By Hisanaga Nomura, Japan Agency for Medical Research and Development, Japan 

Until only 10 years ago, the main types of cancer treatment used to be referred to as “The Three Musketeers,” which were surgery, chemotherapy, and radiotherapy. Since Check-Mate 037 was published, cancer treatment has now expanded to four pillars, to also include immunotherapy. Six years have passed since nivolumab was approved in Japan. When it was approved, immune checkpoint inhibitors (ICIs) had only been used in specialized hospital settings. Nowadays, ICIs are widely used to treat cancer patients in many hospital settings. In Japan, there are lots of minor regional hospitals other than the large cancer centers. ICIs are used in regional hospitals all over Japan. Many times, medical staff and patients and their families do not always understand what immune-related adverse events (irAEs) are and how to recognize them. It is important to explain and recognize the first symptoms of irAE and how to manage them before treatment with immune therapy begins. The irAE team is important not only in specialized hospitals, but also in the general (regional) hospitals.

In January, a seminar was held in Tokyo named “Management of cancer immune-therapy.” Physicians, pharmacists, and nurses from many different hospitals united in one team and participated in this seminar. During the seminar 25 physicians, 38 pharmacists, and 37 nurses belonging to 23 facilities from all over Japan participated. The program is shown below in Figure 1.

Four lectures were held in the morning. At first, a medical oncologist told us about “The diagnosis of irAE and updates on immune therapy.” Next, a clinical pharmacist told us about “Why management of steroid therapy in patients with irAE is tricky.” Next, a nurse told us about “Patient counseling about early detection of irAE.” Finally, a regional nurse told us about “Initiatives for developing irAE regional management teams.”

After lunch, small group discussions were held in groups of 10. In the group discussions, each profession (physician, pharmacist, and nurse) shared their respective opinions on the simulated gastric cancer patient case made by the committee members. An excerpt of the case is shown below (Table 1).

Figure 1. The irAE management seminar schedule

1. Opening Remarks

2. Special Lectures (10:00-12:00)

• The diagnosis of irAE and new information about immune therapy. Medical Oncologist
• Clinical pearls for irAE management using steroids. Clinical Pharmacist
• Patient counseling for early detection of irAE. Oncology Nurse
• The initiatives of irAE management teams in each region. Regional Nurse

Lunch time

3. Small Group Discussion (13:00-16:00)

4. General Comments/Questions for facilitators

5. Closing Remarks  

This example case is a gastric cancer patient: 
There are three episodes in this case. At first, the male patient complained of light rash on the abdomen and upper arm. The participants were asked to consider what kind of symptoms would lead to hospital admittance. Next, the patient experienced heavy malaise. What would you suspect? What would you investigate? Finally, the patient complained of severe diarrhea. Participants discussed how to respond to this case and their respective roles in each of their professions.

Through this seminar, participants had a good opportunity to learn about how other hospitals are approaching the management of ICI and irAE. Participants compared many different hospital approaches during the case discussion. For example, one hospital is utilizing an electronic health record system as a means to share information. Another hospital is using early detection systems using web forms. And another hospital has implemented irAE management in coordination with the community pharmacy.

In the near future doublet ICI therapy, combination therapy with ICI and an EGFR inhibitor, and the combination of ICI with chemotherapy will have an impact the incidence of irAE. It is important for all members of the health care team as well as the patients and their caregivers to be well informed about what to monitor for and how to manage irAE.