A Multidisciplinary Approach to Treating Immune-Related Adverse Events

Monica Fradkin, MPH, BSN, RN, OCN

As part of our coverage of the Oncology Nursing Society Conference that was held May 4th to May 7th in Denver, Colorado, we are speaking with Monica Fradkin, MPH, BSN, RN, OCN, who is the clinical program director of the Smilow Network at Yale New Haven in Connecticut, about utilizing technologies to better care for cancer patients being treated with immunotherapy. At the conference, Monica discussed how nurses can improve care by using standardized nursing assessments, and by educating patients and caregivers.

-Interviewed by Anna Azvolinsky, PhD

OncoTherapy Network: Could you talk about what is maybe especially unique about treatment with immunotherapy that perhaps requires more careful patient monitoring and patient and family care giver education?

Monica Fradkin: Sure. What we realized over the last 4 years or so is that the number of new immunotherapy agents that are coming to market is significantly increasing. What we found is that the side effect profile of the immunotherapies is really about the immune reaction that a patient can experience and that this is very different than the traditional chemotherapy side effects that we are used to seeing:  nausea, vomiting, diarrhea, myelosuppression. And with the immunotherapies, what you see is more hepatitis, endocrinopathies, colitis, and pneumonitis which are very different side effects. So because of this we realized that there were gaps in the level of understanding of how to identify these side effects earlier on.

OncoTherapy Network: Can you talk about some of the technologies that have been developed that you and your colleagues have found can improve the monitoring for immune-related adverse events?

Monica Fradkin: What we use is our electronic medical records, called Epic, and what we leveraged is the capability to customize specific items within the medical records to be utilized by different members of the clinical team. For example, the providers that were not in oncology may not be as familiar with patients on immunotherapy. Also, if a patient is presented to the emergency department or to the primary care office with subtle complaints of something that is going on related to the immunotherapy and the primary care clinician is unaware.

By creating a best practice alerts, this alerts the provider outside of oncology to say, “I have to check with the oncologist before I decide on what should be done as far as care.” We also did this with nursing by creating a customized flow sheet specifically for immunotherapy also outlining by system and body part of where the body can be impacted by the treatment with immunotherapy. For example, for the digestive system, we are looking for enterocolitis and with that we have ways of asking specific questions that are associated with immunotherapies that would be different than the way we would do our focused reassessment for patients on chemotherapy.

OncoTherapy Network: Can you talk about some of the multidisciplinary education tools that are available to help raise awareness about these unique immune-related adverse events, how to identify them and manage them, for both patients and their caregivers?

Monica Fradkin: What we did is we created an education program that would go across all disciplines at the same time. We wanted to be able to sit down with nurses, pharmacists, advanced practice providers as well as physicians to provide the education on immunotherapy: What is the immune system, and how is it impacted as it relates to cancer? What is the mechanism of action and the side effects of these different immunotherapy agents? And how do you manage this? By hitting across all roles you have the opportunity to create a dialog between the different groups to make sure they have an understanding of what they are looking for.

OncoTherapy Network: Are there studies that have been done that show that some or all of these tools can improve patient outcomes?

Monica Fradkin: The goal is that the work that we are doing will be able to standardize not only the assessment, but also the management by using a standardized tool and approach. The goal is that we have earlier identification of potential immune-related side effects as well as a standardized process for documentation.

OncoTherapy Network: Thank you so much for joining us today, Monica.

Monica Fradkin: Thank you for allowing me the opportunity to talk about the work we are doing.