Tag Archives: immuno-oncology

Turning on the Light Switch

June is Cancer Immunotherapy Month, shining a spotlight on advancements in immuno-oncology. 2017 ACCC Institute for Clinical Immuno-Oncology Innovator Award winner Oncology Specialists S.C. at Advocate Lutheran General Hospital has been delivering immunotherapy for cancer for more than six years. For highlights on how they’ve developed their program and how “Turning on the Light Switch” helps their providers and patients talk about managing immune-related toxicities, read on.

by Ann McGreal, RHanging BulbsN

For more than 30 years the world of oncology nursing and the patients we care for has been bound by the expectations of the known effects of chemotherapy on the human body. While these toxicities can be difficult and, at times, even life threatening, for the most part they are predictable. As experienced oncology nurses, we know that after a certain number of days the patient blood counts will likely drop. Our patients being treated with chemotherapy anticipate that they may experience nausea, diarrhea, bone pain, and other side effects. For the most part, with chemotherapy we can expect a logical start, progression, and end to toxicities.

Immuno-Oncology Brings a Paradigm Shift
However, the new dawn of immuno-oncology and the rapidly increasing use of immunotherapy for cancer have upended not only our approach to supporting oncology patients, but also how we approach the toxicities of treatment.

Our practice, Oncology Specialists at Lutheran Advocate General Hospital, in Park Ridge, Illinois, has been on the cutting edge of using immunotherapy for melanoma treatments from the beginning. We were among the highest accrual sites for the original ipilimumab clinical trials. Then, in 2011, immunotherapy took its first big step into the limelight with the FDA approval of ipilimumab for the treatment of Stage IV melanoma. The demand on our clinic for ipilimumab increased greatly.

Initially, our practice was able to deal with the need to think about symptom management in a different way because we were caring for a small population of patients—all in the melanoma space. However, in 2014, with the dawn of PD-L1 checkpoint inhibitors that all began to change. Today, the potential for this class of drug seems unlimited, with more than 500 current studies underway in the U.S., and new indications and approvals occurring on what seems like a daily basis.

Educate. Educate. Educate.
As we implemented immunotherapy in our practice, our nursing team took on the challenge of how best to educate both staff and our patients on the mechanism of action for these new therapies, as well as their potential toxicities.

We quickly learned that peer-to-peer education was the most effective way to help our medical staff develop a better understanding of immunotherapy. We also found that the real challenge lay in accepting that immunotherapy for cancer requires a different way of looking at the total treatment picture. To implement this new treatment paradigm, we needed to better educate our patients so that they had a clear understanding of how immunotherapy differed from traditional chemotherapy and why early reporting of toxicities is so important. This meant we had break through long-held beliefs such as, “everyone gets sick during cancer treatment” and “I should just ‘tough it out’ or they will stop my therapy.” We needed our patients to understand that with immunotherapy just “tough it out” can be a deadly mindset. Patients on immunotherapy need to partner with their providers and report any toxicities early so that their healthcare team can work quickly to resolve the issue.

Flipping the Switch
With this need in mind, we created a set of education tools built around the analogy of the patient’s immune system functioning like a light switch. The immunotherapy treatment turns the switch on. If the treatment starts causing toxicities, the patient’s body cannot turn the switch off by itself. Unless the toxicities are reported, the affected system (the light) will burn out. Today, these education tools and discharge instructions are the backbone of our immunotherapy program.

Next Step: Incorporating into Our EMR
With our staff education and training on managing immune-related toxicities and patient education in place, we looked at processes to ensure cohesive documentation in our EMR so that an on-call physician or covering nurse could easily pick up the treatment thread and assist patients. This not only led to the development of templates but also a standardized treatment plan for immune-related toxicities, including the use of corticosteroids.

At the ACCC 34th National Oncology Conference in October, we’ll be presenting a more in-depth look at how we have developed and grown an immunotherapy program at our practice.  We hope you’ll join us in Nashville.
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Ann McGreal, RN, is an Oncology Nurse Clinician at Advocate Lutheran General Hospital in Park Ridge, Illinois.

Read more about upcoming ACCC 34th National Oncology Conference here.

From ASCO to ICLIO to Your Program—Immunotherapy Moves into the Community

By Amanda Patton, ACCC Communications

Once again immuno-oncology (I-O) was center stage at this year’s American Society of Clinical Oncology (ASCO) Annual Meeting (June 2-6, 2017) where more than 250 presentations featured checkpoint inhibitors. Currently, six immune checkpoint inhibitors have received FDA approval for more than nine cancers, with more than 1,000 studies in progress.

On June 2 at ASCO, two pre-eminent immunotherapy investigators provided perspective on the rapidly evolving immuno-oncology landscape with a look back and a look to the future.  During their presentation, “On the Shoulders of Giants: Historical Approaches to Immunotherapy in Solid Tumors,” James P. Allison, PhD, of The University of Texas MD Anderson Cancer Center, and Suzanne L. Topalian, MD, of the Bloomberg-Kimmel Institute for Cancer Immunotherapy, touched on some of the critical challenges the oncology community faces with these new and emerging therapies, including:

  • How to deal with the flood of information from clinical studies
  • The need to better understand the biologic processes underpinning of side effects of these new therapies
  • The imperative to identify biomarkers.

Read highlights from their presentation in this ASCO Daily News article.

ICLIO’s Evolving Role—Supporting Integration of I-O into Practice
Just as insights from ASCO 2017 will continue to ripple throughout the broader cancer community for weeks and months to come; the wave of new approvals and indications in immuno-oncology will continue to spread from academic settings into community programs and practices, where it is estimated that 85% of the nation’s cancer care is delivered.

Since its inception more than two years ago, the ongoing mission of ACCC’s Institute for Clinical Immuno-Oncology (ICLIO) is to create education, resources, and tools that provide practical, real-world support for multidisciplinary team members engaged in bringing immunotherapy to patients in their communities. Hear about ICLIO’s growth and latest initiatives in this ASCO Post interview with ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, Chief, Division of Hematology Oncology; Professor of Medicine, The University of Tennessee; The West Clinic, PC.

ICLIO In the Community
In 2017, ICLIO launched two exciting new programs—ICLIO Visiting Experts and Case Studies in Immuno-Oncology—that bring clinicians with immunotherapy expertise out to providers in the community.

“It’s an area that ICLIO is spearheading,” said ICLIO Visiting Expert Jarushka Naidoo, MBBCh, Assistant Professor of Oncology at Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University and Bloomberg-Kimmel Institute for Cancer Immunotherapy.  With the ICLIO Visiting Experts program, “Investigators such as myself who are particularly interested in immunotherapy can actually go to community providers and give our hands-on experience of how we give these agents, what are the common side effects that we see, and what are some of the ways we’ve gotten around some of those particular considerations. We’re able to interact with the workshop participants one-on-one and talk about specific cases they’ve managed, some challenges they’ve had, and how we might have dealt with that from an academic perspective.”

Learn more in this Hem/Onc Today interview with Dr. Naidoo:

For the just-launched Case Studies in Immuno-Oncology, an ICLIO faculty member will travel to an ACCC-member program for a 60-minute case-based tumor board discussion on immunotherapy treatment decision-making and the management of associated immune-related adverse events. Learn more and apply.

Immuno-Oncology Advances from ASCO 2017
Access top-level takeaways on advances in immunotherapy for cancer from the ASCO 2017 Annual Meeting in this  ICLIO webinar presented by Lee Schwartzberg, MD, FACP.  View webinar.

View all ICLIO has to offer by visiting accc-iclio.org.


Editor’s note: This post was updated on 6/28/17.

Cooling Down ICER? Five Questions to Consider

By ACCC Communications

Three jigsaw puzzles pieces (sm)Although the value-based reimbursement train has definitely left the station and is picking up speed, those in the oncology community continue to grapple with the thorny issues around understanding and defining value in cancer care. Treatment innovations and costs are driving the value discussion in oncology. New and emerging immuno-oncology therapies, while bringing unprecedented clinical value to many patients, often carry price tags of $100,000 a year or more, and are front and center in these discussions. Patient access in an era of high-priced pharmaceuticals continues to be a major challenge, particularly as many of these innovative therapeutics entail high co-pays and/or co-insurance payments. The result is that some patients face major hurdles to accessing these innovative options.

For those in the oncology community, staying up-to-date on current and proposed value frameworks is essential—not only to advance innovation in cancer care and to ensure patient access to new therapeutic options, but also to protect cancer program economic viability in an era where payment and reimbursement may become increasingly tied to value.

In a recent Institute for Clinical Immuno-Oncology (ICLIO) webinar, a panel of leading experts provided real-world perspectives on value framework development in oncology in the U.S., with a particular focus on the Institute for Clinical and Economic Review (ICER), which has gained prominence in the past 18 months.  For those in the oncology community who may not be familiar with ICER, panelist Jennifer Hinckel, MSc, McGivney Global Advisors, provided background and offered the following five questions to consider in assessing the organization’s recent report related to non-small cell lung cancer (NSCLC):

  • Does ICER have the appropriate expertise to interpret complex clinical data given that there are not disease-specific clinical experts on staff or advisory panels?
  • Does ICER have processes in place to adequately prevent or limit bias or policy/political aims from slipping into its reports?
  • Is ICER’s approach of evaluating products close to the time of approval (or pre-approval) appropriate, given its methodology of including only randomized controlled trial (RCT) data?
  • Does ICER have sufficient staffing to review and update reports in disparate disease areas and to ensure accuracy?
  • Would ICER’s various approaches meet the standards of peer view in a widely published journal?

In a recent op-ed published in the Oncology Business Review, leading lung cancer experts (including ICLIO Advisory Committee Chair, Lee Schwartzberg, MD, FACP) suggest some level-setting principles for value frameworks including the following:

  • Have disease experts as evaluators and authors
  • Have patient-centered endpoints, conclusions, and definitions of value
  • Use rigorous methodologies reflecting evidence-based medicine
  • Apply continuous review and revision
  • Hold peer review and authorship to scientific standards.

Listen to the full ICLIO webinar discussion here.

As noted in a newly-released white paper from the Institute for Clinical Immuno-Oncology, all of the existing first-generation value frameworks have strengths and weaknesses. Each wrestles with defining value, and each exposes inherent tensions between payer concepts of value and the perspectives of patients and providers. As the field of immuno-oncology continues to expand, all stakeholders will need to stay informed and be prepared contribute to ongoing development of value frameworks that consider not only cost and clinical benefit, but patients’ perspectives on value in cancer care.  In the months ahead as the oncology community contributes to the discussion on value determination methodologies in the context of payer negotiations and political pressure to lower costs and enact drug pricing reform, as well as working to ensure access to new and emerging immunotherapy and combination therapies, ICLIO will continue to offer support and resources for the multidisciplinary team serving patients in communities close to home.


ICLIO is an Institute of the Association of Community Cancer Centers (ACCC). In September 2016,  ACCC submitted comments in response to ICER’s national call for proposed improvements to its Value Assessment Frameworks. 

Immuno-Oncology: Moving Forward Together

By Lee S. Schwartzberg, MD, FACP, Chair, ICLIO Advisory Committee

ICLIO-More-to-Discover-white-paper-285x412

As the momentum surrounding immuno-oncology continues to build, the Institute for Clinical Immuno-Oncology (ICLIO) is meeting the need for practical, real-world resources and education for all members of the multidisciplinary cancer care team.  Find out how in this just-released ICLIO white paper, which illuminates current progress with these exciting therapies, real-world challenges, and emerging concerns around continued access as immunotherapy moves into the community setting.

You’ll want to read Immuno-Oncology: There’s More to Discover for:

  • A concise recap of 2016 immunotherapy clinical highlights
  • An update on ICLIO education, resources, and what to expect in 2017
  • A snapshot of policy issues and pressing concerns impacting the future of immuno-oncology in practice.

In this rapidly changing landscape, I encourage all you to partner with the ICLIO. Whatever your role in caring for patients with cancer, the latest ICLIO white paper will provide insight and perspective on the evolving field of immuno-oncology.  Through ICLIO, let’s continue to move forward together on the exciting immuno-oncology journey.

Explore the hub of immuno-oncology information and resources available for the entire multidisciplinary cancer care team at accc-iclio.org and follow ICLIO for updates. ICLIO is an institute of the Association of Community Cancer Centers (ACCC).

Required Reading: “Advancing Immuno-Oncology in the Community Setting”

Lee-Schwartzberg-220x209By Lee Schwartzberg, MD, FACP
Chair, Institute for Clinical Immuno-Oncology, Advisory Committee

Along with their copies copy of the January/February Oncology Issues, ACCC members will receive “Advancing Immuno-Oncology in the Community Setting,” the inaugural white paper from the Institute for Clinical Immuno-Oncology (ICLIO), an institute of the Association of Community Cancer Centers (ACCC).

As members of the oncology community well know, the last five years have brought us thrilling advances in immunotherapy. We’ve seen the introduction of checkpoint inhibitors and vaccines that are unleashing the power of an individual’s immune system to fight cancer. In the past few months, we’ve witnessed a surge of new FDA indications for immunotherapy agents in a number of disease sites, including melanoma, lung cancer, and renal cell carcinoma.

Immuno-oncology is now emerging as the fourth pillar of cancer treatment. It is a new field, bringing new promise and new challenges for patients, providers, and payers.

As Chair of the ICLIO Advisory Committee, I urge you to take a few minutes to explore the ICLIO white paper. Whatever your role in cancer care delivery, you’ll benefit from learning about the resources ICLIO offers today and those planned for tomorrow. Here are three reasons to learn about ICLIO:

  1. The immunotherapy momentum continues to build. There is a robust pipeline of new immunotherapies in development, as well as emerging combination therapies. Staying up-to-date on advances in this new field is imperative—for your cancer program and your patients.
  2. Empowered, informed patients and their families will be asking about (and for) these new immunotherapy options.
  3. The challenges of integrating new therapies occur on many fronts—clinical, administrative, programmatic—and across disciplines. ICLIO brings a multidisciplinary approach to addressing these challenges with practical resources that help build a bridge from bench to bedside so that eligible patients in the community can access these new therapies and receive care in an evidence-based way.

For more, explore ICLIO resources online at accc-iclio.org and learn about future ICLIO initiatives. Take advantage of our upcoming ICLIO webinars in January:

Immunotherapies for the Treatment of Metastatic Renal Cell Carcinoma (mRCC)
January 15, 2016
12 pm, ET

Navigating Patient Assistance Programs for Immunotherapy Treatment
January 21, 2106
12 pm, ET

Coordination of Care for Immunotherapy Patient
January 27, 2016
12:30 pm, ET

Learn more and register for the webinars here. Join our community centered on transformative care!

Institute for Clinical Immuno-Oncology (ICLIO) Conference Spotlights Challenges & Strategies

By Amanda Patton, ACCC Communications

media-ICLIO-iceberg-540x202“The promise of immunotherapy that was seen 100 years ago is now a reality,” said ICLIO Advisory Committee Chair Lee Schwartzberg, MD, FACP, in remarks kicking off the first Institute for Clinical Immuno-Oncology Conference on Oct. 2, in Philadelphia. “Where we are today, particularly with checkpoint inhibitors, is just the tip of the iceberg. . . . We are starting a new era with combination immunotherapy. . . . The challenge is how we will afford these new treatments.”

Conference sessions reflected the reality that adoption of immunotherapy in the community setting comes with challenges, and that strategies for successful implementation are already emerging. Read on for some key conference takeaways.

Immunotherapy is a completely different therapy.

From the clinical perspective, there is the need to understand differences in patients’ responses to immuno-oncology (I-O) therapy, to understand how to manage toxicities, and to educate all members of the multidisciplinary care team, the broader provider community, and patients and caregivers.

In a panel on Immuno-Oncology Applications, Sigrun Hallmeyer, MD, Oncology Specialists, SC, described her experience with implementing immunotherapy in the community setting. “This is really a completely different therapy,” she said. “What happens to patients in terms of side effects is unpredictable. . . . You can have twenty patients with no side effects and the twenty-first patient will have every side effect.”

Despite the challenge of understanding toxicities, Hallmeyer said, “What we are seeing in our community practice mirrors what is happening in clinical trials in terms of efficacy and side effects. . . . This is no longer a niche therapy for one or two tumor types.”

“We need to think in broad terms about educating other providers about immunotherapy toxicities,” said panelist Lee Schwartzberg, MD, The West Clinic, PC. Immunotherapy and toxicity profiles should be discussed in providers’ multidisciplinary conferences and during tumor boards, he said.

Panelist Gordana Vlahovic, MD, MHS, Duke University Medical Center, has been proactive in teaching residents at her program about toxicity profiles. The promise of these therapies is fueling demand, she said. “My practice has referrals from 45 states. Immunotherapy is something that people usually ask for.”

Dr. Hallmeyer agreed. “My patients are educated and well informed. They’ve known about these drugs. There was huge anticipation from the patient perspective and also from physicians.”

Advances in immunotherapy are accelerating more rapidly than the healthcare system’s ability to integrate them, particularly in terms of coverage and reimbursement, panelists agreed. It can take months for new drugs to be assigned J codes. In the meantime, payers may put a “hold” on drug claims, essentially putting the claim in limbo—neither denied or approved. Without a denial, patients cannot apply to patient assistance programs for help.

These are costly therapies, and “insurance and payment for these agents is a huge issue,” said Dr. Hallmeyer. Listen to a podcast of the Immuno-Oncology Applications session here.

Immunotherapy from the payer perspective.

Any discussion of new cancer therapies today must include cost and issues of financial toxicity—for the health system as a whole, for cancer programs and practices, and for patients. “It’s impossible not to be enthusiastic about the topic of today’s discussion,” said Michael Kolodziej, MD, Aetna, “but that doesn’t mean it’s easy.” From the payers’ perspective immunotherapy presents a problem that requires collaborative effort—the critical need to understand the patient population that responds to I-O. “We need to get the right treatment to the right patient at the right time, and we need you [providers] to help us figure it out,” he said.

Over the next two years, a number of immunotherapy drugs are likely to be approved for new indications, increasing the financial challenges, said panelist Michael Seiden, MD, PhD, McKesson Specialty Health. Listen to a podcast of the Payer Directions session here.

Immunotherapy comes with unique administrative challenges.

Three core administrative challenges in I-O implementation were spotlighted by Niesha Griffith, MS, RPh, FASHP, The Arthur G. James Cancer Hospital, The Ohio State University, in a panel discussion on tackling I-O integration challenges:

  • Managing the deluge of immunotherapy information for patients and staff
  • Ensuring appropriate triage of patients
  • Managing reimbursement and patient financial support

Reinforcing the need for provider and staff education on immunotherapy, Griffith cited the critical issue of patients needing emergent care. “Everyone in the practice needs to understand that immunotherapy patients need to be treated differently when they go to the emergency department.”

“Education about I-O toxicities is critical,” commented panelist Steven D’Amato, BSPharm, BCOP, New England Cancer Specialists. “It’s especially important in order to avoid emergency department admissions and unintended downstream costs.”

In tackling the reimbursement and financial issues related to I-O therapies, Griffith said, “I can’t say enough about the importance of financial advocate support.” A key to success at her program has been adding dedicated reimbursement specialists to the pharmacy department.

Using patient assistance programs for immunotherapy agents is essential, she said. And to do this effectively, reimbursement specialists and the clinical team must work together. Administrative staff needs information from and communication with the clinical team to help patients access these therapies. “Financial advocates need to know everything about these new agents,” Griffith said.

While physicians are excited by these new therapies, in private practice it’s essential to have processes and efficiencies in place, especially on the back-end, to ensure reimbursement for I-O therapies, said panelist Spencer Green, MS, MBA (HA), Bozeman Deaconess Cancer Center. “Smaller cancer programs need access to experts to help think through the challenges of implementing new immunotherapy agents,” he said. Listen to a podcast of this session here.

I-O care coordination requires consistent, strong communication before, during, between, and after treatments.

Attendees got a bird’s-eye view from the frontlines of I-O implementation from panelists Catherine Schott, RN, BSN, CCRC, Wheaton Franciscan Healthcare; Jennifer Diehl, RN, Moffitt Cancer Center; and Gary Cohen, MD, Greater Baltimore Medical Center. Ms. Schott offered three essentials for care coordination of I-O patients:

  • Begin care coordination early
  • Encourage early reporting of adverse events
  • Encourage compliance and long-term follow-up visits

Providers and staff—including office staff answering phone lines—need to be well educated about potential adverse events, said Ms. Schott. Educating patients and their families is equally important. She emphasized three key steps in care coordination of patients on I-O therapy:

  • Conducting ongoing patient and caregiver education
  • Providing wallet cards or symptoms logs for patients
  • Encouraging accurate reporting of adverse events.

Schott stressed the importance of good communication during, between, and after treatment. “It’s important to know there may be late occurring side effects,” she said. “As more patients are treated with immunotherapy agents, we need to be vigilant about late occurring side effects.”

“For immunotherapy patients, it’s important to know who to call 24/7,” said panelist Jennifer Diehl. “Other providers may not be familiar with I-O agents, side effects, and treatments.”

Provider-to-provider communication is essential, said Dr. Cohen. Treating patients with these new immunotherapy agents is very different from “our experience in treating cancer patients with traditional chemotherapy or other modalities,” he said.  Assessment of patients is very different. With immunotherapy progressive disease may not always be due to metastasis. Toxicities are different. “With immunotherapy we have to teach our radiation oncologists, our endocrinologists about how immunotherapy agents work.”

Immuno-oncology indications are rapidly evolving.

The conference’s closing session featured Timothy Kuzel, MD, FACP, Northwestern University, discussing evolving I-O indications in renal cell carcinoma and melanoma, and Renato G. Martins, MD, MPH, Seattle Cancer Care Alliance, presenting on evolving immunotherapy indications for lung cancer. “We believe very strongly that molecular profiling is a key component of improvement of care in non-small cell lung cancer,” said Dr. Martins. Listen to a podcast of Dr. Martins’ presentation here.

Learn more from the ICLIO Conference: Access session podcasts and view presentations here.

The Institute for Clinical Immuno-Oncology is a hub of I-O information and resources for the entire multidisciplinary cancer care team—both clinical and non-clinical program staff. Access webinars, articles, and join the ICLIO community: Transform care today!

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The Association of Community Cancer Centers (ACCC) established the Institute for Clinical Immuno-Oncology (ICLIO) to empower multidisciplinary cancer care teams to advance application of immuno-oncology by providing comprehensive I-O resources.