Fast Facts for the Frontline: Immunotherapy

Melissa A. Grier, MSN, APRN, ACNS-BC

Melissa A. Grier, MSN, APRN, ACNS-BC

What is immunotherapy?

Immunotherapy is a type of treatment that uses a patient’s immune system to fight cancer. Rather than attacking the cancer itself, immunotherapy strengthens the immune system and stimulates its ability to attack cancers that have not responded or may have become resistant to cytotoxic therapy.

What are some examples of immunotherapy treatment in oncology?

Medications

• Cancer vaccines (eg, sipuleucel-T for castration-resistant prostate cancer)
• Cytokines (eg, interleukin-2 for renal cell carcinoma)
• Immune checkpoint inhibitors (eg, pembrolizumab, nivolumab, approved for multiple tumor types)
• Monoclonal antibodies (eg, rituximab for chronic lymphocytic leukemia)
• Prophylactic immune therapy (eg, human papillomavirus vaccine to prevent cervical cancer)
• Supportive therapy (eg, leucovorin for methotrexate rescue)

Procedures

• Stem cell transplant for hematologic malignancies

Which patients receive the most benefit from immunotherapy?

Approved indications for immunotherapy include malignant melanoma, renal cell carcinoma, chronic lymphocytic leukemia, non-Hodgkin lymphoma, and prostate, colorectal, lung and breast cancers, among others. Patients with autoimmune conditions (lupus, rheumatoid arthritis, Crohn’s disease) and those who have a history of transplant or liver damage are not candidates for immunotherapy.

How is immunotherapy different from chemotherapy?

Most chemotherapy agents cause nonspecific destruction of both cancer cells and healthy cells. Widespread destruction of rapidly proliferating cells causes side effects that impact patients’ quality of life (fatigue, hair loss, nausea and vomiting, etc). Immunotherapy agents act on the immune system, enabling it to attack and destroy only the cancer cells. Immunotherapy agents act on the immune system, enabling it to attack and destroy only the cancer cells.

What adverse effects might result during and/or after immunotherapy treatment?

Immunotherapy toxicities may occur during and/or after treatment. These are known as immune-related adverse events (irAEs). Immunotherapy essentially kicks the immune system into overdrive, which will impact each patient differently. Without early recognition and treatment, immunotherapy-related toxicities can be life threatening.

These irAEs are essentially an inflammatory reaction. Symptoms may be nonspecific (fatigue, headache, pruritis) or isolated to particular systems (diarrhea, abdominal pain affecting the GI tract). Some effects will only be apparent on investigation of vital signs (hypotension) or lab results (elevated LFTs).

How do I prepare to administer immunotherapy to my patient?

Familiarize yourself with the adverse events associated with the immunotherapy treatment you’ll be administering to your patient. Varied effects present based upon the part of the immune system the therapy is acting upon. Premedication with acetaminophen and an antihistamine will likely be ordered. These should be administered at least 30 minutes prior to beginning treatment to allow time for onset of action.

Reaction to an immunotherapy agent can sometimes be mediated by slowing or stopping the infusion, but may also require treatment with acetaminophen, intravenous H-1 or H-2 antagonists, and/or low-dose IV corticosteroid therapy.

What education should I provide to my patients?

• Explain the differences between chemotherapy and immunotherapy.
• Discuss possible adverse events associated with immunotherapy.
• Provide the patient with the pocket card included with the immunotherapy agent (if present). The card includes information about symptoms the patient should report and also provides treatment guidance for healthcare providers who may be unfamiliar with immunotherapy and its effects, for example, emergency department staff.
• Encourage the patient to report any abnormal symptoms following immunotherapy treatment. Algorithms exist to treat varying grades of adverse reactions, preventing life-threatening progression of early or late treatment effects.
• Explain that apparent disease progression may take place before a response to immunotherapy occurs. Response to immunotherapy can sometimes take weeks or months to manifest.
• Emphasize that response to immunotherapy treatment often lasts longer than response to chemotherapy and other cancer treatment modalities.

Where can I learn more about immunotherapy?

Clinical Care Options: Oncology Nursing - http://bit.ly/2bji6XS

• Immunotherapy in Cancer: Insights for Nurses (CE activity)
• At a Glance: Understanding Immune Checkpoint Inhibitors and Their Role in Cancer Care
• The Oncology Quiz Game: Understanding Immunotherapies and their Role in Cancer Care (2015 webcast from Oncology Nursing Society Congress)

inPractice - http://bit.ly/2bmc5Jr

• Multiple CE activities pertaining to immunotherapy are available

Additional Readings

• Becze E. Manage immune-related adverse events associated with cancer immunotherapies. ONS Connect. September 2014. http://bit.ly/2cbsy9x. Accessed August 25, 2016.
• Green LM. Immunotherapy in cancer care: educating patients about what to expect. Oncology Nursing News. June 2015. http://bit.ly/2cbqrTf. Accessed August 25, 2016.
• Kannan R, Madden K, Andrews S. Primer on immuno-oncoloy and immune response. Clin J Onc Nurs. 2014; 18(3):311-317,326.
• Pirschel C. Immunotherapy is changing the future of cancer care. ONS Connect. June 2016. http://bit.ly/2bAhUGS. Accessed August 25, 2016.
• Rubin KM. Understanding immune checkpoint inhibitors for effective patient care. Clin J Onc Nurs. 2015;19(6):709-717.

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Melissa Grier is a Clinical Nurse Specialist at Via Christi Health in Wichita, Kansas, where she supports the Via Christi Cancer Institute and the nurse residency program.