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Immunotherapy - Psychosocial & Educational Considerations and Resources
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Sheri McMahon discusses Immunotherapy - Psychosocial & Educational Considerations and Resources at ONS Congress 2017. For the ability to view on your mobile phone please visit us at

This transcript is software driven, please understand there may be errors.  Should any inaccuracies or omissions be found, please notify for correction.

Hi. I'm Sheri McMahon. I'm a research nurse specialist with the National Cancer Institute at the office of the Research Nursing Department at National Institutes of Health. Today, we're going to be finishing up the session with other considerations for immunotherapy. We're going to be looking at some educational, financial, and psychosocial aspects of immunotherapy, and then I want to offer some resources to you and to other staff, patients, and families, as well.

Some general education about immunotherapies, I want to remind everyone they have a very nice ONS course for immunotherapy and cancer treatment that's 4.0 credit hours. The Clinical Journal of Oncology Nursing just recently put out an immunotherapy supplement with articles in it that's also a very nice way to look at it. I would recommend maybe even doing some Journal Club articles with you and your staff, other staff, just to introduce some in a more easy way, and they can start learning and getting a better feel for different types of immunotherapy.

When you talk to your patients, you want to make sure that you're teaching them what immunotherapy is, that it's about training their own immune system to activate against the cancer, to recognize it, and to activate; also that a lot of immunotherapies are not about immediate effects, such as lowering tumor markers. It's often about longer-term effects because it can take some time to get the immune system generating effectiveness, so they may see a slowed rate in rise, rather than an actual decrease.

You can also go to the National Cancer Institute, and, as well, that you can find resources there, as well, about immunotherapy. Patient and family ... I also put up here some YouTube videos that have some nice science, but not real complicated way of explaining immunotherapy, vaccines, and oncolytic viruses, as well. In general terms, education needs to be safety oriented with your patients.

What do the patients need to know for that particular type of immunotherapy? General guidelines are about the same for a lot of other cancer treatments, and we need to reiterate some very basic precautions. They need to minimize the risk of their infections. We're talking rest, hydration, frequent hand-washing, and just to know what precautions they need to take, and doing anything you can to help your immune system work.

For the checkpoint inhibitors, we've talked a little bit about this earlier in some of the earlier slides, but just for the systemic inflammatory reactions, like the cytokine release syndrome, you have things for toxicities like the dermatologic pruritus and rashes. The endocrine system, you can have hypo- or hyperthyroidism, so you might want to be checking on TSH levels and teaching them symptoms and looking for symptoms of hypothyroidism, like fatigue, skin dryness, brittleness, thinning hair, sensitivity to cold, memory, constipation, so those are all things that you need to be looking for as a nurse, as well.

For the pulmonary symptoms, you have things such as a cough and dyspnea and maybe loss of appetite. With all these it's actually very important that we eliminate all other possible causes of these side effects, such as infection, so that they can be treated appropriately as soon as possible.

For the CAR T-cells, we talked a little bit about this, so just about the acute infusion reactions that is given. They'll need to be taking premeds. We give acetaminophen, diphenhydramine. If they get chills during the infusion, they may need meperidine. Hypotension, bronchospasms need to be addressed sometimes. Steroids will need to be done. For the tumor lysis syndrome toxicities, we'll need to be checking electrolyte abnormalities for the cytokine release syndromes. Also, you're going to be looking at lab results, looking at organ failure and coagulation disorders.

Many trials now are using treatment algorithms in which they identify and show, by symptom, what the treatment is something like maybe steroids or Enbrel to treat inflammatory conditions. As always with these treatments, the challenge is to try to balance efficacy of these treatments versus the toxicities that the patients get. For the oncolytic viruses’ education points, we know that, among all of these, fatigue is just very, very common. We see flu-like symptoms. We see injection site reactions. Malaise, fever can be run.

With the added information that the patients are going to need for education and your staff is going to be safe infection control administration, isolation precautions. They're going to need personal protective equipment and be taught what they need to do with that and teaching about isolation to the patients, as well. Above all, more good hand hygiene, general precautions of hydration and skin integrity. These are all things that we will see, and they will need to be taught.

We know immunotherapy is very expensive. The societal price tag has been estimated at 174 billion dollars a year annually in the U.S. alone. We know that an annual cost of one immunotherapy treatment can exceed $100,000 and then, of course, the idea is that they combine treatments now, so you can see how it can quickly get out of control. Immunotherapy is often covered by health insurance, but patients still have to deal with rising out-of-pocket costs.

Surgery and other cancer treatments will add more to the financial burden as more and more combinations are being tried together. Studies have reported the prevalence of asset depletion and medical debt for cancer survivors. Patients can face bankruptcy. That's probably more prevalent in the populations that you might expect, such as those who are younger in age, lower household income, or maybe on public health insurance.

Of course, a potential advantage of the immune therapy is that it might have a durable response, so the hope is, maybe in the future, if they have durable remission, patients might be able to return to work and to productivity to help alleviate some of these problems. Given the price tag of these drugs, cost effectiveness will be an important component of the patient conversation and of future research, as well.

Psychosocial considerations. We need to take a multidisciplinary approach. We know that there are some common side effects that we see, such as the fatigue, the anhedonia, which is an inability to experience pleasure from activities that patients usually enjoy, such as exercise, hobbies, and social interactions. Anxiety and depression is common. Social isolation, that feeling of psychological vulnerability and the fear of being a burden.

There's actually also documented a sickness behavior that can be considered an adaptive response that maybe promotes healing by reducing energy expenditure towards unnecessary activities by the patients. These are, we think, because they have the same mechanisms of action. They use the same pathways. They can be acute or chronic, and we know that those who are preexisting psychiatric conditions are at a higher risk for depression, especially, so we need to know what their history is. We need to be assessing and finding out what they are having in order that we can address it and find treatments for them.

Some strategies that patients can use, they need their social support. We know that this is able to decrease the risk of depression in both the general population and in patients that are treated with immunotherapies. Strategies that they can use are prioritizing their activities, using the energy on activities that are the most important to them. They can set aside time to rest, plan to take maybe short, frequent naps if they can during the day, maintaining proper nutrition. They need to stay as active as they can be. Even regular, light exercise, such as 15-minute walk maybe three times a week can increase energy and strength.

They could possibly talk about adjusting their work schedule to take advantage of their peak energy times. Finding support from others who actually understand cancer-related fatigue and how devastating it can be to their quality of life. There are other techniques, such as guided imagery, stress management, and humor therapy. Anything that they can help to improve their coping skills is all very much encouraged. Of course, referrals. We really need to be an advocate for our patients and to give them referrals to all members of the team so that they can get some help and support and feel empowered in their care.

That concludes this module. Thank you for your attention.