Immunotherapy Toxicity: How Much Do Physicians Know?

Maurie Markman, MD


March 15, 2023

This transcript has been edited for clarity.

I'm Dr Maurie Markman from Cancer Treatment Centers of America. I would like to discuss with you a very interesting paper that appeared in the Journal of the National Comprehensive Cancer Network in December 2022, entitled "Physician Awareness of Immune-Related Adverse Events of Immune Checkpoint Inhibitors."

It's an interesting paper and an interesting one to have been published in a cancer journal, but I think it's a very important paper that we need to take seriously — that is, all physicians, but also cancer physicians.

This paper did not look at physician awareness as it relates to oncologists because oncologists have learned over the past 5-plus years of the importance of immune checkpoint inhibitors and the potential toxicities of immune checkpoint inhibitors. But, for many of the side effects that occur with immune checkpoint inhibitors, individuals may go to emergency rooms or their family practitioners.

The question being asked here is, what about non-cancer specialists? Specifically, this was a survey of physicians in emergency medicine, family practitioners, and general internists. Of [413] physicians that were surveyed, 155 (or 38%) returned information.

There's some very provocative information from this survey that is encouraging but may cause one to pause and say that we need more education. For example, one question asked about the risk of the gastrointestinal (GI) tract being a toxicity site of immune checkpoint inhibitors. Of the respondents, 93% knew that the GI tract was potentially at risk. On the other hand, when a similar question was asked about the cardiovascular and renal systems, only 57% of the respondents knew that the cardiovascular system was at risk and only 67% recognized that the renal system was at risk.

When asked whether endocrinopathies are reversible — and we know that most of them are not — unfortunately, 65% of the respondents said yes, they were reversible. That was an incorrect answer.

Another answer relevant to management of adverse events is that 59% of the respondents said giving steroids was potentially very negative and that it would reverse the benefits of the checkpoint inhibitors. In fact, most studies would suggest that, no, that's not true. You can give steroids and they're very important, particularly in a setting where the patient is quite ill. Education is necessary here. Again, remember, these are not cancer specialists, these are not people that give these drugs; these are individuals who might see patients in the emergency room or might see them in their practice.

The final question that was addressed, which is perhaps the most concerning, was when the doctors were asked to self-report their comfort level in recognizing the toxicities of checkpoint inhibitors. The doctors could record from 0 to 100. The median response was 15. When asked, "What do you feel is your comfort level with treatment," the median response, again on a scale of 0 to 100, was 10.

Clearly, there needs to be more education and more support for the non-oncology community related to checkpoint inhibitors if we are going to optimally care for our patients receiving these incredibly important, beneficial drugs, which do have potential for very serious and sometimes emergent side effects.

I want to call your attention to this paper. I encourage you to read it and to consider the roles that you might have in your own community to help educate residents, fellows, general internists, family practitioners, and emergency room physicians about these drugs.

I thank you for your attention regarding the discussion of this paper.

Maurie Markman, MD, is president of medicine and science at Cancer Treatment Centers of America in Philadelphia. He has more than 20 years of experience in cancer treatment and gynecologic oncology research.

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