Debra Madden is a 2-time cancer survivor who was diagnosed with Hodgkin's lymphoma as a young adult and breast cancer nearly 20 years later, which was thought to be secondary to the radiation she had received for her original cancer treatment. Debra became an active Cancer Research Advocate following her second cancer diagnosis at the age of 42 years. She is currently a member of the ECOG/ACRIN Cancer Research Group and the Patient-Centered Outcomes Research Institute's Advisory Panel on the Assessment of Prevention, Diagnosis, and Treatment Options. She also serves on multiple grant review panels, including the Congressionally Directed Medical Research Program Breast Cancer Research Program. Debra blogs at "Musings of a Cancer Research Advocate", (https://draemadden.wordpress.com/) and you can follow her on Twitter at @AdvocateDebM.
It is imperative that we gather more mature data on a much larger number of patients to accurately assess efficacy, safety, potential harms, durability of response, and impact on disease progression and overall survival of the new immunotherapy treatments.
In Part I of this article, Ms Madden discussed the enthusiasm concerning new immunotherapies, the need for caution in interpreting results while the data is still young, and the necessity for more mature data on a much larger number of patients. Here in Part II, she continues her discussion on why it is critical to educate patients and their families concerning what to expect from immunotherapy, with a particular focus on the unique spectrum of adverse effects that may be associated with these agents.
In the popular media and elsewhere, when reporting the potential benefits of immunotherapy, some have stated that when compared with traditional cancer treatments, there are “few to no side effects.” Though immunotherapies are typically not associated with the same side effects that result with chemotherapeutic agents the statement “few to no side effects” does not tell the entire story and may be misleading for patients. In fact, it’s the very promise of cancer immunotherapies—ie, the mechanisms of action that harness and enhance the immune system’s abilities to recognize and fight cancer cells—that may also lead to serious harms in some patients. In addition to enabling a continued attack against cancerous cells, increased inflammatory reactions and enhanced immunologic responses with immunotherapies such as the checkpoint inhibitors may impact normal body cells and tissues, resulting in adverse effects. Autoimmune in nature, such effects are collectively known as “immune-related adverse events (irAEs),” and are thought to occur due to general immunologic enhancement. 4,12
The chart below outlines specific irAEs reported in association with immunotherapy for some patients:4,12
Dermatologic toxicities may result in serious skin reactions, where symptoms may include:
Inflammation of the intestinal lining (colitis) may lead to holes or tears (perforation) in the intestines. Associated symptoms may include:
Inflammation of the liver (hepatitis) can lead to liver failure. Symptoms and findings associated with hepatitis may include:
Nerve damage (neuropathy) may develop, with symptoms that may include:
Endocrine toxicities may primarily affect the pituitary gland (hypophysitis), the thyroid gland (hypothyroidism), and adrenal glands (adrenal insufficiency). Associated symptoms may include:
Adrenal insufficiency, a serious endocrine toxicity potentially associated with the checkpoint inhibitors, is considered an emergency and may cause hypotension, dehydration, and electrolyte imbalances.
Symptoms and signs may include:
Symptoms associated with eye inflammation may include:
Symptoms associated with lung inflammation (pneumonitis) may include:
It is said that Hippocrates wrote, “Natural forces within us are the true healers of disease.” Our hope is that many of the long-sought answers to curing cancer will indeed lie within our own immune systems—and that our next step on this lengthy path will be to find the keys to expanding immunotherapy’s promise to many more of us. In the interim, however, as we strive toward this goal, it’s crucial for our healthcare providers to appropriately inform patients and help to manage expectations.
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2. Feltman R. Why it’s too early to get excited about this “unprecedented” new cancer treatment. The Washington Post website. https://www.washingtonpost.com/news/speaking-of-science/wp/2016/02/16/why-its-too-early-to-get-excited-about-this-unprecedented-new-cancer-treatment/. Published February 16, 2016. Accessed March 21, 2016.
3. Yuhas A. Cancer researchers claim “extraordinary results” using T-cell therapy. The Guardian website. https://www.theguardian.com/science/2016/feb/15/cancer-extraordinary-results-t-cell-therapy-research-clinical-trials. Published February 15, 2016. Accessed March 21, 2016.
4. Green LM. Immunotherapy in cancer care: educating patients about what to expect. Oncology Nursing News website. http://nursing.onclive.com/publications/oncology-nurse/2015/june-2015/immunotherapy-in-cancer-care-educating-patients-about-what-to-expect#sthash.FeNfHPaO.dpuf. Published June 30, 2015. Accessed March 21, 2016.
5. McGranahan N, Furness AJS, Rosenthal R, et al. Clonal neoantigens elicit T cell immunoreactivity and sensitivity to immune checkpoint blockage [published online March 3, 2016]. Science. doi:10.1126/science.aaf1490.
6. Begley S. The newest cancer therapies don’t work on everyone. Now, doctors have a clue why. StatNews website. https://www.statnews.com/2016/03/03/cancer-immunotherapy-neoantigens/. Published March 3, 3016. Accessed March 21, 2016.
7. Garron E. Time to response to immunotherapy and the concept of pseudoprogression (video transcript). Global Resource for Advancing Cancer Education website. Published December 15, 2015. Accessed March 22, 2016. http://cancergrace.org/lung/2015/12/15/gcvl_lu_immunotherapy_response_time_pseudoprogression_concept/
8. Assessing immunotherapy response—why irRC matters: clinical optimization. Institute for Clinical Immuno-Oncology website. http://accc-iclio.org/resources/assessing-immunotherapy-response-why-irrc-matters/. Published June 25, 2015. Accessed March 22, 2016.
9. West H. 5 key points on immune checkpoint inhibitors for lung cancer: game changer or just leveling up? Global Resource for Advancing Cancer Education website. Published January 5, 2014. Accessed March 21, 2016. http://cancergrace.org/lung/2014/01/05/5-key-points-on-immunotherapy-for-lc/
10. Kim T, Amaria RN, Spencer C, Reuben A, Cooper ZA, Wargo JA. Combining targeted therapy and immune checkpoint inhibitors in the treatment of metastatic melanoma. Cancer Biol Med. 2014;11(4):237-246. doi:10.7497/j.issn.2095-3941.2014.04.002.
11. Pilones KA, Vanpouille-Box C, Demaria S. Combination of radiotherapy and immune checkpoint inhibitors. Semin Radiat Oncol. 2015;25(1):28-33. doi:10.1016/j.semradonc.2014.07.004.
12. Postow M, Wolchok J. Toxicities associated with checkpoint inhibitor immunotherapy. UpToDate website. http://www.uptodate.com/contents/toxicities-associated-with-checkpoint-inhibitor-immunotherapy. Literature review current through: Feb 2016. Updated Jan 6, 2016. Accessed March 22, 2016.