Tools to Monitor for ICANS During Lymphoma Treatment With Bispecific Antibodies, CAR T-Cell Therapy

Tools like the Immune Effector Cell Encephalopathy (ICE) score allow oncology nurses and advanced practice providers (APPs) to monitor for immune effector cell-associated neurotoxicity syndrome (ICANS) when patients with lymphoma are treated with bispecific antibodies and CAR T-cell therapy.

At the recent 8th Annual School of Nursing Oncology, Lauren Verity Moore, DNP, MSN, AGACNP-BC, nurse practitioner at the Murfreesboro Clinic of Tennessee Oncology, presented on managing patients with lymphoma while undergoing treatment with bispecific antibodies and CAR T-cell therapy.

Oncology Nursing News also spoke with Moore to learn more about how oncology nurses and APPs can best assess for any signs of ICANS in their patients during treatment.

Transcript:

You are going to have frequent assessments using an ICE score or an ICE tool, Immune Effector Cell Encephalopathy score. And that should be standard across each institution. Regardless of what grading scale you use, you should be calculating an ICE score. And that's going to give you—it's a 10-point score. Hopefully, Darlene, you and I would score a 10 out of 10, if we did that scale right now. But patients often—if they're beginning to experience neurotoxicity, you're going to ask them, “Hey, what year, what month, what city, what hospital are you in?” And if they only get 3 out of those 4, they'll get 3 points. And you go to the next question, “Name 3 objects in the room.” So a chair, a pen, a stethoscope. And you go on to the next thing. Are they able to follow commands? Can they write a sentence clearly? So you're going to keep the sentence the same, and you're going to have this documented. They're going to physically write down a sentence every time you do this assessment. And then can they count backwards by 10s from 100.

So, all of those things [answers] are going to give you, again, an optimal score of 10. For each point that they miss, you're going to then grade them based off of that score. That's one piece of looking for ICANS and neurotoxicity. I would say that's probably the best thing.

Some of the other symptoms, you can see things like seizures, deep motor weakness, hemiparesis, but those are pretty significant. That's really when you're getting into that grade 3, grade 4 ICANS. Like I said, I have found, personally, in my experience, that ICE score is where you're really going to first notice some changes.

You're going to see maybe a small tremor in their sentence writing. They've scored great on everything. They got a 10, but that sentence, you can start to see, is getting a little bit shaky. And they're still going to get the full 10, but you're going to know, I need to keep a close eye on that. Maybe we're starting to get to that ICANS grade 1, or they have even sometimes, like expressive aphasia. They know what they want to say, but they can't quite find the words. And there's no specific grading for that. That's just, again, something that I've seen in practice.

And [engage] family members, too. Again, this is why I really like engaging my family members, because they know [the] patient better than I do. You know that they know them the best, and they're quick to say, “Hey, something seems a little bit off. You know, we were talking about something earlier, and they were just a little bit confused.” “OK, thank you for letting me know. I'm going to reassess, you know, in another hour. Let me just make sure that there's no changes, because things can happen pretty rapidly.”

So again, to recap, you can see things like altered mental status, delirium, tremor. You can see seizures. You can see some focal motor weakness, etc., but I don't typically see those changes as much as I see the early, you know—we're able to intervene before I see anything like that.

This transcript has been edited for clarity and conciseness.