[The Physical and Psychological Impacts and Supportive Care Needs of Patients With Cancer Undergoing Immunotherapy and Their Family Caregivers]

New, science-based cancer treatments have proliferated in recent years. Immunotherapy provides new hope for prolonging survival in patients with advanced-stage cancers. However, patients with cancer must not only face their disease progression, physical, and psychological symptoms, but also deal with the side effects and efficacy of immunotherapy. Patients with cancer may experience complex emotions such as fear, anxiety, depression, or uncertainty relatively frequently and may have many unmet care needs specific to immunotherapy. However, articles on the physical and psychological impacts and supportive care needs experienced by patients with advanced-stage cancers undergoing immunotherapy and their family caregivers are limited in the literature. Thus, this paper was developed to present (1) a brief introduction to cancer immunotherapy; (2) the physical and psychological impacts experienced by patients with cancer undergoing immunotherapy and their caregivers; (3) the status of the supportive care needs of patients and family caregivers during the immunotherapy process; and (4) an assessment of and intervention to address the supportive care needs of these patients with cancer and their caregivers. We hope this article will help clinical healthcare providers understand the physical and psychological impacts and supportive care needs of advanced patients with cancer and their family caregivers during the immunotherapy process. Furthermore, we suggest that appropriate medical care be provided or developed in the future to improve their quality of life during the immunotherapy process and to enhance clinical practices.

Patient expectations are better for immunotherapy than traditional chemotherapy for cancer

Purpose

The main aim of the study was to explore the expectations and knowledge of advanced-stage cancer patients about immunotherapy.

Methods

This mixed methods study included 53 cancer patients on immune checkpoint inhibitors (ICIs), 55 cancer patients undergoing chemotherapy (CT), and 53 non-cancer patients. Participants’ expectations about ICIs and CT were compared. Additional qualitative data were derived from semi-structured interviews.

Results

Among patients who did not receive ICIs, 63 (58%) had never heard of ICIs and 94 (87%) had large gaps in their knowledge of ICIs. Among ICI patients, 33 (62%) simply described ICIs without errors. ICI perception was positive, regardless of whether respondents received or had heard of ICIs, which became particularly evident when compared to CT. ICIs were rated as more promising, and all adverse effects were expected to be significantly lower than those of CT. Knowledge about ICIs was also limited in the interviewed ICI patients. Some patients reported adverse effects of ICIs that were mostly mild and well-tolerated or easily treated.

Conclusions

The lack of understanding of ICIs should be improved by activities to increase the knowledge of ICI patients and the general population. In contrast to CT, ICIs invoked fewer negative associations with efficacy and toxicity. Therefore, attention should be paid to risk awareness when educating patients. (Clinical trial registration number: DRKS00011868)

Trial Registration: German clinical trials register, www.germanctr.de, number DRKS00011868.

Balancing the Hype with Reality: What Do Patients with Advanced Melanoma Consider When Making the Decision to Have Immunotherapy?

BACKGROUND

Immunotherapy has resulted in unprecedented improvements in survival and maintained quality of life for many patients with advanced melanoma. However, durable responses are observed in only a minority of patients, and severe treatment side effects are experienced by 5%-30%. There are no reliable tests that can differentiate between patients who are likely to respond to immunotherapy and those who will not. Hence, new challenges have arisen as clinicians try to facilitate patients in their decision-making regarding immunotherapy. Furthermore, little is known about the real-world patients' experience and understanding of immunotherapy outside the clinical trial setting. Here, we explore the perspectives of patients undergoing immunotherapy for melanoma and focus on factors that influenced their treatment decision-making.

MATERIALS AND METHODS

Twenty-three in-depth semistructured interviews were conducted with patients receiving pembrolizumab for stage IV melanoma at an Australian public cancer hospital. Patients were recruited at a range of time points after commencing therapy, and their experience of treatment was explored. Interviews were audio recorded, transcribed verbatim, coded, and analyzed thematically.

RESULTS

Immunotherapy is viewed as a symbol of hope, with high-profile anecdotes reinforcing this perception. Only a minority of patients expressed a good understanding of the likely efficacy and potential treatment side effects. Patients are reliant on their clinicians' recommendation regarding immunotherapy treatment decisions.

CONCLUSION

Novel treatments such as immunotherapy provide significant hope for patients. This may influence their preference for immunotherapy over and above the usual considerations of the trade-off between efficacy and toxicity. Careful counsel and individualized patient resources may further facilitate treatment decision-making.

IMPLICATIONS FOR PRACTICE

This study highlighted some of the misconceptions held by patients that need to be addressed when discussing the possibility of receiving treatment with immunotherapy for advanced melanoma. Patients placed a lot of importance on high-profile anecdotes rather than truly understanding likely outcomes of treatment based on personal circumstances. The majority of patients had a poor understanding of the potential side effects and long-term implications of treatment with immunotherapy. Careful counsel is required in order to facilitate informed decision-making about treatment and to ensure possible side effects are known and appreciated. Further research is needed to develop tools to aid decision-making in everyday clinical practice.

Reasons for Declining Venom Immunotherapy

INTRODUCTION

Hymenoptera venom allergy is associated with significant morbidity and deterioration in health-related quality of life, and risk of fatal systemic reactions. Although venom immunotherapy is safe and the only effective treatment in allergic individuals, some patients prefer not to pursue this treatment. Since 2011, when the 50% reimbursement was stopped, patients must fully support the cost of immunotherapy. This study aimed to ascertain the reasons why patients decline immunotherapy.

MATERIAL AND METHODS

A medical records review of all patients proposed to receive venom immunotherapy at an Allergy and Clinical Immunology Department in Porto, Portugal, between 2006 and 2015, followed by a phone interview to patients refusing treatment.

RESULTS

A total of 83 subjects were enrolled, with a mean (± SD) age of 44.4 (14.7) years and 55 (66%) males; 27 refused venom immunotherapy between 2006 and 2015. Nineteen were interviewed and 14 of those stated price as the main reason for declining treatment. The only identified risk factor associated with immunotherapy refusal was being proposed after 2011 (OR: 3.29; 95% CI: 1.12 - 9.68; p = 0.03).

DISCUSSION

The number of patients refusing venom immunotherapy doubled since reimbursement was withdrawn. Price was identified as the major obstacle to treatment completion. Immunotherapy proposal after reimbursement was stopped was associated with a 3-fold increase in the risk of refusing treatment.

CONCLUSION

These findings show how economic decisions may have a detrimental effect on patient care, as immunotherapy refusal left them exposed to an avoidable life-threatening risk.

Awareness, understanding, attitude and barriers toward prescribing modern cancer immunotherapies in the Arabian Gulf countries

INTRODUCTION

The use of modern immunotherapy has been evolving over the past few years, and various new agents have been developed for new indications at multiple primary sites in oncology. It is important for physicians who are involved in cancer care to be aware and updated about new therapeutic agents and their indications, potential benefits, and side effects.

PATIENTS AND METHODS

From October to November 2017, we conducted a survey on the awareness, understanding, attitude, and barriers associated with prescribing modern cancer immunotherapies among physicians in the Arabian Gulf countries. The study included practicing physicians who delivered chemotherapy; trainees were not eligible. A total of 460 physicians were contacted and invited to complete an online survey, of which approximately 74.8% did not respond, and 4 (3.4%) were excluded because they had not recently treated patients with cancer. 112 (24.3%) physicians completed the survey (completion rate = 25.2%). An online electronic survey questionnaire was developed via Planet Surveys. The survey was designed with multidisciplinary inputs of the study investigators practicing in the Arabian Gulf countries, piloted, and subsequently revised on the basis of feedback from 10 additional oncologists. The final survey included 23 questions and took 8-10 minutes for completion.

RESULTS

All respondents were aware of modern immunotherapies, but 62.5% reported having limited experience in implementing them, whereas 31.3% reported good experience. The overall physicians' attitudes toward modern immunotherapy were favorable, with a mean score of 7.4 (scale of 1-10, with 10 being extremely favorable). Efficacy, clear indications, and good safety profile were perceived as key potential benefits. Cost, lack of experience, and lack of access to specific testing were the major barriers.

DISCUSSION AND CONCLUSION

There was a high level of awareness and an overall positive attitude toward modern cancer immunotherapy among oncologists in the Arabian Gulf countries, but there was a limited experience in prescribing cancer immunotherapeutic agents. Efficacy, clear indications, and good safety profile were perceived as key potential benefits, whereas cost, lack of experience, and lack of access to specific testing prior to prescription were the major barriers. Patients were likely to be receptive to modern immunotherapy as a therapeutic option for cancer treatment. Long-term efficacy data, financial support programs, and educational activities for prescribers may increase the access to modern immunotherapy.

[Psychological aspects of immunotherapies in the treatment of malignant melanoma]

Psychological problems may arise in connection with oncomedical treatments in three ways: 1. acute and/or 2. chronic ways, as well as 3. co-morbid psychiatric diseases that already exist must also be taken into account. Immunotherapies have the most common and also clinically relevant psychological side effects. Fatigue, anhedonia, social isolation, psychomotor slowness is reported during treatment. Anti-CTLA-4 antibody (ipilimumab) immunotherapy can present one of the most modern opportunities for adequate treatment for patients having distant metastasis or unresectable tumour. In relation to immunotherapies, acute psychological side effects (acute stress) emerging during treatments develop in a way that can mostly be linked to environmental factors, e.g. notification of diagnosis, hospitalisation, progression, deterioration in quality of life, imminent dates of control. Crisis is a temporary and threatening condition that endangers psychological balance. In such conditions, enhanced psychological vulnerability must be taken into account and doctors play a key role in the rapid recognition of the condition. Chronic psychological problems, which may arise from the depressogenic effect of the applied treatment or originated from a pre-melanoma psychiatric condition, may exceed the diagnostic and psychotherapeutic competences of a clinical psychologist. Even in case of a well-defined depressogenic biological mechanism such as the activation of the pro-inflammatory cytokine pathway, positive environmental effects can reduce symptoms and thus increase compliance. Side effects can be treated successfully using psychotherapeutic methods and/or psychiatric medicines. The application of routinely used complex psychosocial screening packages can provide the easiest method to identify worsening psychological condition during immunotherapy and give rapid feedback to the oncologist and the patient. Team work is of particular importance in a situation like this as it requires complex, interdisciplinary and high-level professional collaboration. Multidisciplinarity is the basic framework for modern tumour therapy where, under the guidance of oncologists, the work of specialist nurses, social workers, physiotherapists, dieticians and last but not least psychiatrists/psychologists are indispensable and play a significant role.

Exacerbation history is associated with medication and appointment adherence in MS

Disease-modifying treatments are designed to prevent exacerbations in multiple sclerosis (MS). To date, few studies have examined the relationship between disease activity and treatment adherence in MS. The primary aim of this study was to examine the association between disease activity (e.g., annualized relapse rates), medication adherence, and appointment adherence in relapsing-remitting MS. Retrospective exacerbation and appointment data were collected and used to predict prospective medication adherence. Results indicated that patients with higher annualized relapse rates missed fewer doses of medication and were less likely to miss appointments. Conversely, patients with relatively stable disease were more likely to demonstrate poor medication adherence and poor appointment adherence. Patients who missed more appointments also missed more doses of their disease modifying medication. Future studies may wish to examine clinical methods designed to improve immunotherapy adherence among patients who are in relatively symptom-free stages of relapsing-remitting MS.

[Health-related quality of life in children with Hymenoptera venom allergy treated with VIT and quality of life of their parents]

Hymenoptera venom allergy, although rare in children, by its potential fatalities, leads to many psychosocial consequences, influencing quality of life of children and their parents. Aim of this paper is the estimation of health-related quality of life of venom allergic children treated with specific immunotherapy, and their parents. Assessment of factors influencing health-related quality of life levels was also performed.

MATERIAL AND METHODS

Sample under study consisted of 73 children: mean age 10.6, SD 2, 4, treated because of Hymenoptera venom allergy in 5 clinical allergy centers in Poland. Data was collected using VQLQ questionnaire adapted for children and their parents. Determinants of quality of life were assessed with multivariate linear and logistic regression models. Analysis were done with SPSS 15 for Windows package.

RESULTS

Girls reported higher level of anxiety than boys (B = 0.47; 95% CI = (0.01; 0.94)). Level of caution in children increased along with increase of their anxiety against re-sting (B = 0.49; 95% CI = (0.27; 0.71)). Level of anxiety of children who were under treatment from 6 months to 2 years was lower than level of anxiety of parents of children treated shorter than 6 months (B = -1.21; 95% CI = (-2.16; -0.25)). The lowest level of caution was reported by parents of children aged 10 year or less (B = -0.86; 95% CI = (-1.67; -0.05)), while the highest was reported by parents of children aged 11 years (B = 0.86; 95% CI = (0.20; 1.53)) in comparison to parents of children aged 12 years or more. Parents' caution increased along with increase of their anxiety (B = 0.61; 95% CI = (0.40; 0.83)). Higher level of limitations was imposed by parents of children treated with rush or ultra rush method, in comparison to parents of children treated with conventional method (B = 1.27; 95% CI = (0.21; 2.33)). Levels of quality of life in children and their parents were strongly dependent in the same dimensions.

CONCLUSIONS

1. Levels of quality of life in particular dimension in children is related to level of the same dimension in parents. 2. Age of children influenced level of caution of their parents. 3. Treatment duration influenced level of anxiety of parents. 4. Safety feeling acquired by parents at the beginning of treatment improves their quality of life in all dimensions.

[Immune activation and depression in the elderly]

Besides the monoamine hypothesis, the stress hypothesis and the vascular hypothesis, the inflammatory hypothesis might be an etiological explanation for late-life depression. There is a growing amount of evidence to support this hypothesis. In animal studies, injection with cytokines was shown to cause behavioural changes ('sickness behaviour') similar to depressive symptoms in humans. Cytokine treatment of certain tumours and chronic hepatitis can also cause depressive symptoms. The prevalence of depression in patients with autoimmune diseases is higher than in the general population. Etanercept had a favourable effect on the depressive symptoms in patients with psoriasis, independent of improvement of physical symptoms. Cytokines affect the hypothalamus-pituitary-adrenal axis and cerebral neurotransmitter systems, both of which are thought to be involved in depression. Immune activation has been associated with depression, and several anti-depressive treatments affect immune parameters, although inconsistently. Since the aging process is associated with a dysregulation of the immune system, the inflammation hypothesis might be particularly true in late-life depression.

Efficacy of IL-2 immunotherapy in metastatic renal cell carcinoma in relation to the psychic profile as evaluated using the Rorschach test

BACKGROUND

Despite the well-documented importance of the psycho-emotional status in modulating the anticancer immunity, at present no study has been performed to analyse the influence of the psychological condition on the efficacy of IL-2 cancer immunotherapy. Previous clinical studies have already suggested that the evidence of anxiety may negatively affect the therapeutic efficacy of IL-2 immunotherapy of cancer. Moreover, previous psycho-oncological investigations showed that the suppression of sexual pleasure and sexual identity would represent one of the most frequent psychological profiles in cancer patients. On this basis, a study was planned in an attempt to evaluate relations existing between psychological status, analysed using the Rorschach test and efficacy of IL-2 immunotherapy in the treatment of metastatic renal cell cancer patients.

PATIENTS AND METHODS

The study included 30 consecutive metastatic RCC patients. IL-2 was injected s.c. at a dose of 3 million IU twice/day 5 days/week for 4 consecutive weeks, corresponding to one complete immunotherapeutic cycle, followed by a second cycle after a 21-day rest period.

RESULTS

A complete response (CR) was achieved in only 1/30 (3%) patients; a partial response (PR) was obtained in 6/30 (20%) patients. The tumor response rate (CR +PR) was 7/30 (23%) patients. The performance of a psychological analysis was accepted by 24/30 (80%) patients. A normal sexual identity was present in 7/24 (29%) patients. The tumor response rate achieved in patients with sexual identity was significantly higher compared to these who had no sexual identity or who refused the psychological investigation (p<0.05 and p<0.01, respectively). In the same way, the increase in mean lymphocyte number obtained in patients with sexual identity was significantly higher compared to that found in the other two groups of patients.

CONCLUSION

This study demonstrated that the psychological status prior to treatment may be associated with the clinical response to IL-2 cancer immunotherapy.

Psychological stress affects response to sublingual immunotherapy in asthmatic children allergic to house dust mite

While the clinical and immunologic efficacy of sublingual immunotherapy (SLIT) in allergic diseases has been extensively demonstrated, some patients display a poor clinical response. Psychological stress has been shown to play a role in atopy and also to affect response to immunomodulating therapies such as vaccination with microbial antigens. This study addresses the possibility of response to SLIT being affected by psychological stress. Forty children with mild asthma caused by allergy to Dermatophagoides pteronyssinus and farinae were subjected to SLIT and then divided after 6 months into two groups based on the results of the stress integrated measure (SIM) test: group 1 (24 stressed patients, mean SIM value of 60.1) and group 2 (16 non-stressed patients, mean SIM value of 7.6). There was also a higher prevalence of psychosocial stressing factors (divorced/absent parents, low income households, non-working parents) among stressed patients. The symptom score, peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV(1)) and serum eosinophie cationic protein (ECP) concentration were evaluated at both times. The serum concentration of neuroendocrine parameters [prolactin, cortisol, adrenocorticotropic hormone (ACTH)] was also measured after 6 months of therapy. While all the clinical parameters and ECP concentration improved after SLIT, symptom score, PEF and ECP showed a significantly greater improvement in non-stressed patients. The concentration of neuroendocrine parameters was significantly increased in stressed patients. Our findings show that psychological stress can affect response to SLIT also in allergic subjects and are consistent with data recently reported showing a correlation between stress and poor response to antimicrobial vaccines. Our data also suggest that stress evaluation may become a useful prognostic factor in immunotherapy.

Evidence-based patient information about treatment of multiple sclerosis--a phase one study on comprehension and emotional responses

OBJECTIVE

This study analysis the comprehension and emotional responses of people suffering from multiple sclerosis when provided with an evidence-based information module. It is a core module of a comprehensive decision aid about immunotherapy. The core module is designed to enable patients to process scientific uncertainty without adverse effects. It considers existing standards for risk communication and presentation of data.

METHODS

Using a mailing approach we investigated 169 patients with differing courses of disease in a before-after design. Items addressed the competence in processing relative and absolute risk information and patients' emotional response to the tool, comprising grade of familiarity with the information, understanding, relevance, emotional arousal, and certainty.

RESULTS

Overall, numeracy improved (p < 0.001), although 99 of 169 patients did not complete the numeracy task correctly. Understanding depended on the relevance related to the course of disease. A moderate level of uncertainty was induced. No adverse emotional responses could be shown, neither in those who did comprehend the information, nor in those who did not develop numeracy skills.

CONCLUSION

In conclusion, the tool supports people suffering from multiple sclerosis to process evidence-based medical information and scientific uncertainty without burdening them emotionally.

PRACTICE IMPLICATIONS

This study is an example for the documentation of an important step in the development process of a complex intervention.

Physician attitudes, opinions, and referral patterns: comparisons of those who have and have not taken an allergy/immunology rotation

BACKGROUND

Interest in the field of allergy/immunology (A/I) is increasing, yet resident training programs are under pressure to shorten elective rotations such as A/I. It is unclear if there are differences between those who have and have not taken an A/I rotation.

OBJECTIVE

To evaluate differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation.

METHODS

An anonymous questionnaire was sent to 375 primary care physicians at one academic medical center. Subjects were separated into 5 cohorts based on specialty and level of training (internal medicine faculty, internal medicine resident, pediatric faculty, pediatric resident, and internal medicine-pediatric resident).

RESULTS

Of the participants, 227 (61.0%) completed the survey. Compared with those who had not taken an A/I rotation, those who had taken an A/I rotation were more likely to feel they knew the types of cases seen by an allergist (75.9% vs 33.3%), to feel they knew an adequate amount about A/I (59.3% vs 19.5%), to feel they were exposed to an adequate amount of A/I during residency (64.8% vs 9.8%), to view immunotherapy as effective (70.0% vs 52.3%), and to have referred a patient to an allergist (77.8% vs 46.0%).

CONCLUSIONS

There are significant differences in the attitudes, opinions, and referral patterns between physicians who have and have not taken an A/I rotation. Allergic diseases are increasing, yet residency training programs are under pressure to shorten rotations such as A/I to accommodate federally mandated work hour restrictions. The potential for inadequate care of allergic diseases may be an important issue if these trends continue.

Cytokine-induced changes in mood and behaviour: implications for 'depression due to a general medical condition', immunotherapy and antidepressive treatment

Several lines of evidence indicate that cytokine-mediated communication pathways between the immune system and the brain are involved in the pathophysiology of depression: (1) . Depression is highly prevalent in various medical conditions, including infectious, autoimmune and neurodegenerative diseases. This clinical association cannot be attributed solely to psychological distress, and it probably reflects direct activation of illness-induced physiological processes. (2). Experiments in humans and in animals demonstrate that exposure to cytokines induces depressive-like mood and behavioural alterations. (3). Cytokine immunotherapy in cancer and hepatitis patients elicits a major depressive episode in a large percentage of the patients. (4). Several types of depression that are not directly associated with a physical disease (e.g. major depression, melancholia, dysthymia) were also associated with cytokine hypersecretion. (5). Antidepressant drugs possess anti-inflammatory characteristics, which may partly account for their therapeutic effect. Congruently, antidepressants were found to reverse cytokine-induced major depression in humans and depressive-like behaviours in animals. (6). Cytokines affect brain systems that were implicated in the aetiology of depression, including the hypothalamus-pituitary-adrenal axis and monoaminergic systems. These conclusions strongly suggest that during medical conditions elevated levels of cytokines directly contribute to the induction of depression. Therefore, illness-associated depression should not be underestimated (in terms of prevalence and severity), and should be treated with antidepressant drugs, which may act on the specific physiological mechanisms of this disorder.

Participants' perceptions of a peer-helper, telephone-based social support intervention for melanoma patients

This descriptive study investigated perceptions of a peer-helper, telephone-based, social support intervention for melanoma patients receiving immunotherapy. Participants were 59 male and female Stage 3 or4 melanoma patients (helpees) at a Comprehensive Cancer Center and 29 former patients (helpers). Helpers were matched with helpees about to begin immunotherapy based on the site of the melanoma, age, and, when possible, biological sex. The intervention consisted of 2 required telephone contacts initiated by the helper before the helpee's first and second immunotherapy treatments. The reactions to this social support intervention were assessed using surveys and telephone interviews with both open- and closed-ended questions. Results indicated that (a) helpees became more sensitive and open to available social support in their environment; (b) helpers and helpees thought the intervention was effective; and (c) the telephone, as a medium for providing support, was a satisfactory substitute for face-to-face interaction. Limitations of the study and future directions for telephone-based support programs for melanoma patients are discussed.

Perceptions of Herceptin: a monoclonal antibody for the treatment of breast cancer

In September 1998 Trastuzumab (Herceptin) became the second monoclonal antibody approved for the treatment of a malignant condition, and the first antibody approved for the treatment of a solid tumor. It is a mouse-human chimeric antibody that produces anti-tumor effects by blocking the HER2-neu receptor, and can also interact with human immune cells to effect antibody dependent cell-mediated cytotoxicity. Pivotal trials in breast cancer showed that it has activity as a single agent in a subset of patients whose tumors greatly over-express HER2, but results were even more impressive when it was used in combination with chemotherapy. It should also prove to be useful in the treatment of subsets of patients with other adenocarcinomas whose tumors over-express HER2.

The appropriate use of skin testing and allergen immunotherapy in young children

Immunotherapy is clearly effective in the treatment of allergic rhinitis and Hymenoptera sensitivity and probably effective in the treatment of asthma. Few studies evaluate the risks and benefits of immunotherapy in young children. Current evidence suggests that young children are at increased risk for systemic reactions from immunotherapy. Furthermore, immunotherapy or adverse reactions resulting from immunotherapy may result in significant psychologic problems. The potential risks of immunotherapy would be justified if immunotherapy were demonstrated to be safe and additive to other therapies. Immunotherapy might be particularly effective in treating or helping to prevent house dust mite- or cockroach-associated asthma. Until the efficacy of immunotherapy is demonstrated in young children, we agree with the European Academy of Allergology and Clinical Immunology position that immunotherapy in young children is relatively contraindicated.