This article aims to help you understand

• How checkpoint inhibitor immunotherapy works with your immune system to help your body fight cancer
• The importance of informing your cancer care team immediately of any changes you experience

The Difference Between Immunotherapy and Chemotherapy

Immunotherapy has revolutionized cancer care over the past two and one-half decades. As part of cancer treatment, immunotherapy may be used by itself or in various combinations with surgical, chemotherapy, or radiation therapy.

Immunotherapy is different from chemotherapy.

Cancer cells typically rapidly replicate or reproduce.

Chemotherapy attacks rapidly multiplying cells in your body to eradicate cancer cells. Chemotherapy will often affect quickly replicating normal cells, such as your hair and the lining of your intestines, causing many of the symptoms we associate with chemotherapy.

Immunotherapy works with your immune system to recognize and destroy cancer cells.

There are several varieties of immunotherapy, and they each work in different ways. One is not necessarily better than the other for fighting your cancer; an immunotherapy treatment decision depends on several factors, including your cancer cell type.

A few words on cancer treatment planning

Some cancer treatment plans combine chemotherapy and immunotherapy, other combinations may include radiation or surgery, and some may consist of only one treatment type.

The treatment decisions depend on several factors unique to each individual, including:

• past medical history
• current overall health
• current medical conditions
• to what areas of the body the cancer has spread
• how deep the cancer is embedded
• with what critical organs the cancer is entwined or near
• the cancer cell type
• the aggressiveness of the cancer
• chance of recovery from treatment
• ability to tolerate a treatment

Consider this is your life and future steps forward. Embrace speaking up for yourself and understanding your treatment plan. You and your doctor can discuss all of the above factors to decide on your goal of treatment (Mayo Clinic, 2021):

• cure
• control of the cancer (which may be for several years), with a good quality of life
• comfort

Some keys to success with cancer treatment

There are some relatively simple things you can do that may have a positive impact on how well you do through your treatment and your goal of cancer treatment:

●      Consider writing down the various parts of your treatment plan and each part's timing.

●      Keep a cancer care journal to help you be an active part of your healthcare team.

●      Read and review the information about your treatment and cancer that your healthcare team gave you.

●      Write your questions in your journal about your

○      treatment plan

○      medications

○      cancer

○      symptoms and managing symptoms

○      financial concerns with treatment in your journal

○      diagnostic testing schedules

○      treatment and doctor office locations

○      insurance coverage

●      Note the answers to your questions in your journal

●      Maintain your health to the best of your ability with exercise cleared by your doctor, regular sleep, and a good diet (CDCBreastCancer, 2022).

●      Wash your hands often before touching your face or eating to avoid illness; avoid sick people and crowds (CDCBreastCancer, 2022).

●      Understand your insurance benefits and ensure you are with in-network providers to avoid large bills, which avoids some stress. Member service for your health insurance can assist you. Consider requesting a case manager from your health insurance company.

A brief schooling on the white blood cells of your immune system

White blood cells find and attack foreign organisms in your body. Several types of white blood cells form this pillar of your immune system (Cleveland Clinic, 2021). They are a motley but effective crew:

• Neutrophils – go into dark places without fear, killing bacteria, fungi, and foreign matter
• Lymphocytes – these Special Ops cells fight viruses and produce proteins to help your body combat infections; they are the mighty T Cells and B Cells
• Eosinophils – think of eosinophils as your exterminator; they find and destroy scary parasites and cancer cells; they might help out the basophils here and there.
• Basophils –  go after the allergens and cause inflammatory responses of coughs, sneezes, and runny noses (tell your desk-mate next time you sniff that it is your basophils' fault)
• Monocytes - the kindly custodians, defend against infection by sweeping up those damaged cells

Are you ready? We are going to a dance with T Cells.

How Immune Checkpoint Inhibitors (ICI) work:
or what happens when Checkpoint Inhibitors crash the T-Cell and cancer cell dance party?

Cancer cells use proteins called checkpoint proteins to disguise themselves from T Cells.

Think of the cancer cell checkpoint protein and the T Cell partner protein as joining hands to dance together. The checkpoint inhibitors prevent the cancer cells and T Cells from becoming friendly dance partners.

Normally, the cancer cell binds its checkpoint protein to a partner protein on the T Cell (so they become friendly dance partners). This binding prevents the T Cell from recognizing the cancer cell as a foreign invader (or an enemy dancer partner).

Checkpoint inhibitors stop the checkpoint proteins from binding with their partner proteins on T Cells (and unmasks the enemy dance partner cancer cell). With checkpoint proteins inhibited, T Cells recognize the cancer cells as invaders and will attack them.

Possible Serious Effects on Your Body and How to Stay Ahead of Them

Many cancer care professionals consider immune checkpoint inhibitors the most significant cancer treatment developed in the past decade. The downside to this progress in the fight against cancer is the checkpoint inhibitor T Cells may attack healthy cells of organs, causing inflammation.

This inflammation may lead to possible mild to severe or even life-threatening issues. These are called Immunotherapy-Related Adverse Events, or irAEs. 

An irAE can occur anywhere in the body at any period of time after beginning this therapy.

 A good way to judge if you are possibly having symptoms is if anything feels or looks different from how it did before you started therapy, it is a symptom.

Journaling or logging your symptoms can make them easier to

• describe
• track
• report to your cancer doctor

Report symptoms as soon possible, even if minor.

Your doctor can use this information to treat the possible inflammation, an irAE, often before it becomes severe.

The Most Common Immune Adverse Events from Checkpoint Inhibitor Immunotherapy

Because these are common does not make them any less significant. The most common side effects are:

• rash
• diarrhea
• fatigue

Rash or redness, itchiness:  This is one of the most common irAEs and affects up to 70% of people who receive an ICI.   Skin reactions from ICIs can get worse quickly, so the more rapidly you and your doctor get the rash under control, the better. Immediately report any symptoms of itchiness, redness, rash, bumps, weeping, or open areas to your doctor.

Diarrhea: Abdominal pain and bowel movements that are watery, bloody, or with mucous in them are all cause for concern. Report any of these symptoms, which could indicate a condition known as colitis, immediately to your doctor. Control of colitis begins with immediately reporting any symptoms to your doctor, followed by prompt evaluation and treatment.

Fatigue: Being bone-tired or fatigued may seem somewhat expected in cancer treatment. Fatigue with Immune Checkpoint Inhibitors (ICIs) could be a symptom of one of the more severe reactions. All symptoms are important to report immediately to your doctor, including fatigue.
 
If your fatigue is determined as not related to anything more serious, try to manage your fatigue with the following or similar strategies (Memorial Sloan Kettering Cancer Center, 2022):

• good sleep hygiene
• exercise
• good nutrition
• meditation
• managing your work schedule
• getting rest
• planning activities around rest times
• obtaining emotional support

If you find fatigue considerably impacts your quality of life, talk with your doctor to see if there are other things you can do to combat the fatigue. Consider discussing different treatment options with your doctor if the quality of your life is deeply affected by fatigue.

With ICIs, anything which feels or looks different is essential to report to your doctor

Signs and symptoms which may seem incidental to you but are important to report immediately are:

• diarrhea
• rash
• darkened urine
• headache
• blurred vision
• numbness or tingling in your extremities
• a new cough
• shortness of breath
• difficulty moving or feeling any of your fingers, toes, arms, or legs
• fatigue
• anything which feels or looks different or is changing

Management by your doctor of your immune-related Adverse Event (irAE)

Your checkpoint inhibitor cancer treatment will likely continue uninterrupted or with only a brief interruption with early recognition and treatment of an irAE (Schneider et al., 2021).
 
Your doctor may use steroids, other medications, or other treatments to get the inflammation under control so that you can stay on your ICI treatment (Schneider et al., 2021).
 
Sometimes, diagnostic tests are needed to confirm the type or degree of inflammation to determine the best course of action (Schneider et al., 2021).
 
Your doctor may refer you to a specialist to manage your inflammation, such as a gastroenterologist for managing colon inflammation (colitis) or a dermatologist for managing skin rashes and itchiness (Schneider et al., 2021).
 
Some types of organ inflammation require permanent stoppage of immunotherapy to protect overall health, no matter how early you and your doctor identify it (Schneider et al., 2021). An example of this would be inflammation of the heart.

Early identification is vital to treat these serious and possibly life-threatening conditions immediately.

Other important things to understand

Read information about your checkpoint inhibitor immunotherapy given to you by your doctor. It may contain important information for you to know, such as:

●      understand what type of inflammation you are most at risk for with your specific treatment

●      make sure you know how to report symptoms to your doctor and the necessary phone numbers for reporting

●      carry a wallet card for your particular type of immunotherapy

●      ask what other important information your doctor wants you to know

●      know your treatment or medication schedule

●      Don't be afraid to ask your doctor questions. Use your journal to write down questions for your doctor when you think of them

A wallet card communicates the specific immune checkpoint inhibitor you receive with other healthcare providers. Different checkpoint inhibitors have different levels of risk for the organs on which they may have the most effect. Individual immunotherapy websites often have wallet cards available to print. You can make your own wallet card, writing on a piece of paper to carry with you:

●      the name of your immune checkpoint inhibitor

●      when you started the treatment

●      the name of your doctor with a phone number

●      the name of your hospital and a phone number

●      A wallet card identifying the current specific checkpoint inhibitor therapy is an essential communication tool to show other healthcare providers, especially when traveling.

●      Review the information your doctor has given you regarding your treatment and make a note of important points.

To summarize:

●      Immune checkpoint inhibitors can be an effective medical cancer therapy. They have revolutionized cancer treatment.
 
 

●      Immune checkpoint inhibitors allow the T Cells of your immune system to recognize and attack cancer cells.
 
 

●      Immune checkpoint inhibitors may cause mild to severe inflammation anywhere in the body.
 
 

●      The severity and or location of the inflammation determines your doctor's decision regarding continuing, pausing, or stopping the immune checkpoint inhibitors.
 
 

●      Early recognition and reporting to your doctor of inflammation symptoms possibly caused by immune checkpoint inhibitors often leads to better outcomes.
 
 

●       A good way to judge if you are possibly having symptoms is if anything feels or looks different from how it did before you started therapy, it is a symptom.

●      Journaling or logging your symptoms can make them easier to describe, track, and report to your cancer doctor.

●      Report symptoms as soon as possible, even if minor. Your doctor can use this information to treat the possible inflammation, irAE, often before it becomes severe.

With quick recognition and reporting of possible inflammation from your immune checkpoint inhibitor, you are giving yourself the best opportunity for your cancer treatment to work for you and have a good quality of life.

The information in this article is not intended to take the place of advice from your physician and is not medical advice.

References:

Apalla, Z., Rapoport, B., & Sibaud, V. (2021). Dermatologic immune-related adverse events: The toxicity spectrum and recommendations for management. International Journal of Women's Dermatology, 7(5Part A). https://doi.org/10.1016/j.ijwd.2021.10.005

ASCO Staff. (2022, March 1). What oncologists think about when recommending a cancer treatment plan. Cancer.Net. https://www.cancer.net/blog/2022-03/what-oncologists-think-about-when-recommending-cancer-treatment-plan

Cancer Care. (2022, June 24). Communicating with your health care team (K. Nugent LCW, Ed.). CancerCare. https://www.cancercare.org/publications/53-doctor_can_we_talk_tips_for_communicating_with_your_health_care_team

Cancer.Net. (2022, May). Side effects of immunotherapy (Cancer.Net Editorial Board, Ed.). Cancer.Net. https://www.cancer.net/navigating-cancer-care/how-cancer-treated/immunotherapy-and-vaccines/side-effects-immunotherapy

CDCBreastCancer. (2022, June 9). Staying healthy during cancer treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/cancer/survivors/patients/staying-healthy-during-cancer-treatment.htm

Cleveland Clinic. (2021, July 23). White blood cells: What are they, normal ranges, role & function. Cleveland Clinic. https://my.clevelandclinic.org/health/body/21871-white-blood-cells

Cleveland Clinic. (2023a). Chemotherapy: Types & how they work. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/16859-chemotherapy

Cleveland Clinic. (2023b). How immunotherapy works to treat cancer. Cleveland Clinic. https://my.clevelandclinic.org/health/treatments/11582-immunotherapy

Hashash, J. G., Francis, F. F., & Farraye, F. A. (2021). Diagnosis and management of immune checkpoint inhibitor colitis. Gastroenterology & Hepatology, 17(8).

Mayo Clinic Staff. (2021, June 18). Cancer treatment decisions: 5 steps to help you decide. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cancer/in-depth/cancer-treatment/art-20047350

Memorial Sloan Kettering Cancer Center. (2022, December 12). Managing cancer-related fatigue. Memorial Sloan Kettering Cancer Center. https://www.mskcc.org/cancer-care/patient-education/managing-related-fatigue

National Cancer Institute. (2022, April 7). Immune checkpoint inhibitors. National Cancer Institute. https://www.cancer.gov/about-cancer/treatment/types/immunotherapy/checkpoint-inhibitors#what-side-effects-are-caused-by-immune-checkpoint-inhibitors

Schneider, B. J., Lacchetti, C., & Bollin, K. (2022). Management of the top 10 most common immune-related adverse events in patients treated with immune checkpoint inhibitor therapy - PubMed. JCO Oncology Practice, 18(6). https://doi.org/10.1200/OP.21.00776

Schneider, B. J., Naidoo, J., Santomasso, B. D., Lacchetti, C., Adkins, S., Anadkat, M., Atkins, M. B., Brassil, K. J., Caterino, J. M., Chau, I., Davies, M. J., Ernstoff, M. S., Fecher, L., Ghosh, M., Jaiyesimi, I., Mammen, J. S., Naing, A., Nastoupil, L. J., Phillips, T., … Bollin, K. (2021). Management of immune-related adverse events in patients treated with immune checkpoint inhibitor therapy: ASCO guideline update - PubMed. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 39(36). https://doi.org/10.1200/JCO.21.01440

Thank you for reading Patient Education Essentials, the Write Shift RN blog.

Disclaimer: This article was written as a guest post for Write Shift RN LLC's blog. The information in it may not be wholly fact-checked or edited, allowing the reader to see the writer's work and skills firsthand. This information is not intended as medical advice. It is for informational and educational purposes only. Always talk to your doctor or other qualified healthcare providers about any questions or concerns you may have regarding medical conditions.