Brielle Benyon

Survivorship care plans can come in varying forms. While the jury is still out regarding the best way to deliver survivorship care, there are some key components that should be included, explained Dr. Michelle Melisko.

Dr. Melisko is an associate clinical professor in the department of medicine at the UCSF Helen Diller Family Comprehensive Cancer Center. She recently discussed cancer survivorship at the Educated Patient Women’s Cancer Summit.

“One thing I think is really interesting and challenging in the survivorship era is that we’re making so much progress in precision medicine of cancer treatment … but unfortunately still, even to this day – even though there is a big focus on survivorship – there’s still less money and effort directed toward how therapies result in differential toxicity,” Melisko said.

Hopefully one day there will be better predictive models of which patients will have severe side effects from treatment. But as for now, survivorship care that comes earlier rather than later may be key in improving outcomes.

Melisko said that a good cancer survivorship plan should include the following:

Recommendations for appropriate treatment and screenings that can diagnose or prevent recurrence and/or secondary cancers

Assessment of medical and psychosocial late effects

Interventions that address and mitigate side effects from cancer treatment

Coordination between primary care physicians, oncologists, specialists, and patients

Much of what Melisko discussed includes taking care of current and potential future side effects from cancer treatment. She said that research is now focusing on analyzing patients’ genetics to better predict who will develop these side effects – a discipline called pharmacogenetics.

“The future is incorporating pharmacogenetics into personalized medicine, so that we can actually separate out which patients will get no benefit but develop toxicity from therapy, and those who will benefit but might have some toxicity,” Melisko said.

Researchers are analyzing patient genetics as well as patient-reported outcomes to create more efficacious personalized cancer drugs.

At Melisko’s institution, she said that these patient-reported outcomes are taken “from the get-go,” as soon as a patient begins receiving cancer care at UCSF. On the intake form, there are questions about the patients’ medical and social histories, PROMIS scores (which measure patient function), and psychosocial history.

UCSF researchers analyzed 428 patients who completed this form between 2014 and 2015. They found that more than half of the patients met the criteria to be referred to supportive care, which could include social work, onco-fertility specialists, genetic counseling, psycho-oncology, and more.

“We believe that by identifying patient needs early, we consider survivorship to be from the time of diagnosis, and we’re hoping that we can actually improve patient-reported outcomes,” Melisko said.

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Patients and their doctors should discuss survivorship issues – such as anxiety and fertility issues – sooner rather than later. 

Early Survivorship Care May Improve Patient Outcomes

While immunotherapy can drastically improve outcomes for patients with cancer, it can also come with side effects that patients and their caregivers should be aware of. Some of these toxicities can be mild, while others are serious, but palliative care and open communication with health care providers can help.

 Educated Patient Lung Cancer Summit, Dr. Sally J. York, an associate director of clinical education and medical sciences of the training program at Vanderbilt University Medical Center, provided an overview of immunotherapy-related side effects, and how they differ from common side effects that a patient might see on chemotherapy.

“The immune system, we know, has potential for really great good… we see some very good durable responses,” York said in her presentation. “But it can also cause some really significant harm.”

Common side effects from immunotherapy treatment include endocrine issues, pneumonitis, hepatitis, colitis, arthritis and rash, while rarer side effects are encephalitis (brain inflammation), uveitis, myocarditis/myositis, pancreatitis, gastritis, nephritis, and neurotoxicity (when something goes wrong in the brain or central nervous system).

There is one common thread among most immunotherapy-related side effects: they are a result of inflammation somewhere throughout the body. Additionally, palliative care may be able to help.

“Palliative care is a specialty that’s really focused on symptom management and supportive care. It’s important to know that it’s not the same thing as a referral to hospice,” York explained. “Palliative care providers are trained and have expertise in pain management and psychosocial support.”

York also noted that studies have proved that palliative care has improved outcomes for patients with advanced cancers.

“Palliative care referral does not mean that anyone is giving up. That’s probably one of the biggest misconceptions that I have to emphasize with my patients. It’s worth seeing a palliative care provider early, and it’s going to benefit (patients).”

Skin problems the most common side effect seen with immunotherapy treatment, appearing in more than 50% of patients. It usually shows up two to four weeks after treatment started, and commonly appears as a rash that may be itchy.

Patients should notify their health care team if they have any new skin issues after starting immunotherapy treatment. Usually, the skin toxicity is low-grade and can be treated with topical creams and antihistamines.

For more serious skin toxicity (grade 3 or 4), a patient will usually receive oral corticosteroids, and may have their treatment held. If the rash does not resolve or is blistering, doctors may consider conducting a biopsy on the lesion.

Immunotherapy-related colitis (inflammation of the colon) most typically appears as diarrhea, but a patient might have abdominal pain or blood in their stool, too. It is most commonly associated with Opdivo (nivolumab)/Yervoy (ipilimumab) combination treatment, and, on average, appears about 6 weeks after treatment started.

The treatment for colitis depends on what grade it is, York explained.

Grade 1 (patient has four or fewer stools a day): anti-diarrhea medicine and close monitoring

Grade 2 (4-6 stools per day): Hold Yervoy, give an anti-diarrhea medicine, monitor the patient and give them steroids if there is not an improvement after one week. A colonoscopy may also be considered, too.

Grade 3/4 (6 or more stools per day): Administration of intravenous steroids and permanently stop treatment with Yervoy. If there is no improvement after 3 or so days, the patient may need additional immune suppression.

Immunotherapy treatment may also cause liver issues, commonly referred to as hepatic toxicities or hepatoxicity. Patients may not be able to spot this side effect themselves, since there are typically no symptoms. Doctors usually catch hepatic toxicity through abnormal lab values on blood tests.

Low-grade hepatic toxicity can be treated by holding therapy and monitoring the patient, patients experiencing grade 3 or higher liver issues may have their therapy permanently discontinued and given steroids or immunosuppression.

Like hepatotoxicity, liver inflammation – called pneumonitis – may be difficult for a patient to catch. It can only be diagnosed through imaging done by a doctor.

Grade 1 pneumonitis needs no treatment but should be closely monitored. A patient may have grade 2 pneumonitis if they are experiencing shortness of breath. Then, if they are being treated with Keytruda (pembrolizumab), it should be held, and the patient should be given steroids. Then, patients can be weaned off the steroids and back on to their immunotherapy.

More serious pneumonitis (grade 3/4) will require a patient to receive oxygen. At this point, their doctor will prescribe them steroids and permanently discontinue immunotherapy treatment. If their lung issues do not get better, they may have to have further immunosuppression.

In summary, York emphasized that patient-provider communication is key when it comes to managing side effects.

“These side effects that our patients experience needs to be reported promptly to the provider,” she said. “Because they need to manage promptly to avoid really bad outcomes.”

For more news on cancer updates, research and education, don’t forget to

Dr. Sally J. York goes over the types of immunotherapy-related side effects, and what patients with lung cancer and their caregivers should look out for. 

Immunotherapy Side Effects: Know What to Look For

There are multiple factors that doctors take into consideration when diagnosing and staging multiple myeloma, leading to better treatment for the disease, explained Dr. Nikhil C. Munshi.

Munshi, director of basic and correlative science at the Jerome Lipper Multiple Myeloma Center at Dana-Farber Cancer Institute, recently discussed diagnosis and risk assessment in myeloma at 

®’s Multiple Myeloma Educated Patient® Summit.

To diagnose myeloma, doctors traditionally start with a blood test. Then, they usually conduct a bone marrow biopsy to determine how many myeloma cells are in the patient’s bone marrow. Finally, patients may undergo an X-ray to see if there are any holes in the bones, which would indicate progressive disease.

“This is the standard workup that we have been doing for the last 15 or more years,” Munshi said. “But now, (clinicians) are doing many more things.”

More recently, serum-free light chain (SFLC) testing has become standard. SLCL tests for immunoglobulins, which are partially made up of light chains, in the blood. When there are more light chains than heavy chain, the immunoglobulin cannot bind to them, making them free in the blood. A high level of free light chains indicates that there may be an issue.

The blood tests that are used in myeloma diagnosis have evolved too. Clinicians will perform protein electrophoresis, where they are looking for monoclonal spike – commonly referred to as “m spike.” In doing so, they are able to test the amount of myeloma that is in the blood.

“A higher level means that there is more myeloma,” Munshi explained. “When the level goes down, we know that the myeloma is being controlled.”

This test can tell if myeloma treatment is working or not. Now that there is a simple blood test, patients may not need to undergo bone marrow biopsies as much.

Once myeloma is diagnosed, clinicians look at the prognosis of the disease, as well as the molecular makeup to determine which treatment would be best.

When a patient has symptomatic myeloma – which can include affected kidney function and/or bone lesions – they should be treated.

X-rays, PET and CT scans are also used to determine to what extent the myeloma has affected the patient’s bones and surrounding regions, such as the liver.

“In the old days, when bone marrow was involved to 70, 80 or even 90%, we wouldn’t start treatment,” Munshi said. “Now this new criteria tells us that if it is more than 60%, we should begin to think about treating this patient.”

When it comes to prognosis, doctors analyze proteins such as albumin and beta 2 macroglobulin, as well as results from a fluorescence in situ hybridization (FISH) genetic test.

“In looking at the genetic makeup of the multiple myeloma, we can establish the long-term plan. We could say, ‘since your myeloma is on the more aggressive side, we’ll need to do treatment for a longer period of time,” Munshi said.

However, Munshi explained that patients should not get too caught up in the stage of myeloma that they are given. A late-stage (stage 3 or 4) diagnosis might not be as deadly in myeloma as it is for other cancers.

“The reason is that even those who are stage 3 do quite well with new treatment and with the new drugs we have,” Munshi said, explaining that a stage 3 patient might receive a multi-drug maintenance regimen instead of a single-drug therapy.

“What we are beginning to do is incorporate more knowledge that we are gathering over time, looking at mutations and other things to make this next generation of staging a system that is comprehensive. And we need to keep that in mind,” Munshi said.

For more news on cancer updates, research and education, don’t forget to 

Advancements in the diagnosis and staging of multiple myeloma continue to shape treatment decisions and improve outcomes. 

Accurate Diagnosis, Staging Improves Myeloma Outcomes

While chemotherapy-induced nausea/vomiting can be effectively treated in patients with breast cancer, there is potential for the common side effect to return, especially in those whom treatment for the condition did not work the first time it was administered, according to study results presented at the 2020 San Antonio Breast Cancer Symposium.

Although many previous studies have evaluated chemotherapy-induced nausea/vomiting prevention strategies, Dr. Rudolph Navari noted there is limited research when it comes to subsequent bouts of the side effect.

“We sought to evaluate individual patients’ risk for repeat (chemotherapy-induced nausea/vomiting),” Navari, of the World Health Organization Cancer Care Program, said, explaining that this study was assessing how chemotherapy-induced nausea/vomiting risk changes with each chemotherapy cycle for patients with breast cancer.

Navari and colleagues collected data from a prospective, four-cycle chemotherapy-induced nausea/vomiting prophylaxis trial involving Akynzeo (netupitant/palonosetron) plus the steroid dexamethasone for patients with breast cancer who were receiving anthracycline and cyclophosphamide chemotherapy. A post-hoc analysis was also performed on a 2006 trial evaluating ondansetron plus aprepitant.

When patients did not experience chemotherapy-induced nausea/vomiting — defined as vomiting or the use of rescue medication within five days after chemotherapy — they were deemed to have a complete response. Other patients were deemed to have failed chemotherapy-induced nausea/vomiting prophylaxis treatment.

Of 402 patients who received 1,299 cycles of anthracycline and cyclophosphamide chemotherapy, 75.4% had a complete response to nausea and vomiting prevention drugs. Over the course of four cycles of chemotherapy, there were 253 chemotherapy-induced nausea/vomiting prophylaxis treatment failures. However, of the 303 patients who had a complete response to nausea and vomiting prevention therapy in the first cycle of chemotherapy, most (between 93% and 98%) achieved a complete response in subsequent cycles.

Among those who failed nausea and vomiting prevention therapy during the first cycle of chemotherapy, subsequent failure rates were higher, at 49.8% failing at some point between cycles 2 through 4.

Of 433 patients who received 1,537 cycles of ondansetron plus aprepitant in the 2006 trial, nearly half (49.2%) of patients experienced anti-nausea and vomiting treatment failure during the first cycle of therapy, and 46.7% failed at any point between the first four cycles.

As also seen in the group who received Akynzeo plus dexamethasone, patients who had a complete response during the first cycle had an increased chance (between 80.5% and 92.7%) of complete response in later cycles. Similarly, patients who had failed anti-nausea or vomiting therapy in the first cycle also had an increased chance (between 72.2% and 74.8%) of failure in subsequent cycles as well.
“Patients with treatment failure in cycle one did face a higher repeat failure rate,” concluded Navari. “These findings strongly suggest an individual patient with chemotherapy-induced nausea/vomiting on cycle one predict (chemotherapy-induced nausea/vomiting) in subsequent cycles.”

Approximately half of the patients with breast cancer who failed anti-nausea or vomiting therapy for chemotherapy-induced nausea/vomiting during their first cycle of treatment failed to avoid the side effect at some point during the next three treatment cycles. 

Patients Who Experienced Chemotherapy-Induced Nausea/Vomiting During First Cycle of Cancer Treatment May Be at Greater Risk for Recurrence of the Side Effect

Brielle Benyon | Contributors

Early Survivorship Care May Improve Patient Outcomes

Immunotherapy Side Effects: Know What to Look For

Accurate Diagnosis, Staging Improves Myeloma Outcomes

Patients Who Experienced Chemotherapy-Induced Nausea/Vomiting During First Cycle of Cancer Treatment May Be at Greater Risk for Recurrence of the Side Effect

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