May 1, 2019
Mark B. Faries, MD, is co-director of the Melanoma
Program and head of Surgical Oncology at the Los Angeles
Clinic & Research Institute and the surgical director for
Experimental Therapeutics at Cedars-Sinai Medical Center.
He is a member of the Multispecialty Coordination &
Communication Working Group. He is a member of the Multispecialty Coordination &Communication Working Group.
Immuno-oncology (IO) has radically altered the patient care
paradigm. One of most important changes attributed to IO is
improvement in outcomes and lengthening of survival. This
good news comes with multiple challenges, not least of which is
the need for new and better communication and coordination
among multiple specialties over time. IO requires providers to
adapt to more multidirectional, dynamic relationships to optimize
patient care. Management of potential toxicities of IO is involving
specialties that have not historically had much of a role in oncology.
This includes gastroenterologists to help manage colitis or
enteritis, endocrinologists to treat hypophysitis or hypothyroidism,
dermatologists to care for dermatitis, and many others. Late events,
including responses, recurrences, and toxicities, are also more
common now, often occurring months after the start of treatment
or even later. For patients with metastatic solid tumors, these long
timelines are a fairly new development.
What can we do to proactively address this paradigm shift? First,
we must open more lines of communication so that we can provide
more updates with each follow-up visit, meet more requests for help
in unfamiliar clinical situations, and support shared problem-solving.
Here, despite continued shortcomings, electronic medical records
can help with messaging and forwarding reports. But often, there
is no replacement for a direct conversation about a patient or a
Second, we must engage and educate our patients. Since
patients undergoing immunotherapy often don’t “look like” cancer
patients, their history of cancer therapy may not be obvious to a
physician who is seeing them for an “unrelated” symptom. For
example, severe diarrhea requires a substantially different work-up
in the Emergency Department in a patient who has received
checkpoint blockade. Well-informed, prepared patients can provide
information about their diagnosis and treatment to non-oncology
physicians on the front lines—whether through treatment education
they have received or even by presenting an IO wallet card to the
clinician. In larger practice settings, creating an oncology “toxicity
team” can establish a single, broadly available resource for nononcology
physicians to reach out to for guidance and information
in evaluating an IO patient.
Finally, as patients move from active therapy to post-treatment
survivorship and long-term follow-up, we must clearly identify which
member of the patient’s care team will be primarily responsible for
their care. As more patients enjoy long-term, durable responses,
their medical home will likely revert to their primary care physician.
Although when and how this transition occurs will vary, good
communication among all parties is key to ensuring that everyone
is on the same page as it is happening.
There is much we do not yet know about the optimal strategies
for caring for immuno-oncology patients, including those who
do very well over the long term. One thing is certain: Things will
continue to change, and ongoing communication will be essential