January 4, 2018 at 1:51 am #4592Expert NurseLisa Kottschade
How do you approach the patient with a pre-existing autoimmune condition who will be starting on ICI therapy?January 4, 2018 at 8:42 pm #4597Expert NurseKrista Rubin
There is much in the literature regarding this issue and for those not familiar with the literature, it is worth reviewing. Bottomline- underlying autoimmune disease should NOT automatically be a contraindication to I/O therapy. However, as I am sure your practice is similar- there is no absolute right or wrong answer.
In our practice, decision to recommend I/O therapy to someone with underlying autoimmune dz (such as RA, colitis, psoriasis, etc) will vary depending on multiple factors to be considered based on each INDIVIDUAL patient. For example:
-is the underlying autoimmune issue well controlled?
-are they on immunosuppressive medications currently? what line of therapy (1st line, 5th line…)
-is there a specialist involved that would be willing to co-manage with oncology?
-is the patient reliable to report any new or worsening symptoms? do they have family/caregiver support?
-do they have additional comorbidities that would further increase risk
-Importantly- what is tumor burden- and have they had prior melanoma therapies?
Really, the decision comes down to is risk/benefit. If a patient has significant tumor burden and prognosis is poor- and they WILL die from their melanoma without intervention, then the benefits of trying I/O would seem to outweigh risks. Then there is the flip side to that as well.
We often see patients in consultation regarding safety of I/O therapy in such a patient. If the primary oncologist does not have enough of a comfort level with making such a decision, we will often weight in, and we are happy to co-manage or provide consultations regarding symptom management. There is not right answer here, as I am sure you know.
What I hate to hear about, is a patient being denied treatment to potentially life-prolonging or life-saving therapy due to lack of comfort or knowledge by a provider.
I would be very interested to hear how others address.
PS- my answer above relates to metastatic diasease. The adjuvant setting is a whole different discussion!!January 5, 2018 at 2:50 am #4598Expert NurseVirginia Seery
Great question Lisa! Our approach to this issue follows Krista’s guidelines with each particular patient’s situation evaluated independently weighing the risks and benefits. Several years ago we would have avoided I/O therapy in patients with autoimmune conditions, but that practice has now changed as more information has come out showing that it can be offered to some patients.
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