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SITC Handbook Addresses Multispecialty Needs to Manage Immunotherapy Toxicities

Tony Berberabe, MPH
Published Online:2:12 PM, Wed November 13, 2019
Igor Puzanov, MA, MSCI, FACP
Igor Puzanov, MA, MSCI, FACP
The advent of immunotherapy has delivered unprecedented and durable anti-tumor responses as well as long-lasting survival benefits in some patients. Yet many clinicians may not be familiar with managing the unique toxicities that accompany these emerging cancer treatments. What’s needed is a handy resource that provides practical guidance about recognizing and managing immunotherapy toxicities, written for community-based oncologists, emergency department physicians, advanced practice providers, members of the healthcare team, and specialists in all the major organ systems.

That was the rationale for the development of the Society for Immunotherapy of Cancer’s (SITC) handbook, SITC’s Guide to Managing Immunotherapy Toxicity, which provides clinicians with a practical reference to manage the adverse events associated with immune checkpoint inhibitors in the clinic.

“Community-based oncologists will especially benefit from the handbook. They have to absorb vast amounts of information about new drugs and their side effects. I can also see advanced practice practitioners who work with oncologists and those who work as hospitalists, emergency room and intensivist specialists, as well as their team members, benefitting from the handbook,” said co-editor Igor Puzanov, MD, MSCI, FACP, a professor of oncology and director of Early Phase Clinical Trials Program in the Department of Medicine at Roswell Park Comprehensive Cancer Center, and a professor of medicine at Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.

Written by world-renowned leaders in the immuno-oncology field, the handbook provides the practicing physician and other allied healthcare providers with authoritative access to the latest data and recommendations regarding toxicity management for checkpoint inhibitors.
And as immune checkpoint inhibitors become a mainstay in oncology care, the handbook will serve as a resource for clinical oncologists, emergency physicians, hospitalists and other medical practitioners in both the hospital and community clinic settings.

The handbook is organized into two sections, for ease of use: Part 1 discusses mechanisms of action, indications, and toxicities commonly observed with anti–CTLA-4 agents and anti–PD-1/PD-L1 agents. Part 2 narrows in on the common and uncommon toxicities that affect major organ sites throughout the body.

“The book is useful for any physician or advanced practitioner taking care of our patients treated with immunotherapy,” said Puzanov, who is also chief of melanoma at Roswell Park Cancer Center.

In the handbook, clinicians can quickly find information about what types of adverse events to expect in patients receiving immunotherapies, organized by agent as well as organ system. For each, practitioners will learn about general management options, before receiving more specific guidance on toxicities including rash and mucosal irritation, toxicities affecting the muscles and joints, gastrointestinal toxicities such as diarrhea and colitis, pneumonitis, and toxicities affecting the endocrine, neurologic, cardiac, renal, hematologic, and ocular systems. Additionally, managing toxicities for special populations including patients with autoimmune disorders and geriatric patients is addressed extensively. The handbook also addresses important patient support and quality of life issues such as fatigue, financial toxicity, and treatment cost-effectiveness.

According to Puzanov, the handbook can be read from cover-to-cover, or be used as quick reference in the clinic. For example, an emergency department physician could turn to the handbook after examining a patient being treated with immuno-therapy who arrives at the emergency department with a fever.

“An emergency department physician who is familiar with chemotherapy toxicities may mistakenly think the patient who comes in with immunotherapy-related fevers, requires a culture and a round of antibiotics, which can lower the efficacy of the immune therapy,” said Puzanov. “A quick look through the handbook will help point toward an alternative explanation for the symptoms and the correct workup and therapy.”

As one of the first societies to recognize the need for education in the immunotherapy field, SITC was at the forefront of identifying and managing immune-related adverse events through such efforts as hosting a toxicity management workshop, convening expert leaders in a toxicity management working group, and publishing a paper of their findings in the Journal of ImmunoTherapy of Cancer. The handbook was developed based on the results of these prior SITC efforts, seeking out ways to address the growing need for standardization to provide better treatments and ultimately, improve patient outcomes.

“Managing the patient with cancer requires an interdisciplinary approach and the handbook addresses the needs of the multiple specialists who are delivering patient care,” Puzanov said.

The importance of making evidence-based decisions about toxicity management is emphasized and summarized in the handbook so physicians, providers, and patients can contribute to decision-making. Additionally, the proper grading and management of adverse events is explored to help avoid inappropriate treatment discontinuation, which is a major contributor to unfavorable outcomes.

In addition to Puzanov, Marc S. Ernstoff, MD, Caroline Robert, MD, PhD, Adi Diab, MD, and Peter Hersey, MD, PhD, served as co-editors of the handbook, and it includes a forward penned by Howard L. Kaufman, MD, FACS, Past President, Society for Immunotherapy of Cancer, Massachusetts General Hospital and Lisa H. Butterfield, PhD, Immediate Past President, Society for Immunotherapy of Cancer, Parker Institute for Cancer Immunotherapy.

As an added resource for the community, SITC is preparing two Cancer Immunotherapy Guidelines devoted to the management of checkpoint inhibitor toxicities as well as immune effector cell– related adverse events.

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