Optimizing Inpatient Care for Lung Cancer Patients with Immune Checkpoint Inhibitor- Related Pneumonitis Using a Clinical Care Pathway Algorithm

Purpose

Immune checkpoint inhibitor-related pneumonitis (ICI-P) is a condition associated with high mortality, necessitating prompt recognition and treatment initiation. This study aimed to assess the impact of implementing a clinical care pathway algorithm on reducing the time to treatment for ICI-P.

Methods

Patients with lung cancer and suspected ICI-P were enrolled, and a multi-modal intervention promoting algorithm use was implemented in two phases. Pre- and post-intervention analyses were conducted to evaluate the primary outcome of time from ICI-P diagnosis to treatment initiation.

Results

Of the 82 patients admitted with suspected ICI-P, 73.17% were confirmed to have ICI-P, predominantly associated with non-small cell lung cancer (91.67%) and stage IV disease (95%). Pembrolizumab was the most commonly used immune checkpoint inhibitor (55%). The mean times to treatment were 2.37 days in the pre-intervention phase and, 3.07 days (p=0.46), and 1.27 days (p=0.40) in the post-intervention phases 1 and 2, respectively. Utilization of the immunotoxicity order set significantly increased from 0% to 27.27% (p = 0.04) after phase 2. While there were no significant changes in ICU admissions or inpatient mortality, outpatient pulmonology follow-ups increased statistically significantly, demonstrating enhanced continuity of care. The overall mortality for patients with ICI-P was 22%, underscoring the urgency of optimizing management strategies. Notably, all patients discharged on high-dose corticosteroids received appropriate gastrointestinal prophylaxis and prophylaxis against Pneumocystis jirovecii pneumonia infections at the end of phase 2.

Conclusion

Implementing a clinical care pathway algorithm for ICI-P management standardizes care practices and enhances patient outcomes, underscoring the importance of structured approaches.

Treatment patterns and outcomes of high-grade immune checkpoint inhibitor-related pneumonitis in an oncology hospitalist service

PURPOSE

Immune checkpoint inhibitors (ICI) have become standard of care for some types of lung cancer. Along with expanding usage comes the emergence of immune-related adverse events (irAEs), including ICI-related pneumonitis (ICI-P). Treatment guidelines for managing irAEs have been developed; however, how clinicians manage irAEs in the real-world setting is less well known. We aimed to describe the outcomes and care patterns of grade ≥ 3 ICI-P in an onco-hospitalist service.

PATIENTS AND METHODS

We included patients with lung cancer treated with ICI who were admitted to an oncology hospitalist service with a suspicion of ICI-P. We described the hospitalization characteristics, treatment patterns, discharge practices, and clinical outcomes of patients with confirmed ICI-P. The primary outcome was time to start treatment for ICI-P.

RESULTS

Among 49 patients admitted with a suspicion of ICI-P, 31 patients were confirmed to have ICI-P and subsequently received ICI-P directed treatment. Pulmonology was consulted in 97% of patients. Median time to start treatment for ICI-P was 1 day (IQR 0-3.5 days). All 31 patients received corticosteroids. Inpatient mortality was 32%. Majority of patients discharged with steroids were prescribed prophylaxis for gastritis and opportunistic infections. Thirty-eight percent of patients were seen by pulmonology and 86% were seen by the oncology team post-discharge.

CONCLUSION

Our study confirms prior findings of high mortality among patients with high-grade ICI-P. Early diagnosis and treatment are key to improving clinical outcomes. Understanding the care patterns and adherence to treatment guidelines of clinicians caring for this patient population may help identify ways to further standardize management practices and improve patient outcomes.

Risks, diagnosis, and management of recurrent cancer-associated thrombosis (CAT): a narrative review

This paper aims to provide a narrative review of the risks, diagnosis, and management of recurrent venous thromboembolism (VTE) in cancer patients. There is an established association between cancer and VTE, with cancer being a major risk factor for VTE. A history of VTE, short duration of oral anticoagulation, and a proximal DVT are all associated with increased risk for recurrent VTE. Studies have shown that certain cancers (e.g., metastatic genitourinary, lung, and colorectal cancers) are associated with recurrent VTE. Published literature shows that cancer is prothrombotic, and various mechanisms have been postulated as pathways for increased thrombogenesis and hence recurrent VTE in cancer. The symptoms, signs, laboratory information, and imaging results for the diagnosis of recurrent VTE are similar to those of an initial VTE. Management of recurrent VTE involves using low molecular weight heparin (LMWH) or a direct oral anticoagulant (DOAC). Vitamin K antagonists (VKA) or inferior vena cava (IVC) filters are less commonly used.

Thrombosis, cancer, and COVID-19

Cancer and coronavirus disease 2019 (COVID-19) have unusual similarities: they both result in a markedly elevated risk of thrombosis, exceptionally high D-dimer levels, and the failure of anticoagulation therapy in some cases. Cancer patients are more vulnerable to COVID-19 infection and have a higher mortality rate. Science has uncovered much about SARS-CoV-2, and made extraordinary and unprecedented progress on the development of various treatment strategies and COVID-19 vaccines. In this review, we discuss known data on cancer-associated thrombosis (CAT), SARS-CoV-2 infection, and COVID-19 vaccines and discuss considerations for managing CAT in patients with COVID-19. Cancer patients should be given priority for COVID-19 vaccination; however, they may demonstrate a weaker immune response to COVID-19 vaccines than the general population. Currently, the Centers for Disease Control and Prevention recommends an additional dose and booster shot of the COVID-19 vaccine after the primary series in patients undergoing active cancer treatment for solid tumors or hematological cancers, recipients of stem cell transplant within the last 2 years, those taking immunosuppressive medications, and those undergoing active treatment with high-dose corticosteroids or other drugs that suppress the immune response. The mainstay of thrombosis treatment in patients with cancer and COVID-19 is anticoagulation therapy.

Immune checkpoint inhibitor (ICI)-related pneumonitis among patients with lung cancer admitted to an Oncology Hospitalist Service: Treatment patterns and hospitalization outcomes

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Background: Immune checkpoint inhibitors (ICI) have gained success in the treatment of multiple malignancies including lung cancer. However, immune-related adverse events (irAE) are common with pneumonitis being one of the most fatal having a 10% mortality rate. As such, early identification and treatment of irAEs are important. We describe the treatment patterns and hospitalization outcomes of patients with lung cancer with grade ≥3 ICI-related pneumonitis (ICI-P) admitted to an oncology hospitalist service at a comprehensive cancer center. Methods: We performed a retrospective review of patients with lung cancer admitted to our oncology hospitalist service with a suspicion of ICI-P between January 1, 2019 and November 30, 2019. ICI-P was confirmed if the patient received irAE-specific management, or if there was multidisciplinary consensus among treating providers. Descriptive statistics were utilized. Here we present the demographic and clinical characteristics of the study population as well as hospitalization outcomes. Results: We identified 49 patients with lung cancer who received at least one dose of ICI before being admitted with a suspicion of ICI-P. The mean age was 67y, with 63% being male and 86% having a diagnosis of non-small cell lung cancer. The most common ICI received by patients was pembrolizumab (67%). 84% were on active ICI treatment at the time of hospitalization and the median time from the 1st ICI dose to hospitalization was 3.5 months. Pulmonology was consulted in 88% of patients. Only 63% (n=31) of those admitted with a suspicion of ICI-P were confirmed to have ICI-P. The mean time to first ICI-P directed treatment was 2.2 days from admission with all 31 patients receiving corticosteroids. 23% required infliximab and 10% required IVIG. Patients with confirmed ICI-P had a median length of stay of 8 days, with 19% requiring ICU stay. The ICI-P inpatient mortality rate was 32%. Of those discharged alive (n=21), 90% were discharged on oral corticosteroids. GI and PJP prophylaxis were prescribed for 95% and 81% of the discharged patients, respectively. The 30-day readmission rate for this subgroup was 29%. 86% were seen by their oncologist within a median time of 8 days from discharge. Conclusions: Studies have shown that patients with grade ≥3 ICI-related pneumonitis (i.e. requiring hospitalization) have high mortality rates and this was consistent with our findings. Treatment for ICI-related pneumonitis was started >2 days from admission in our study population. A high index of suspicion is necessary to expedite work-up, and a multidisciplinary approach is key to confirm diagnosis and promptly initiate treatment. Readmission rate was high. Care coordination and strategies for safe transitions of care at discharge should be ensured to improve the overall outcome.

Systematic review of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the management of oral mucositis in cancer patients and clinical practice guidelines

PURPOSE

To update the clinical practice guidelines for the use of antimicrobials, mucosal coating agents, anesthetics, and analgesics for the prevention and/or treatment of oral mucositis (OM).

METHODS

A systematic review was conducted by the Mucositis Study Group of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO). The body of evidence for each intervention, in each cancer treatment setting, was assigned an evidence level. The findings were added to the database used to develop the 2014 MASCC/ISOO clinical practice guidelines. Based on the evidence level, the following guidelines were determined: Recommendation, Suggestion, and No Guideline Possible.

RESULTS

A total of 9 new papers were identified within the scope of this section, adding to the 62 papers reviewed in this section previously. A new Suggestion was made for topical 0.2% morphine for the treatment of OM-associated pain in head and neck (H&N) cancer patients treated with RT-CT (modification of previous guideline). A previous Recommendation against the use of sucralfate-combined systemic and topical formulation in the prevention of OM in solid cancer treatment with CT was changed from Recommendation Against to No Guideline Possible. Suggestion for doxepin and fentanyl for the treatment of mucositis-associated pain in H&N cancer patients was changed to No Guideline Possible.

CONCLUSIONS

Of the agents studied for the management of OM in this paper, the evidence supports a Suggestion in favor of topical morphine 0.2% in H&N cancer patients treated with RT-CT for the treatment of OM-associated pain.

Handoff Tool Enabling Standardized Transitions Between the Emergency Department and the Hospitalist Inpatient Service at a Major Cancer Center

Communication failures during patient handoff can lead to serious errors. A quality improvement team created a standardized handoff tool/process (DE-PASS: Decisive problem requiring admission, Evaluation time, Patient summary, Acute issues/action list, Situation unfinished/awareness, Signed out to) for admitting patients from the emergency department (ED) to the hospitalist inpatient service of a tertiary cancer center. DE-PASS mirrors the institution's ED workflow, stratifies patients as stable/urgent/emergent, and establishes requirements for verbal and email communications between providers. Comparison of preintervention and postintervention results from the 1-month pilot revealed that within a 24-hour period, DE-PASS reduced the number of intensive care unit transfers by 58% ( P = .393), the number of rapid-response team calls by 39% ( P = .637), and time to inpatient order by 31% ( P = .004). ED physicians' and hospitalists' satisfaction with DE-PASS increased. Reduction in intensive care unit transfers was sustained after the pilot ( P = .029). DE-PASS feasibility was evidenced by 100% uptake. By stratifying patients by risk level, DE-PASS reduced admission-to-evaluation times for unstable patients, potentially improving patient safety.

Utilizing electronic technologies to measure patient-reported outcomes (PRO) assessment completion time

69

Background: Patient-reported outcomes (PROs) contribute to the assessment and treatment of cancer-related fatigue (CRF). Paper-based symptom assessments are cumbersome and time-consuming. Electronic assessments are an efficient alternative. This study describes CRF Clinic patients at a major cancer Institution, the time they required to complete self-reported CRF symptom assessments via a tablet computer (iPad), and the factors influencing PRO assessment completion time. Methods: From 1/1/2011 to 8/21/2012, 190 newly-referred CRF Clinic patients utilized an iPad to complete standardized CRF symptom assessments for: fatigue, pain, depression, anxiety, stress, sleepiness, and apathy. A web-based assessment module (BrightOutcome) was employed, which recorded assessment start and completion times. Non-Parametric test statistics were utilized for analysis. Results: Of the initial 190 patients, 3 were excluded due to non-cancer diagnoses and 1 was excluded due to an erroneous completion time of 8,903 minutes. Sample size is 186 patients; mean age was 55.49 years (range: 31-89); 69.4% (n = 119) were female. Patient mean fatigue score (Brief Fatigue Inventory) was 6.4. Mean assessment completion time was 16.73 minutes (range: 4-47). Assessments took longer to complete for patients ≥ 65 years (mean: 21.53 minutes; range: 9-43), males (mean of 18.3 vs. 16 minutes for females), patients with severe fatigue (7-10) (mean 18.31 minutes; range: 4-47), greatest apathy (38-72) (mean: 19.5 minutes; range 8-47), those with active cancer (mean: 18.02 minutes vs. 15.15 minutes in cancer survivors), and those with 2 or more comorbidities (mean: 18.41 minutes vs. 15.86 minutes in those with less than 2 comorbidities). Pain severity and interference, anxiety, depression, stress, and sleepiness did not statistically significantly impact assessment completion time. Conclusions: Patients who are older, male, fatigued, apathetic, with active cancer or with 2 or more comorbidities may require longer in-clinic time to complete standard symptom assessments. Further studies exploring these and other patient characteristics potentially impacting the integration of new technologies into patient care and research are warranted.

Toxicities of the anti-PD-1 immune checkpoint antibody nivolumab in the acute inpatient setting

227

Background: Knowledge of immune-system regulation led to the discovery of immune checkpoints molecules, which have demonstrated anti-tumor activity across various malignancies. These advances represent a new set of challenges for clinicians, including non-oncologists treating the cancer patient, who must develop a working knowledge of the mode of action of these agents, their unique response kinetics, and how to diagnose and effectively manage their toxicities. Nivolumab is a monoclonal immune checkpoint antibody that binds to the PD-1 receptor on T-cells, blocking PD-1 pathway-mediated anti-tumor immune response inhibition. Methods: Review of current literature and analysis of 3 cases of patients with Nivolumab-related toxicities at a major cancer center. Results: Case #1: 74 years-old female with NSCLC who was started on nivolumab after developing disease progression with various regimens. Nivolumab was held 4 months later due to development of erythematous, edematous papules and plaques, with overlying ulcerations and crust in forearms, thighs and trunk. Also, paronychias and loss of nail beds in both great toes. She developed no new lesions after discontinuation of immunotherapy. Case #2: 71 years-old male with right lung NSCLC, started on Nivolumab after evidence of disease progression after completion of carboplatin/paclitaxel. Four months later developed grade 2 Nivolumab-induced pneumonitis; this was withheld and ultimately discontinued due to persistent pneumotoxicity in spite of corticosteroids. Case #3: 41 years-old male with synchronous right lung ALK-positive adenocarcinoma, on crizotinib, and left lung squamous cell carcinoma, on nivolumab. He developed nivolumab-induced ANCA-negative glomerulonephritis, which was discontinued while continuing the crizotinib. His renal function normalized 3 months later, with GFR going from 14 to 122. Conclusions: Most adverse events with the anti-PD-1 agent Nivolumab are generally reversible after discontinuation of therapy, yet some high-grade immune-related adverse events require management with corticosteroids and other immune modulating agents. Further research is needed.

Meta-analysis of cardiovascular toxicity risks in cancer patients on selected targeted agents

PURPOSE

The purpose was to estimate the risk and severity of cardiovascular toxicities associated with selected targeted agents.

METHODS

We searched English-language literature for randomized clinical trials published between January 1, 2000 and November 30, 2013 of targeted cancer therapy drugs approved by the FDA by November 2010. One hundred ten studies were eligible. Using meta-analytic methods, we calculated the relative risks of several cardiovascular toxicities [congestive heart failure (CHF), decreased left ventricular ejection fraction (DLVEF), myocardial infarction (MI), arrhythmia, and hypertension (HTN)], adjusting for sample size using the inverse-variance technique. For each targeted agent and side effect, we calculated the number needed to harm.

RESULTS

Regarding CHF, trastuzumab showed significantly greater risk of all-grade and high-grade CHF. There was significant increased risk of all-grade DLVEF with sorafenib, sunitinib, and trastuzumab and high-grade DLVEF with bevacizumab and trastuzumab. Sorafenib was associated with significant increased all-grade risk of MI based on one study. None was associated with high-grade risk of MI or increased risk of arrhythmia. Bevacizumab, sorafenib, and sunitinib had significant increased risk of all-grade and high-grade HTN.

CONCLUSIONS

Several of the targeted agents were significantly associated with increased risk of specific cardiovascular toxicities, CHF, DLVEF, and HTN. Several had significant increased risk for high-grade cardiovascular toxicities (CHF, DLVEF, and HTN). Patients receiving such therapy should be closely monitored for these toxicities and early and aggressive treatment should occur. However, clinical experience has demonstrated that some of these toxicities may be reversible and due to secondary effects.

Safer transitions of care at a major cancer center: The emergency center to hospitalist experience

247

Background: Failures in communication lead to serious medical errors particularly during transitions of care. A standardized handoff of patients requiring admission to the inpatient setting between the Emergency Center (EC) and the Hospitalist Inpatient Service (HIS) at a comprehensive cancer center was lacking during this vulnerable time. Methods: A quality pilot study using Plan, Do, Study, Act methodology was conducted. First, root cause analysis and process mapping of the current state was performed to identify pitfalls of the handoff process between the EC and the Hospitalist Service. Second, a validated standardized handoff tool, “I-PASS” (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver) was selected and then transformed to DE-PASS, where D stands for Decisive problem requiring admission and E for Evaluation, to suit the EC workflow. The DE-PASS identified patients at higher risk for complications as urgent and emergent in the evaluation section and required a verbal communication in addition to an email using DE-PASS format. Third, we measured pre versus post intervention impact metrics. ICU transfers and Rescue Team calls within 24 hours were obtained from 822 patients. Time interval between EC admission physician order and HIS order was analyzed in a population of 174 randomly selected patients. Provider satisfaction with handoffs was surveyed. Results: The DE-PASS utilization ranged from 75% to 100% by the end of the pilot. The data analysis revealed a 60% reduction in the number of ICU transfers and a 64% reduction of Rescue Team calls post intervention. There was an 18% reduction in the interval time for an inpatient order in the medical record. EC Physicians satisfaction with DE-PASS increased by 10% and the Hospitalists increased by 40%. Conclusions: Implementation of the standardized handoff tool DE-PASS led to improved communication between two clinical services of a major cancer center. Patients’ safety improved by designation of risk stratification and reducing the time to evaluate unstable patients by the receiving HIS. Physician’s satisfaction with the handoff process increased.

Improving transitions of care through implementation of a standardized handoff at a comprehensive cancer center

242

Background: Communication failures cause two-thirds of sentinel events in hospitals. These adverse occurrences are often both fatal and preventable. Consequently, improving the quality of handoffs has been identified by multiple accreditation constituents as a top priority patient safety goal. This project was part of an institutional initiative to standardize handoffs among physicians, trainees, and midlevel providers. Methods: Four subgroups were identified as pilot areas: Gynecologic Oncology (Gyn Onc) fellows to nocturnalists, Surgical Oncology fellows, Pediatric Oncology residents and fellows, and Emergency Center attending staff to inpatient hospitalists. This abstract focuses on the Gyn Onc and Pediatric Oncology services. All teams used a PDSA cycle (Plan, Do, Study, Act) to conduct its pilot study. A gap analysis, root cause analysis, and process mapping were performed in each area to identify specific handoff issues. A validated standardized handoff tool, I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver), was selected. Of note, “Illness severity” highlights patients identified at higher risk for complications and denotes their status as “watcher” or “unstable.” Interventions included I-PASS skills training and utilization of the I-PASS mnemonic. Each service developed a standardized definition to identify patients classified as “watchers.” Medical errors, ICU transfers, and provider satisfaction were assessed pre- and post-intervention. Results: Results from 40 handoff surveys showed communication errors dropped by 10% (16.49 vs 14.93). Minor harm as result of a problematic handoff decreased by 45% (2.55 vs 1.39), with a 55% reduction in ICU transfers. There was an overall increase in handoff satisfaction using I-PASS and 100% standardization of handoffs across the Gyn Onc and Pediatric Oncology units. Conclusions: Implementation of I-PASS, a validated standardized handoff was associated with reductions in medical errors and improvement in communication. Our institution is moving toward implementing I-PASS across all units to increase the safety and quality of patient care.

Meta-analysis: Risk of congestive heart failure (CHF) in selected targeted agents

64

Background: Congestive heart failure (CHF) is among the most serious cardiovascular side effects of targeted agents (TA) impacting the clinical outcomes (including survival) of cancer patients on this therapy. Although clinical trials have reported this toxicity, often sample sizes are small and systemic evaluations are lacking. The objective of this study is to estimate risk and severity of CHF due to selected TAs. Methods: We identified 110 English language studies of 26 TA’s approved by the Food and Drug Administration as of November 2013 via MEDLINE. Of those, 8 studies including nearly 8000 patients provided TA-related data on the incidence and severity of CHF. Using meta-analytic methods, we calculated the relative risks of CHF, adjusting for sample size using the inverse variance technique. For each TA, we also determined the number needed to harm. Results: See table. Conclusions: In 5 studies including more than 7,000 patients, trastuzumab showed significantly greater risk of CHF. For every 9 patients treated with trastuzumab, there was 1 additional case of CHF compared to control regimens. A careful patient selection before therapy and early detection of CHF by judicious monitoring of patients on this therapy may prevent serious complications and allow maintenance of cancer treatment. [Table: see text]

Opioid and adjuvant analgesics: compared and contrasted

An adjuvant (or co-analgesic) is a drug that in its pharmacological characteristic is not necessarily primarily identified as an analgesic in nature but that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids. The therapeutic role of adjuvant analgesics (AAs) is to increase the therapeutic index of opioids by a dose-sparing effect, add a unique analgesic action in opioid-resistant pain, or reduce opioid side effects. A notable difference between opioids and AAs is that unlike opioids some AAs are associated with permanent organ toxicity, for example, nonsteroidal anti-inflammatory drugs (NSAIDs) and renal failure. It is impossible to predict in advance in a given individual what opioid dose they may require to control cancer pain. Most AAs have a ceiling effect for their analgesic actions, but often with continued dose-related toxicities and side effects (with the exception of glucocorticoids). The blood levels of opioids (and their metabolites) can be measured with great precision and accuracy. There is sometimes a role for drug blood levels of certain AAs, like tricyclic antidepressants or anticonvulsants when used for neuropathic pain. Age affects metabolism of most opioids. The therapeutic window of opioids is wide, with no ceiling effect. Most AAs (except corticosteroids) have a narrow therapeutic window. Naloxone is a pure opioid antagonist that competes and displaces opioids from their receptor sites. All clinically useful opioids are mu opioid receptor agonists. Not all routes of administration are available to all opioids. Adjuvant analgesics lack the versatility in routes of administration that opioids possess. Dosing flexibility is a major advantage when treating cancer-related pain with opioids. Dose flexibility is much less with AAs than opioids. Unlike opioids, the analgesic response is usually observed within hours to days of attaining an adequate dose with most AAs (1-2 days). Rotation among opioids is a useful therapeutic strategy to improve analgesic response or minimize toxicity. Most AAs are unsuitable for rescue dosing because of their pharmacological characteristics. The mu agonist side effect profile is similar among the different opioid agents, regardless of the route of administration. The appropriate use of AAs will reduce opioid-related side effects. No apparent tolerance to analgesia develops with AAs. Abrupt discontinuation of an opioid after chronic repeated use for more than a few days will cause a withdrawal syndrome of variable severity. Adjuvant analgesics are an essential tool in cancer pain.

Olanzapine as an antiemetic in refractory nausea and vomiting in advanced cancer

Nausea and vomiting are difficult symptoms to manage in patients with advanced cancer. Several classes of antiemetics are available, including phenothiazines, butyrophenones, substituted benzamides and selective serotonin antagonists, as well as corticosteroids. Most patients will respond to either single agents or combinations that frequently include corticosteroids. A minority of patients will have nausea that fails to respond. The atypical antipsychotic, olanzapine, relieves nausea in some patients failing to respond to the usual antiemetics. Two case reports are presented and the rationale for olanzapine's benefit is discussed.