Cancerous cells can dysregulate immune checkpoints as an important means to avoid immune surveillance and destruction. Mechanisms by which immune checkpoints are dysregulated include T-cell inactivation, cell signaling disruption, upregulation of immunosuppressive immune cells, and elaboration of immunosuppressive cytokines. Specifically, cancerous cells can upregulate inhibitory immune checkpoint proteins, including cytotoxic T-lymphocyte associated protein-4, PD-1, and programmed death ligand 1. Blockade of these inhibitory checkpoint molecules removes the constraints on T-cell activation, amplifies antigen-specific T-cell responses, and encourages powerful antitumor responses.
The 5 immune checkpoint inhibitors currently approved by the FDA are pembrolizumab, nivolumab, atezolizumab, avelumab, and ipilimumab. These immunotherapeutic agents have proved efficacious in various tumor types, significantly increasing overall survival and inducing highly durable tumor responses. As these agents are immune-modulating in nature, they have the potential to induce autoimmune activity and immune-related adverse events (irAEs), including hepatitis, enterocolitis, thyroiditis, pneumonitis, and dermatitis. IrAEs require immediate identification and surveillance to avoid treatment cessation or delay, or, even worse, death.
Proper communication among clinicians is imperative for the safety of patients receiving immunotherapy. Nursing handoff communication is an effective means to monitor and manage irAEs; however, limited data exist in the outpatient oncology setting. An initiative was therefore undertaken in a phase 1 outpatient oncology setting with registered nurses (RNs), nurse practitioners (NPs), and 10 oncologists. The goal of this initiative was to develop and implement a nursing handoff communication process to monitor and follow up on patient status, and to identify and effectively manage irAEs. The communication tool that was developed listed patients experiencing adverse events and a schedule to contact them for telephone assessment. Each day, an RN was designated to contact the patient and complete an assessment, including systems review, symptom evaluation, and medication reconciliation. The findings were documented in the electronic medical record, escalated to the NP if needed, and then inputted into the e-mail handoff for further follow-up by the subsequent nurse.
Staff engagement with utilization of the handoff tool was 100%. The nursing handoff process improved communication and patient outcomes. The RNs reported improved efficiency and accountability, and the patients were appreciative of the thorough and diligent care. Future outcome measures for this initiative will include aligning emergency department admissions with symptom management data.
Active surveillance and early recognition of irAEs is pivotal for the safety of patients receiving immunotherapy. Although seemingly daunting and arduous, the development of a communication tool is an effective and necessary strategy for early recognition and effective management of irAEs. Structured tools can improve nurse-to-nurse handoff compliance and communication. Leveraging technological advancements, such as e-mail capability, can enable RNs to focus assessments and improve communication.
Gordon R, et al. ONS Abstract 104.
