This article was organised and fully funded by Bristol Myers Squibb, as a follow-up to a roundtable hosted in collaboration with HSJ. Bristol Myers Squibb has not determined the content of the article, but the company has reviewed the article to check for accuracy. This article has no promotional intent. Bristol Myers Squibb does not intend to encourage the use of, or advocate the promotion of, its products through the objectives of this article.
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The rapid expansion in the number of sites and situations that call for the use of immune checkpoint inhibitors, or so called oncological immunotherapies, has led to significantly improved outcomes for patients. However, the quid pro quo for such improvements is the evolution of drug toxicity, with serious toxicities requiring hospital review which affects a number of patients. Whilst oncologists are proficient in the management of oncology treatment side effects, immunotherapies bring three main new challenges. Firstly the toxicities have a completely different manifestation than other systemic anticancer therapies (SACT) because they are immune in nature and often mimic autoimmune disease. Secondly there is a requirement for active management in the form of immunosuppression, unlike the supportive approach required for other SACT. Thirdly the management requires significant time off therapy and intense, active monitoring to ensure the patients’ toxicities are improving. Ultimately this has led to a fundamental shift in the requirements of oncological management – one which clinicians are increasingly challenged by, particularly as novel tumour sites begin to use these agents.
Due to the autoimmune and auto-inflammatory mimicry, pluripotent across all organ systems, immunotherapy toxicities require significant input from other medical specialities across multiple organ groups to ensure there is sufficient knowledge to successfully manage them. This is a novel situation and the need for specialist input and access to specific investigations such as endoscopy, echocardiogram and specific imaging, is rising year on year as usage increases. Awareness, structured services and capacity needs to be considered, not just from an oncological perspective but also wider medical services. Alongside direct clinical contact, there appears to be an evolving role for multidisciplinary, organ-specific, meetings to discuss complex patients as well as an increasing educational ask, both within and external to oncology, including primary, acute and medical services. This requirement is expanding as awareness and management of toxicity needs to be implemented across the health service and is no longer just seen within oncology services.
As clinicians’ experience with the immunotherapy class increases, the provision and developments needed to manage patients effectively are becoming clearer. The disparity of need between patients with immunotherapy toxicity and other SACT toxicities is not always fully appreciated and therefore there is a true requirement for clinical and management teams to work collaboratively to develop services which meet these evolving needs. This will allow exchange of knowledge and experiences between teams resulting in successful funding applications and subsequent service implementation.
Currently service development and patient support are happening at grass roots level in individual trusts as time and capacity allows. However, as the impact of immunotherapy grows, consideration should be given to whether there could be a more joined up, national service approach especially given the population needs are similar irrespective of geographical or socio-economic factors. In the short term this could be characterised by a national support network to promote best practice and clinical insights but in the longer term may lean towards national commissioning against a set of standards mirroring that of the acute oncology model.
Job code: ONC-GB-2100747
September 2021
