Communication and Education: Improving Patient Outcomes With Bispecific T-Cell Engager Therapies

I never considered communication an area where I would struggle as a nurse or even as a nurse practitioner. My first degree was in social work; if anything, I felt I excelled at communication. As a nursing professor for the past 8 years, I have always prioritized communication and patient education, having taught prelicensure, graduate, and doctoral students. In my nursing career, I found communication and education to be important tools used to empower, reduce anxiety, and build therapeutic relationships with patients and families.

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However, this was not always true. One of the hardest lessons learned occurred after I inadvertently failed at communication and education before transferring a patient to the intensive care unit (ICU). The patient’s family tearfully shared their perception of not being prepared for the possibility of toxicities necessitating the ICU when they began treatment. In addition, a goals-of-care conversation was initiated while in the ICU and without the involvement of the oncology team.

The family verbalized feelings of abandonment and uncertainty without the oncology team to guide decisions and the perception that I did not educate them that the ICU team was assuming all care. This event was a catalyst for a personal journey to make certain each patient and caregiver is empowered with the information needed and that interprofessional communication is a goal.

I was reminded of this patient’s experience and applicability with emerging bispecific T-cell engager therapies. Our institution has a robust cellular therapy program that has previously focused on hematologic malignancies. Bispecific T-cell engager therapies have recently been introduced for solid tumor diagnoses such as small cell lung cancer, uveal melanoma, and synovial sarcoma. The delivery of bispecific T-cell engager therapies for patients with solid tumors presents new challenges requiring effective communication among teams. These patients are often comanaged by the cellular therapy team, the medical oncology team, and sometimes ICU teams consisting of nurses, advanced practice providers, pharmacists, physicians, and social workers.

Interprofessional communication and patient education are crucial aspects of oncology care from diagnosis to end of life. When considering bispecific T-cell engager therapies, patients and caregivers require education regarding expectations, the treatment regime, supportive care, potential toxicities, and identification of team members involved and the roles of each. Although this is true with every oncologic therapy, bispecific T-cell engager therapies require additional considerations.

Initially, the patient may need assistance with resources, education on treatment timeline, and coordination of outpatient vs inpatient hospitalization. Education should also focus on the potential for serious toxicities commonly associated with oncologic therapies, such as cytopenias requiring transfusions, infections, neutropenic fever, tumor lysis syndrome, and hypersensitivity reactions, but also toxicities such as cytokine release syndrome (CRS) and immune effector–associated neurotoxicity syndrome (ICANS).

There should be clear and concise education on being near the facility in case of complications, home monitoring of vital signs and symptoms, when to notify the team, how to contact the team, time frame, and specific dates patients will be at the highest risk of these potentially life-threatening complications.¹ Patients and caregivers should be taught the frequency of monitoring at home in addition to symptoms of concern. CRS symptoms may consist of fever above 100.4°F, hypoxia less than 90% or change from baseline, hypotension with a decrease in systolic blood pressure of over 10 mm Hg from baseline or less than 90 mm Hg, and/or an increased heart rate greater than 100 or more than 20 beats per minute above baseline at rest.^1,2

In addition, patients are taught to monitor for ICANS, which often presents with headache and dizziness; other symptoms can be progressive with confusion, difficulty writing or speaking, changes in consciousness, abnormal behaviors or actions, and/ or seizures.^1,2 Initially, it is important to educate that CRS and ICANS are managed based on severity and symptoms, and both conditions may overlap. The severity of CRS may necessitate hemodynamic monitoring in an ICU with increased oxygenation needs requiring mechanical ventilation, vasopressors, intravenous fluids, and medications.^1,2 The severity of ICANS may also necessitate an ICU admission due to altered levels of consciousness, seizures, and cerebral edema.^1,3

The patient and caregiver should be empowered with information. Still, we cannot forget the interprofessional aspect of delivering these therapies and how we approach communication with the patient and caregiver. The patient and caregiver need to understand that the severity of these complications may involve a multidisciplinary effort between the oncology teams, intensivist, and neurointensivist. Any acute ICU admission related to a complication of bispecific T-cell engager therapy should necessitate a goals-of-care discussion. Caregivers should be educated early to request the oncology team be present and involved in conversations regarding goals of care and decision-making while under ICU care. This is crucial as ICANS and CRS can mimic other conditions, and the patient may appear critically ill.

However, there may be potential for recovery with appropriate management based on the severity of the illness, with the oncology team providing expertise and information. Mnemonics such as REMAP can guide the interprofessional team: reframe, expect motion, map out goals, align with goals, and propose a plan.⁴ This mnemonic can be used to discuss the overall prognosis, acknowledge distress, evaluate the perception and wishes of the patient and caregiver, and develop a plan moving forward. Social workers or a palliative care team may also be required to address associated psychological distress. In addition, there may be a need for frequent delineation of team member roles to enhance interprofessional communication among multiple disciplines.

In reflection, my experience almost a decade ago continues to impact why I advocate for patients today. As professionals, we must also realize the power of a patient’s or caregiver’s perception and the impact when communication is lacking or education has not been delivered. Communication and education are driving factors affecting the successful delivery of all oncologic care, especially with emerging bispecific T-cell engager therapies. We must initiate difficult conversations early to plan for the unknown. The patient and caregivers must have the resources and knowledge to help recognize, monitor, and report common toxicities; understand management; and be empowered to request and participate in goals-of-care conversations with their oncology teams.

References

1. Crombie JL, Graff T, Falchi L, et al. Consensus recommendations on the management of toxicity associated with CD3×CD20 bispecific antibody therapy. Blood. 2024;143(16):1565-1575. doi:10.1182/blood.2023022432
2. Childers JW, Back AL, Tulsky JA, Arnold RM. REMAP: a framework for goals of care conversations. J Oncol Pract. 2017;13(10):e844-e850. doi:10.1200/JOP.2016.018796
3. Huddle card: immune effector cell associated neurotoxicity syndrome. Oncology Nursing Society. October 2023. Accessed December 15, 2024. https://www.ons.org/sites/default/files/2023-10/Huddle%20Card-ICAN%20.pdf
4. Huddle card: oncologic emergencies: cytokine release syndrome (CRS). Oncology Nursing Society. November 2024. Accessed December 15, 2024. https://www.ons.org/sites/default/files/2024-11/huddle-card-cytokine-release-syndrome.pdf