Subspecialty Insights in Immuno-Oncology: A Closer Look at APPs

This post is the first in the “Subspeciality Immuno-Oncology Insights” series written by members of the ACCC Immuno-Oncology Institute. This series will bring forward perspectives and real-world strategies for tackling current challenges in the delivery of immunotherapies for cancer, as well as thought-provoking, potential next steps for optimizing care in this rapidly growing field. Reader response is encouraged. 

Advanced Practice Providers (APPs), such as nurse practitioners and physician assistants, play a fundamental role within medical oncology departments and the care of patients with cancer—offering another, yet independent, layer of support in an era of great progress in anti-cancer therapies and immunotherapies. 

Patient Education & Symptom Management

At The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center in Baltimore, Md., we see patients throughout their cancer journey, including those being treated with immune checkpoint inhibitors. While our APPs conduct patients’ medical history and physical at baseline, it is crucial to know what symptoms they initially present with and how their symptoms may evolve while on therapy. As APPs, we are poised to manage toxicities that can occur from immune checkpoint inhibitors—also known as immune-related adverse events (irAEs). We do an entire review of systems, from head to toe, to see if patients are experiencing any side effects that are related to their immune checkpoint inhibitor treatment. It is important to delineate what symptoms are present prior to starting therapy and how these symptoms may change after each infusion, as it could indicate a potential toxicity.

We do so clinically, but also by educating patients on what potential toxicities may occur, how toxicity symptoms may present, and when to contact their cancer care team when such toxicities arise. Our APPs conduct an education session with patients and provide written handouts, which include complete drug information and possible side effects, prior to their treatment start. We then educate patients on what symptoms to monitor for and how these symptoms may look, feel, or present. We emphasize the importance of calling their cancer care team so that symptoms can be assessed in a timely and methodical way. Many APPs are poised to manage the toxicities that can occur from these immune checkpoint inhibitors. 

Triaging & Addressing Treatment-Related Symptoms

Often, APPs are the first to hear about the side effects patients are experiencing because we receive the triage call when patients contact their care team. We then see these patients within our clinics or urgent care visits to help work-up the symptoms. We collaborate with other members of the care team, who may be within additional subspecialties, to perform a diagnostic work-up as well as manage and treat the irAE(s). APPs are pivotal in ordering labs and imaging, while also interpreting the results and helping manage these patients along with their medical oncologist or subspecialist. We rely upon our insights from managing former occurrences as we educate patients, manage their irAEs, and, in cases when immunotherapies need to be halted, determine whether it is safe for them to restart their immune checkpoint inhibitor. 

One of the most significant improvements within our infrastructure that impacts care delivery and aids the management of those on immune checkpoint inhibitors is patient and caregiver education—we see daily how this improves patient care and health outcomes. We teach, guide, and coach patients to be their own advocates by enhancing their knowledge of the treatment they are receiving, self-observe their symptoms, compare these symptoms to earlier time points in their treatment, and speak up about how their symptoms may be different now than at baseline.

APPs also want to support our other healthcare colleagues who do not routinely treat patients with cancer. We encourage other providers, who patients may see during their anti-cancer treatment, to reach out to patients’ primary cancer care team, consider immune checkpoint inhibitors as part of their differential diagnosis, and include it as part of their diagnostic work-up. 

For both patients and the providers caring for patients with cancer, advanced practice providers can be a key resource to help identify, expedite, manage, and treat the wide variety of irAEs that patients may experience.  

Visit the ACCC website for more information on the ACCC Immuno-Oncology Institute, including additional tools and resources to support the management of patients being treated with immunotherapies.

The ACCC Immuno-Oncology Institute is supported by Bristol Myers Squibb and Merck.

Sarah Sagorsky, MPAS, PA-C, is board certified by the National Commission on Certification of Physician Assistants and senior physician assistant in the Upper Aerodigestive Medical Oncology Department at The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center in Baltimore, Md. She earned her master’s degree from St. Francis University in Loretto, Pa. Sagorsky was nominated by the ACCC Immuno-Oncology Institute Executive Committee to author the first blog in this series to provide her insights into the role of APPs on the cancer care team and managing patients’ treatment-related symptoms.