Hoffner Brianna, Rubin Krista M
University of Colorado Cancer Center-Anschutz, Aurora, Colorado; and Massachusetts General Hospital, Boston, Massachusetts.
J Adv Pract Oncol. 2019 Mar;10(Suppl 1):9-20. doi: 10.6004/jadpro.2019.10.2.10. Epub 2019 Mar 1.
Immune checkpoint inhibitors (ICIs) have improved outcomes for many patients with advanced cancers. However, managing the immune-related adverse events (irAEs) associated with these agents is challenging. Late recognition and/or inadequate irAE management can result in ICI discontinuation or termination, negatively impacting patient outcomes and increasing unplanned emergency department visits, hospital admissions, and costs of care. Improved clinician training and infrastructure development are needed to adequately address irAEs and maximize the potential benefits of ICIs. Advanced practice providers (APPs) are well positioned to drive these improvements. Two aspects of care may reduce the burden of irAE management: improved telephone triage and the implementation of dedicated oncology acute care services. Evidence-based protocols should be used for telephone triage. Protocol development may benefit from an evaluation of current irAE management guidelines together with resources from the Melanoma Nursing Initiative and Immuno-Oncology Essentials. Patients and their caregivers must be educated to recognize and report early symptoms suggestive of an irAE, thereby supporting triage efforts. Advanced practice providers should also advocate for the development of dedicated oncology acute care facilities staffed with clinicians well trained to recognize, grade, and manage irAEs. This manuscript reviews multiple existing models of telephone triage and dedicated oncology acute care. Oncology APPs are poised to lead the staffing, infrastructure, and educational changes necessary to reduce the burden of irAEs in patients receiving ICI therapy.
免疫检查点抑制剂（ICIs）改善了许多晚期癌症患者的治疗效果。然而，处理与这些药物相关的免疫相关不良事件（irAEs）具有挑战性。对irAEs的识别延迟和/或管理不当可能导致ICI停药或终止，对患者的治疗效果产生负面影响，并增加非计划性急诊科就诊、住院率和护理成本。需要改进临床医生培训和基础设施建设，以充分应对irAEs并最大限度地发挥ICIs的潜在益处。高级实践提供者（APPs）在推动这些改进方面具有得天独厚的优势。护理的两个方面可能会减轻irAE管理的负担：改进电话分诊和实施专门的肿瘤急症护理服务。电话分诊应使用基于证据的方案。方案制定可能受益于对当前irAE管理指南的评估，以及黑色素瘤护理倡议和免疫肿瘤学要点提供的资源。必须对患者及其护理人员进行教育，使其能够识别和报告提示irAE的早期症状，从而支持分诊工作。高级实践提供者还应倡导建立专门的肿瘤急症护理设施，配备训练有素、能够识别、分级和管理irAEs的临床医生。本文综述了多种现有的电话分诊和专门的肿瘤急症护理模式。肿瘤学APPs有望引领人员配备、基础设施和教育方面的变革，以减轻接受ICI治疗患者的irAEs负担。
