Immunotherapy Is Rapidly Changing Nursing Practice

It is an exciting time to be an oncology nurse. Over the past several decades, cancer treatment has considerably changed patient outcomes and adverse effect (AE) profiles. One of the most dramatic changes is the concept of immunotherapy, which has been studied for more than a century. Recent discoveries have led to a new class of immune agents.1 The rising stars in cancer treatment are the agents that modulate and strengthen the body’s immune response when battling the cancer. They include the following classes: checkpoint inhibitors, chimeric antigen receptor T cells, monoclonal antibodies, bispecific antibodies, and oncolytic viral immunotherapy.2 The highly unique, and often life-threatening, AEs motivate oncology nurses to have a fundamental understanding of all immunotherapies.

COMPETENT NURSES

Immunotherapies offer challenges for nurses trying to deliver safe and evidence-based care. One way to assure this happens is by maintaining initial and annual competencies. Oncology nurses are on the front lines of administering immune therapy. Therefore, competencies should be obtained for safe handling and AE profile management. Competent nurses should have knowledge of the following: mechanism of action, administration principles, toxicity and adverse reactions, and nursing assessment and management.3 Oncology nurses are experts in handling AEs from earlier cancer drugs caused by a compromised immune system; however, the new classes of immune therapeutics may cause overwhelming inflammatory responses and autoimmunity.4 Nursing management for the “new” immunotherapy AE profile requires competent nurses to understand that management differs from traditional chemotherapy and biotherapy.

PATIENT SAFETY

Many oncology patients may have received chemotherapy and are more familiar with the AE profile. As oncology nurses, we need to assist patients in understanding the difference between traditional chemotherapy, immunotherapy, and targeted therapy. As you educate your patients on immunotherapy, discuss the advantages of it over the more traditional approaches by emphasizing the following: 1) the immune system can distinguish between normal cells and cancer cells, and attack the unhealthy cancer cells; 2) compared with traditional chemotherapy, immunotherapy is generally less toxic and patients experience a good quality of life (QOL). The events associated with the immunotherapy agents are infections, inhibition of angiogenetic pathways, severe inflammatory syndromes, and autoimmune disorders.

As the FDA rapidly approves new treatments, oncology nurses are challenged to understand and manage the very distinct AE profiles of all immunotherapies. The most common AEs are associated with “turning on” the immune system: dermatitis, pruritus, fever, chills, diarrhea/colitis, and extreme fatigue.5 However, there are rare adverse reactions that can be life-threatening and occur 6 to 12 weeks after the initiation of therapy. Olszanski and Zitella noted that most adverse reactions are mild and most of the immunotherapy drugs are well tolerated.

ADMINISTRATION OF IMMUNOTHERAPY

Safe administration is a priority for nurses and the Oncology Nursing Society (ONS). The quick growth of the immunotherapy field often means that nurses are administrating agents for the first time in their practice. Thus, procedures and policies must be created and followed. ONS states that until more is understood about long-term AEs and the safety of healthcare workers, immunotherapy should be treated with the same level of care and security as other anticancer agents. 3 The safety standards set forth by the American Society of Clinical Oncology (ASCO) and ONS include guidelines to reduce errors in all areas of chemotherapy administration that should serve as the bases for policies and procedures adapted for immunotherapy safety.

Oncology nurses need to have an understanding of the basic concepts of immunotherapy and be aware of 2 important principles of immunotherapy treatment:

1) Immunotherapy is often given in combination with other modalities: chemotherapy, radiation therapy, and other immuno- oncology agents.

2) Dose reduction is not a principle of immunotherapy treatment. The dose is either held or given in full.5 By using the principles of chemotherapy safety outlined in Chemotherapy and Biotherapy Guidelines and Recommendation for Practice, 7 nurses can deliver research-based safe care, reduce medication errors, and reduce hazardous exposure from these new agents.

In February, ASCO named Immunotherapy 2.0 as the advancement of the year. The rate of research in this incredible field has been breathtaking. Oncology nurses stand to play a pivotal role in these new therapies, especially with AE management.

They have been excellent in improving chemotherapy patients’ QOL by being experts in chemotherapy-induced nausea and vomiting, neutropenia, fatigue, and other AEs. Nurses should bring the same evidence-based practices to managing immunotherapy patients and become experts in the specialty. Patients look to us for guidance, education, and keeping them safe during treatment. They trust us as we guide them along their treatment trajectory. New oncology therapies offer nurses a new challenge, and we will accept this challenge with our patients’ safety and QOL as our primary motivations.

Patricia Jakel, RN, MN, AOCN, is an advance practice nurse for the Solid Tumor Program at UCLA Healthcare. She oversees the care of 25 to 35 patients receiving chemotherapy, radiation therapy, symptom management, and end of life care. Jakel mentors new nurses to the art of oncology nursing.

References1. Farkona S, Diamandis EP, Blasutig IM. Cancer immunotherapy: the beginning of the end of cancer? BMC Med. 2016; 4:73. doi: 10.1186/s12916-016-0623-5.2. Fridman WH, Zitvogel L, Sautès-Fridman C, Kroemer G. The immune contexture in cancer prognosis and treatment [ePub ahead of print]. Nat Rev Clin Oncol. 2017. doi: 10.1038/nrclinonc.2017.101.3. Wiley K, LeFebvre K, Wall L, et al. Immunotherapy administration: Oncology Nursing Society recommendations. Clin J Oncol Nurs. 2017;21(2): 5-8. doi: 10.1188/17.CJON.S2.5-7.4. Kroschinsky F, Stolzel F, von Bonib S, et al; Intensive Care in Hematological and Oncological Patients (iCHOP) Collaborative Group. New drugs, new toxicities: severe side effects of modern targeted and immunotherapy of cancer and their management. Crit Care. 2017;21(1):89. doi: 10.1186/s13054-017-1678-1.5. Olszanski AJ, Zitella LJ. Advances in the use of immunotherapy in oncology. J Adv Pract Oncol. 2017;8(3):221-225. doi: 10.6004/jadpro.2017.8.3.2.6. Neuss MN, Gilmore TR, Belderson KM, et al. 2016 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards, including standards for pediatric oncology. Oncol Nurs Forum. 2017;44(1):31-43. doi. 10.1188/17ONF 31-43.7. Polovich M, Olsen M, LeFebvre K. Chemotherapy and Biotherapy Guidelines and Recommendation for Practice. 4th ed. Pittsburgh, PA: Oncology Nursing Society; 2014.