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Managing IO Toxicities: Three Keys to Success

By Sigrun Hallmeyer, MD

Sigrun Hallmeyer, MD
Medical Director, Advocate Lutheran General
Hospital Cancer Service Line
Advocate Aurora Health

Dr. Hallmeyer was born and raised in East Berlin, Germany.  Due to limited opportunities, a few weeks after her eighteenth birthday, she risked her life to escape to West Germany, where she completed her high school education in the West German system. After the fall of the Berlin Wall in November 1989, she returned to her family in Berlin and was accepted to the medical faculty of the Humboldt University of Berlin.

During her medical studies, she visited the United States for several clinical clerkships and was impressed with the high level of academic education as well as the administration of medical care. These rotations laid the foundation for her desire to pursue a career in America.

Dr. Hallmeyer completed her residency in Internal Medicine at Pinnacle Health Hospitals, Harrisburg, Pennsylvania, and completed her fellowship in hematology and oncology in Pennsylvania, and came to Chicago in 2002 to train at the University of Illinois at Chicago campus as a fellow in hematology/oncology at the University of Illinois in Chicago.

She joined Oncology Specialists, a private practice, in 2005 and is proud to be a member of a team of physicians and nurses who offer the highest quality of patient care. The atmosphere in the practice is very team oriented; everybody is focused on one common goal: provision of state-of-the-art, compassionate and complete care for patients and their family members.  Dr. Hallmeyer has specialized in the care of patients with breast cancer and melanoma. She has an avid interest in immuno-oncology, as well as a deep interest in cancer survivorship. In 2017, Oncology Specialists joined the Advocate Health Care system, the largest integrated healthcare system in Illinois, and was re-named the Advocate Medical Group.

Most recently, Dr. Hallmeyer served on the American Society of Clinical Oncology expert panels for management of immunotherapy-related toxicities and for sexual dysfunction in cancer survivors.

In 2017, Oncology Specialists joined the Advocate Health Care system, the largest integrated healthcare system in Illinois, and was re-named the Advocate Medical Group.

Dr. Hallmeyer adds, “I feel that I have the privilege of treating a very special group of patients, and I am honored to be able to provide help and support at a very difficult juncture in a patient’s life. By working here at Advocate Medical Group, I feel that my childhood dream from East Germany has come true.”

May 1, 2019

Our busy community practice first began treating patients with immunotherapy through participating in the original ipilimumab clinical trials. We quickly realized that this new treatment paradigm would require us to create and implement an effective screening and management tool for our immunooncology (IO) patient population. Then, when a patient who called in over the weekend to report persistent and worsening diarrhea after cycle 2 of combination immunotherapy and was told to increase his Imodium and start a “BRAT (bananas, rice, applesauce, toast)” diet, we recognized that we had missed an opportunity to prevent the subsequent high grade colitis, which required prolonged high-dose steroids and other interventions.

We were also listening to our nurses, as they expressed frustration with the variance in responses they received when talking to different physicians about the management of IO toxicities. For example, the dose and duration of steroids ordered differed not only from physician to physician, but also from patient to patient. Simply put, we lacked a practice-wide guideline. As a result, it was left to the doctor-nurse team to decide on the steroid, proper dosing, how to administer (topical/oral/IV), and how/when to taper.

In response, we put together an IO team, discussed implementation challenges, and ultimately developed an action plan. We created a nurse-driven education tool for our patients and an EMR triage, response, and documentation system that is guideline-based and standardized. All patients on IO therapy are flagged as “in active therapy” in our EMR and ANY call received by the front desk is channeled to the treatment nurse. The nurse initiates the standardized interventions, documenting the type and dose of steroids administered in the EMR flow sheet. This information is then communicated to the treating physician.

Patients are thoroughly educated. For after-hour calls, patients have a well-rehearsed script identifying them as IO patients and alerting the on-call physician to the potential IO side effects. Some of our high-risk patients even have prescription steroids at home, which they will initiate after first confirming with the nurse/physician to allow for speedy access. This program is highly effective and was seamlessly integrated into our practice. In 2017 our team won an ACCC Immuno-Oncology Institute Innovator Award for our program, Turning on the Light Switch: A Model Immunotherapy Program at an Oncology Practice. The recent release of comprehensive guidelines for the management of IO toxicities from the American Society of Clinical Oncology and National Comprehensive Cancer Network is wonderful; in fact, some of our team members actively participated in their development!

It is with great pride, but also with significant humility, that we continue to expand our IO program, one patient, one nurse, and one physician at a time. As we grow, we continue to prioritize key success factors in navigating the complex terrain of IO.

The views and opinions expressed herein are those of the author(s)/faculty member(s) and do not reflect the official policy or position of their employer(s) or the Association of Community Cancer Centers.