 Emens, LA et al (2017) European Journal of Cancer. 81: Fay, A.P. (2016) et al Expert Review Quality of Life in Cancer Care1: FDA Approved Drug Products. Available at: Retrieved July 9, Health Canada Drug Product Database. Available at: https//healthproducts.canada.ca/dpd-bdpp/index-eng.isp. Retrieved July 9, 2017.

55 References Keytruda / Pembrolizumab (2017). Prodcut Monograph. Merck Canada inc. Kirkwood, J.M. et al. (2012). CA Cancer J Clin 62 ( ) Medina, P.J. & Adams, V.R. (2016). Pharmacotherapy 36: Mellman, I. et al. (2011). Nature. 480: Murphy,J.F. (2010). Oncology 4: National Cancer Institute. 150 years of Advances Against Cancer. Opdivo Nivolumab (2017) Product Monograph. Bristol Meyers Squibb. Surveillance, Epidemiology and End Results (SEER). Program of the National Cancer Institute. Available at

56 References Suarez-Almazor. M.E. et. al (2017). Arthritis Rheumatology. 69: Tarcentriq Atezolizumab Product Monograph. Hoffman LaRoche Yervoy Ipilimumab. Product Monograph. Bristol Meyers Squibb

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