The unexpected challenges of immunotherapy
Authors: A.C. Olsson-Brown, T.J. Guinan, M. McKay, S. Chow, R. Lord, M. Pirmohamed, J.J. Sacco
Journal: Annals of Oncology (2018)

Background: As the indications and licencing of oncological checkpoint inhibitors (CPI) expands rapidly there are increasing challenges. The need for increased capacity and delivery, support and toxicity management for patients receiving immunotherapy (IO) has been steadily increasing. It is not the numbers alone that are causing a shift in patient management but also the novelty of immune related adverse events (irAEs), the complexity of their management and longditudinaity of treatment. Methods: This study retrospectively reviewed the number of patients receiving IO and assessed the impact of IO on treatment delivery, acute and inpatient services at the Clatterbridge Cancer Centre (CCC), a UK tertiary cancer centre, between June 2016 and June 2018. Results: A total of 624 patients received licenced CPIs at CCC over the 2 year period. Over the study period there was a 3.7 fold increase in new patients commencing on treatment in the initial and final 6 month period. Five tumour groups were represented. CCC administered 1408 individual treatments in 2016/2017 rising to 3140 in 2017/18. An on-treatment review service (OTR) commenced in June 2017. The OTR activity has increased from 87 individual encounters in July 2017 to 244 in June 2018. Within acute services the centralised telephone triage service saw in increase in IO related calls from 84 calls in Q3 2016/2017 to 316 Q4 2017/2018. This has translated into increased face-to-face patient review with triage attendances rising from 13 to 166. Furthermore IO related admissions have increased from 15 to 120, equating to an 8 fold increase, between the first and last 6 months of the reviewed period. Conclusions: Immunotherapy has significantly altered the oncological treatment landscape in a very short timeframe. This has left cancer centres ill equipped for the vast impact IO has had in terms of delivery demands, support and acute services. Whilst acute management protocols are plentiful they are alone insufficient to manage the increasing impact of IO. These novel and expanding needs require specific and innovative approaches to allow effective managment. In response to this CCC has developed a comprehensive IO strategy adopting a systems approach and incorporating education development, multilevel management protocols, collaborative working and IO specific services. Legal entity responsible for the study: Clatterbridge Cancer Center. Funding: Has not received any funding. Disclosure: A.C. Olsson-Brown: MRC Clinical Fellow at the University of Liverpool; Medical Research Council Fellowship in Clinical Pharmacology and Therapeutics, funded by the MRC(MR/N025989/1), Roche Pharma, Eli Lilly, UCB Pharma, Novartis, the Universities of Liverpool & Manchester. R. Lord: Recipient of travel bursary: AstraZeneca. M. Pirmohamed: Programme Director: Medical Research Council Fellowship in Clinical Pharmacology and Therapeutics, funded by the MRC(MR/N025989/1), Roche Pharma, Eli Lilly, UCB Pharma, Novartis, the Universities of Liverpool & Manchester. J.J. Sacco: Grants and personal fees: Bristol Myers Squibb; Personal fees: Immunocore; Grants: AstraZeneca; Other: MSD Merck. All other authors have declared no conflicts of interest.