Evaluation of a Multidisciplinary Immunotherapy Toxicity Monitoring Program for Patients Receiving Ipilimumab for Metastatic Melanoma

Assessment of Symptoms and Adverse Events Related to Immunotherapy in Patients With Cancer: An Integrative Review

CONTEXT

Clinical practice guidelines advocate for routine assessment of symptoms and adverse events during immunotherapy treatment of cancer. Outside the clinical trial setting, there are few examples of such assessment in practice.

OBJECTIVES

To identify, appraise, and synthesize the available literature regarding the assessment of immune-related symptoms and adverse events in patients with cancer beyond the clinical trial setting. Specifically, we aimed to identify the measurement instruments used, who completes these and when.

METHODS

We completed an integrative review following established methods including a systematic literature search of electronic databases, a dual process for screening, quality appraisal, and data extraction. We included primary studies (retrospective or prospective) reporting the use of instruments or strategies to assess symptoms or adverse events in patients with cancer treated with immunotherapy. Outcomes of interest included: 1) how immune-related symptoms and adverse events were assessed; 2) types of assessment instruments; 3) frequency of instrument use and mode of administration; 4) the reported duration and intensity of symptoms and 5) adverse events and associated management strategies. Data were synthesized narratively.

RESULTS

We screened 2138 articles and included 16 articles representing 2553 patients with cancer undergoing immunotherapy. All articles were published between 2018 and 2022 and were of sound methodological quality. Seven studies were retrospective chart reviews, and the remaining studies prospectively collected data, with seven collecting patient reported outcomes. In studies where data were collected at more than one time point (n = 6), weekly assessment during immunotherapy was the most common frequency. The potential for implementation of assessment into routine clinical practice was described in just four studies.

CONCLUSION

Despite recommendations from clinical practice guidelines for routine assessment of symptoms and adverse events during immunotherapy treatment for cancer, there are few examples of how this is undertaken in clinical practice. The use of patient reported outcome measures to assess toxicity from immunotherapy is uncommon but offers the potential to identify symptoms early and facilitate timely intervention. Our review highlights the available instruments, how they have been used and the need for more applied research in this field to optimize patient outcomes.

Inflammation and tumor progression: signaling pathways and targeted intervention

Cancer development and its response to therapy are regulated by inflammation, which either promotes or suppresses tumor progression, potentially displaying opposing effects on therapeutic outcomes. Chronic inflammation facilitates tumor progression and treatment resistance, whereas induction of acute inflammatory reactions often stimulates the maturation of dendritic cells (DCs) and antigen presentation, leading to anti-tumor immune responses. In addition, multiple signaling pathways, such as nuclear factor kappa B (NF-kB), Janus kinase/signal transducers and activators of transcription (JAK-STAT), toll-like receptor (TLR) pathways, cGAS/STING, and mitogen-activated protein kinase (MAPK); inflammatory factors, including cytokines (e.g., interleukin (IL), interferon (IFN), and tumor necrosis factor (TNF)-α), chemokines (e.g., C-C motif chemokine ligands (CCLs) and C-X-C motif chemokine ligands (CXCLs)), growth factors (e.g., vascular endothelial growth factor (VEGF), transforming growth factor (TGF)-β), and inflammasome; as well as inflammatory metabolites including prostaglandins, leukotrienes, thromboxane, and specialized proresolving mediators (SPM), have been identified as pivotal regulators of the initiation and resolution of inflammation. Nowadays, local irradiation, recombinant cytokines, neutralizing antibodies, small-molecule inhibitors, DC vaccines, oncolytic viruses, TLR agonists, and SPM have been developed to specifically modulate inflammation in cancer therapy, with some of these factors already undergoing clinical trials. Herein, we discuss the initiation and resolution of inflammation, the crosstalk between tumor development and inflammatory processes. We also highlight potential targets for harnessing inflammation in the treatment of cancer.