Moving Beyond Silos

Non-oncology specialists are increasingly viewed as critical members of the multidisciplinary team caring for patients receiving immunotherapy for cancer. Although many immune-related adverse events (irAEs) can be effectively managed when recognized early, irAEs vary considerably from side effects associated with chemotherapy, and can be potentially life-threatening.¹ The appropriate management of dysimmune toxicities requires the expertise of specialists in dermatology, gastroenterology, neurology, endocrinology, rheumatology, cardiology, and more.^2,3

The literature increasingly emphasizes the importance of involving relevant non-oncology specialists as members of the immuno-oncology (I-O) care team to support management of irAEs;^1,3-12 However, in practice, there remains little cross-pollination about I-O toxicities between oncologists and relevant specialists, and oncologists face challenges in integrating specialists into the oncology multidisciplinary team and educating these non-oncology clinicians about I-O drug-mediated toxicities.

A notable barrier to such integration is that few non-oncology specialists have had direct experience of treating patients with immune-related toxicities. Indeed, oncologists who treat a lot of patients with I-O agents and are comfortable managing toxicity are likely to be more conversant with managing system-related irAEs than specialist providers. Non-oncology specialists may also harbor misunderstandings about the mechanisms of action of checkpoint inhibitors, which can lead to inappropriate delay in toxicity management and jeopardize patient outcomes.

To learn more about a unique approach to combining oncology and subspecialist expertise toward the goal of effective irAE management, the ACCC Institute for Clinical Immuno-Oncology recently spoke with medical oncologist Ryan Weight, DO, MS from the Sidney Kimmel Cancer Center (SKCC) of the Thomas Jefferson University, Philadelphia, Pennsylvania.

Establishing Dialogue, Building Relationships

The National Comprehensive Cancer Network and the American Society of Clinical Oncology are currently in the process of collaboratively developing clinical recommendations for managing irAEs. Most recently, the Society for Immunotherapy of Cancer (SITC) has issued consensus guidelines and recommendations on recognition and clinical management of immune-related side-effects from cancer immunotherapy being published today in the Journal for ImmunoTherapy of Cancer (JITC).

However, a few expert or consensus guidelines for managing irAEs currently exist, and gaps in evidence remain within existing guidelines. Consequently, many oncology providers have been working within their own institutions to develop irAE management protocols for patients who develop toxicities and adverse events. Yet Weight cautions that “we’re all doing so in silos. We would be a much stronger group and we could advocate for our patients in a much more efficient manner if we spoke to each other about these issues and how people are approaching them.”

To create that kind of dialogue at SKCC and, ultimately, establish effective strategies to appropriately manage patients who develop irAEs, Weight has established a cross-specialty I-O Working Group.

As a first step toward building this Working Group, Weight identified non-oncology providers at SKCC likely to have a pre-existing familiarity with the language and concepts of immunotherapy, or interest in how the immune system interacts with a designated organ system that might be affected by I-O treatment—for instance, non-oncology providers working in organ transplant, viral therapy, and treating hepatitis viruses. Weight then contacted providers via email and phone to ask if they would be interested in learning more about I-O and engaging in discussions about a specialist referral network for patients with irAEs.

Providers who were unable to participate, or who felt that they lacked the background or knowledge base to offer insightful ideas, were quick to recommend a colleague who might be better suited. Via this process, Weight was able to identify someone from almost every subspecialty who was willing to sign on. Subsequently, he spent time with each member in person or on the phone to review available guidelines, if they existed, or information in the specialist’s field, and discuss management strategies for patients who might present with system-specific irAEs.

Weight’s meticulous efforts to identify and connect with providers interested in I-O revealed a range of “people that are out there that are interested in these things that you may not have previously known.” In fact, he was surprised to discover that some specialty providers had significant background experience in oncology—like the cardiologist who had a personal interest in cardio-immunology, and the dermatologist with subspecialty training in early immuno-oncology, who brought expansive insight from experience gained at Memorial Sloan Kettering and the National Institutes of Health melanoma group.

Weight acknowledges that while his approach was time consuming to coordinate—it took six months to get clinicians on board and build guidelines—it encouraged providers to think ‘outside the box.’ To support such thinking, Weight also drew up a list of questions to:

"...provide to specialists that are related to their field, but that they may not have thought about in an I-O context, or about topics that are unknown or unanswered in that particular field, and questions that we as medical oncologists may not know the answer to. This focused, pragmatic approach enabled specialists to give an intellectual response as to how one might approach these problems, to which we don’t yet have answers.”

More specifically, the process has generated irAE management recommendations that oncologists might not have viewed as possibilities.

Building Algorithms, Educating Others

The Working Group’s first step was to build treatment algorithms for system-based adverse events management. Management algorithms provide a structured approach to effective identification and management of irAEs within a given cancer program, and are especially valuable for clinicians and care teams unaccustomed to immune-related toxicity.¹² In doing so, Weight encouraged the group to ask scholarly questions that would also expand the field in irAE management, such as: “Which antibody panels or pretreatment testing would be necessary to predict or help manage immune adverse events?”

The next step has been to educate other clinicians on I-O in general via medicine grand rounds and other educational forums, and on adverse management via case-based discussions. Weight says at SKCC there has been a groundswell of interest in these education initiatives from medical oncologists who are starting to have access to I-O drugs for specific tumor types, as well as from infusion and floor nursing staff, pharmacy, and hospitalists.

This is a welcome development, as Weight notes:

“Our house staff and our hospitalists are the people who often end up seeing I-O patients on the inpatient side. Although it’s not their primary responsibility to take care of oncology patients, they are asking for education on immuno-oncology. I think there’s a huge interest across the board in learning more about immuno-oncology, because providers see these patients. And when they see them, if they haven’t been educated on I-O, they really struggle to understand and manage a lot of these very unique problems.”

The process of establishing an irAE Working Group is still ongoing, and Weight would like to identify a rheumatologist and a neurologist to participate. He is also prioritizing ways to integrate the irAE specialist group’s work into patient engagement and care.

To this end, the I-O program has identified a nurse practitioner (NP) in the outpatient infusion center who will act as a point person for I-O questions and same day visits for immuno-toxicity. Weight or one of his medical oncology colleagues advise the NP, and integrate specialist providers as needed.

Although Weight has made considerable headway in establishing dialogue with subspecialty providers about immune-related toxicities, challenges remain to prepare subspecialists to interact effectively with I-O patients and with the I-O team. While some specialists in the Working Group have been able to accommodate seeing patients with emergent irAEs, an ongoing goal of SKCC’s I-O program is to create pathways to non-oncology specialists that support prompt and expedient access to care.

This, for Weight, is the cornerstone of effective irAE management:

“How quickly can they get patients into their office in an attempt to avoid an admission to the hospital or simply to alleviate the patient’s anxiety and concerns around the problem that they might be having? Access to care really is the crux of the issue. Providers really need to understand the importance of having a mechanism in place that enables them to be accessible to the best degree that they are able to be.”

References

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