Accreditation/Credit Designation

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Physicians’ Education Resource®, LLC, designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Acknowledgment of Commercial Support

This activity is supported by educational grants from AstraZeneca and Merck & Co, Inc.

Community Practice Connections™: The “Don't Crash” Crash Course in Managing Immune-Related Adverse Events in Oncology

Release Date: November 27, 2019
Expiration Date: November 27, 2020
Media: Internet - based

Activity Overview

Given the importance of rapid assessment when a patient arrives in the emergency room, you need to have every tool available to provide a timely course of action. New therapies for cancer, such as immune checkpoint inhibitors (ICIs), have changed the field of oncology. These agents, however, can also lead to acute symptoms that can be life-threatening if not correctly diagnosed and managed. The “Don’t Crash” Crash Course in Managing Immune-Related Adverse Events in Oncology will provide you with knowledge about immune-related adverse events (irAEs), as well as optimal differential diagnostic and management strategies toward ensuring that patients can recover from irAEs and continue their cancer treatment.

This online educational activity features the Community Practice Connections™ platform, consisting of clinical vignettes and video clips featuring short expert interviews with oncologists and emergency department physicians who specialize in the diagnosis and management of irAEs experienced by patients undergoing immunotherapy for their cancer diagnosis. This activity consists of an overview on the mechanism of action of ICIs, which informs the etiology of irAEs. Through case-based scenarios, you will learn how to rapidly recognize and manage irAEs, such as colitis, pneumonitis, and thyroid dysfunction, in patients presenting in an emergency situation.

Benefits of Participating

  • Evaluate disease-related, comorbidity-related, and medication-related factors associated with irAEs
  • Learn the common and less frequent toxicities of immunotherapy
  • Listen to expert faculty discuss best practices for recognizing and managing various irAEs associated with immunotherapies
  • Increase knowledge and confidence in treating patients undergoing immunotherapy during an emergency situation

Acknowledgement of Commercial Support

This activity is supported by educational grants from AstraZeneca and Merck & Co, Inc.

Instructions for This Activity and Receiving Credit

  • You will need to log in to participate in the activity.
  • Each presentation may contain an interactive question(s). You may move forward through the presentation; however, you may not go back to change answers or review video/content until you finish the presentation.
  • At the end of the activity, “Educational Content/Video” will be available for your reference.
  • In order to receive a CME Certificate, you must complete the activity.
  • Complete the Posttest and pass with a score of 70% or higher, complete the Evaluation, and then click on “Request for Credit.” You may immediately download a CME Certificate upon completion of these steps.

Target Audience

This educational activity is directed toward emergency medicine physicians, nurses, and other professionals who have an interest in the emergency care of patients with cancer.

Learning Objectives

Upon successful completion of this educational activity, you should be better prepared to:

  • Recognize the mechanistic characteristics of checkpoint inhibitors in the context of the potential for immune-related adverse events (irAEs) with these agents
  • Evaluate disease-related, comorbidity-related, and medication-related factors associated with an increased risk for, or impact of, specific types of irAEs
  • Review potential irAEs, with an understanding of the relative frequency of specific types of irAEs, as well as best practices for toxicity management
  • Develop evidence-based multidisciplinary approaches to promptly recognize and address potential irAEs associated with immune checkpoint inhibitors

Faculty, Staff, and Planners’ Disclosures

Faculty

D. Ross Camidge
D. Ross Camidge, MD, PhD
Professor, Division of Medical Oncology
Joyce Zeff Chair in Lung Cancer Research
University of Colorado Anschutz Medical Campus
Aurora, CO

Disclosures: Consultant: Bristol-Myers Squibb, EMD Serono, Roche/Genentech.

Christopher Baugh
Christopher Baugh, MD, MBA
Vice Chair, Clinical Affairs
Department of Emergency Medicine
Brigham and Women’s Hospital
Associate Professor
Harvard Medical School
Boston, MA

Disclosures: no relevant financial relationships with commercial interests to disclose.

Tejas Patil
Tejas Patil, MD
Hematology/Oncology Fellow
University of Colorado Anschutz Medical Campus
Aurora, CO

Disclosures: Shareholder: CRISPR, Guardant Health, Novartis, Roche/Genentech; Other: Honoraria: Roche/Genentech.

Erin Schenk
Erin Schenk, MD, PhD
Assistant Professor of Medicine, Division of Medical Oncology
University of Colorado Anschutz Medical Campus
Aurora, CO

Disclosures: Speakers Bureau: Roche/Genentech.

The staff of Physicians' Education Resource®, LLC (PER®) have no relevant financial relationships with commercial interests to disclose.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that create a COI.

Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical education purposes only and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic or treatment options for a specific patient’s medical condition.

The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER® or the company that provided commercial support.

PER Pulse™ Recaps

1 of 3

Community Practice Connections™: The “Don’t Crash” Crash Course in Managing Immune-Related Adverse Events in Oncology is a continuing medical education (CME)-certified program. For this program, D. Ross Camidge, MD, PhD; Christopher Baugh, MD, MBA; Tejas Patil, MD; and Erin Schenk, MD, PhD, provide expert guidance for emergency department healthcare professionals on managing immune-related adverse events (irAEs) experienced by patients being treated with immunotherapies for their cancer.

This first of 3 PER Pulse™ Recaps summarizing the online activity focuses on the essentials of immunotherapy for emergency department physicians. Below are some highlights from the activity featuring Dr D. Ross Camidge:

  • Recent statistics estimate that 1 in every 20 patient visits to the emergency department (ED) is cancer-related, with more than 15 million people living with cancer or a history of cancer in the United States.1 With the approval of several cancer immunotherapeutic agents in recent years, more than half of patients now receive this type of therapy,2 which has distinct AEs that may be unfamiliar to ED physicians and nurses.
  • Immunotherapy using immune checkpoint inhibitors (ICIs) boosts the body’s natural defenses to fight cancer. Normally, the immune system is activated when T cells are activated.3 Tumor cells express immune checkpoint proteins (eg, CTLA-4, PD-1, PD-L1) to evade immune detection and continue to grow unregulated.3,4 Several approved ICIs that target PD-1, PD-L1, and CTLA-4 disrupt this evasive maneuver, releasing the inhibition of T-cell activation and restoring the body’s natural immune response against cancer.
  • Although ICIs are involved in activating and amplifying T cells to attack tumor cells, sometimes healthy cells can be affected, causing inflammatory conditions similar to autoimmune conditions. The timing of irAE onset can be delayed 1 month or more after treatment initiation, and duration of irAEs can last many months, even after treatment has been discontinued.5,6 Among the more common, early-onset irAEs are rash and colitis. Less common irAEs, such as neurologic events and hypophysitis, tend to arise much later after treatment initiation.

“[Medical oncologists] love it when you call us and say, ‘Hey, your patient is in the emergency room. I just want to check what treatment she was on.’ We would love to be involved. Just give us a call.”

— D. Ross Camidge, MD, PhD

References

  1. Rivera DR, Gallicchio L, Brown J, Liu B, et al. Trends in adult cancer-related emergency department utilization: an analysis of data from the Nationwide Emergency Department Sample. JAMA Oncol. 2017;3(10):e172450. doi: 10.1001/jamaoncol.2017.2450.
  2. Haslam A, Prasad V. Estimation of the percentage of US patients with cancer who are eligible for and respond to checkpoint inhibitor immunotherapy drugs. JAMA Netw Open. 2019;2(5):e192535. doi: 10.1001/jamanetworkopen.2019.2535.
  3. Sukari A, Nagasaka M, Al-Hadidi A, Lum LG. Cancer immunology and immunotherapy. Anticancer Res. 2016;36(11):5593-5606. doi: 10.21873/anticanres.11144.
  4. Pardoll DM. The blockade of immune checkpoints in cancer immunotherapy. Nat Rev Cancer. 2012;12(4):252-264. doi: 10.1038/nrc3239.
  5. Daniels GA, Guerrera AD, Katz D, Viets-Upchurch J. Challenge of immune-mediated adverse reactions in the emergency department. Emerg Med J. 2019;36(6):369-377. doi: 10.1136/emermed-2018-208206.
  6. Davies M, Duffield EA. Safety of checkpoint inhibitors for cancer treatment: strategies for patient monitoring and management of immune-mediated adverse events. Immunotargets Ther. 2017;6:51-71. doi: 10.2147/ITT.S141577.

2 of 3

Community Practice Connections™: The “Don’t Crash” Crash Course in Managing Immune-Related Adverse Events in Oncology is a continuing medical education (CME)-certified program. For this program, D. Ross Camidge, MD, PhD; Christopher Baugh, MD, MBA; Tejas Patil, MD; and Erin Schenk, MD, PhD, provide expert guidance for emergency department healthcare professionals on managing immune-related adverse events (irAEs) experienced by patients being treated with immunotherapies for their cancer.

This second of 3 PER Pulse™ Recaps summarizing the online activity focuses on strategies for managing a patient with immune-related colitis. Below are some highlights from the activity featuring Dr Christopher Baugh:

  • Diarrhea and colitis are the second most commonly reported irAEs, after skin toxicities, occurring in approximately 1 of every 3 patients.1 These symptoms typically develop approximately 5 weeks to 8 weeks from treatment initiation but can occur or recur months after discontinuing immunotherapy.2,3
  • Colitis symptoms tend to resolve in 4 weeks with corticosteroid treatment in approximately 40% to 60% of patients.2,4 However, corticosteroids should be tapered slowly over a 4- to 6-week period to prevent symptom rebound.
  • Because symptoms are more often associated with anti–CTLA-4 therapy than with anti–PD-1/PD-L1 therapy, anti–PD-1/PD-L1 therapy may be restarted in patients with grade 3 colitis if symptoms resolve to less than grade 1, but it must be discontinued permanently in those with grade 4 symptoms.

“With the cancer patient, what we’re seeing increasingly is moving that call to the oncologist as part of the initial assessment and not waiting. The oncologist could really help us recognize these immune-related adverse events.”

— Christopher Baugh, MD, MBA

References

  1. Ibrahim RA, Berman DM, de Pril V, et al. Ipilimumab safety profile: summary of findings from completed trials in advanced melanoma. J Clin Oncol. 2011;29(suppl 15; abstr 8583). doi: 10.1200/jco.2011.29.15_suppl.8583.
  2. Weber JS, Dummer R, de Pril V, et al; MDX010-20 Investigators. Patterns of onset and resolution of immune-related adverse events of special interest with ipilimumab: detailed safety analysis from a phase 3 trial in patients with advanced melanoma. Cancer. 2013;119(9):1675-1682. doi: 10.1002/cncr.27969.
  3. NCCN Clinical Practice Guidelines in Oncology. Management of Immunotherapy-Related Toxicities, version 2.2019. National Comprehensive Cancer Network website. nccn.org/professionals/physician_gls/pdf/immunotherapy.pdf. Published April 8, 2019. Accessed November 14, 2019.
  4. Wang Y, Abu-Sbeih H, Mao E, et al. Endoscopic and histologic features of immune checkpoint inhibitor-related colitis. Inflamm Bowel Dis. 2018;24(8):1695-1705. doi: 10.1093/ibd/izy104.

3 of 3

Community Practice Connections™: The “Don’t Crash” Crash Course in Managing Immune-Related Adverse Events in Oncology is a continuing medical education (CME)-certified program. For this program, D. Ross Camidge, MD, PhD; Christopher Baugh, MD, MBA; Tejas Patil, MD; and Erin Schenk, MD, PhD, provide expert guidance for emergency department healthcare professionals on managing immune-related adverse events (irAEs) experienced by patients being treated with immunotherapies for their cancer.

This third of 3 PER Pulse™ Recaps summarizing the online activity focuses on strategies for managing a patient with immune-related pneumonitis. Below are some highlights from the activity featuring Dr Erin Schenk:

  • Although uncommon, with an overall incidence of 5% associated with immune checkpoint inhibitor (ICI) therapy, pneumonitis can be a potentially fatal irAE in patients with high-grade symptoms.1,2
  • Patients with mild pneumonitis, characterized as asymptomatic and confined to <25% of the lung, can often be treated in the outpatient setting.
  • Moderate pneumonitis is characterized by shortness of breath, cough, chest pain, and fever, whereas severe pneumonitis involves all lobes of the lung and >50% of the lung parenchyma. Life-threatening pneumonitis involves serious respiratory compromise. Most patients with moderate and all patients with severe/life-threatening symptoms require inpatient care.1

“As a medical oncologist, more and more, my clinical practice is overlapping with my colleagues in emergency medicine, and communication really is key with immune-related adverse events.”

— Erin Schenk, MD, PhD

References

  1. Naidoo J, Wang X, Woo KM, et al. Pneumonitis in patients treated with anti-programmed death-1/programmed death ligand 1 therapy. J Clin Oncol. 2017;35(7):709-717. doi: 10.1200/JCO.2016.68.2005.
  2. Nishino M, Giobbie-Hurder A, Hatabu H, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: a systematic review and meta-analysis. JAMA Oncol. 2016;2(12):1607-1616. doi: 10.1001/jamaoncol.2016.2453.

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