Drs Fatima Cardoso, Hope Rugo, Rebecca Dent, and Zoe Quandt discuss a multidisciplinary approach in managing immunotherapy side effects to optimize patient care in metastatic breast cancer.
www.medscape.com/viewarticle/...
-TRANSCRIPT-
Fatima F. Cardoso, MD: Hello, and welcome to this commentary on immunotherapy side effects and the need for multidisciplinary care. My name is Fatima Cardoso. I'm a medical oncologist. I'm based in Lisbon, Portugal.
I'm joined by my friends and colleagues, Drs Hope Rugo, Rebecca Dent, and Zoe Quandt. I will ask each of you to please give a short introduction of yourself.
Hope S. Rugo, MD, FASCO: I'm Hope Rugo. I'm a breast medical oncologist at the University of California San Francisco's Comprehensive Cancer Center, and I'm very interested in immunotherapy as a treatment but also in identification and management of toxicity, and have focused much of my recent interests in this area. Excited to be here!
Rebecca A. Dent, MD: My name is Rebecca Dent and I'm thrilled to be on this panel. I'm a medical oncologist at the National Cancer Center Singapore, and also chair of the Division of Medical Oncology. I have a great interest in triple-negative breast cancer; hence, we've been experimenting, we'll say, with immunotherapy now for almost a decade. I'm really excited to share some of our experiences today.
Zoe E. Quandt, MD, MS: My name is Zoe Quandt. I'm also at University of California San Francisco. I'm an endocrinologist with a focus in onco-endocrinology and a physician scientist in this same area. I'm excited to be joining you all to talk more about the endocrine side effects of immunotherapy.
Reorganizing Care
Cardoso: Thank you. We will start with addressing this need for multidisciplinary care. How much did you have to reorganize care for breast cancer patients since we started using immunotherapy?
Here, in our institution, we just started using immunotherapy about 1 or 2 years ago for breast cancer, and that meant reorganizing the care for these patients regarding support from other specialties.
Rebecca, what happened in Singapore when you started using immunotherapy for breast cancer, since you have many more years of experience?
Dent: My experience goes back about 15 years. I was a melanoma doctor in my other life in Canada. We first started using combination immunotherapy. I got very used to being a little more proactive and worried about patients because the side effects we see are much different from what we see with chemotherapy.
When I moved to Singapore and we started using immune checkpoint inhibition in clinical trials, one of the things one of my colleagues did was get some of our juniors very quickly to identify specialists, including endocrinologists, GI, and skin - with endocrinologists, of course, being first and foremost - maybe mid-career, who were really interested and could engage and help us because the problems that we saw were unique. They weren't typical problems. We had to work - and we continue to - very closely to try to distinguish how much is potentially a toxicity from chemotherapy vs the cancer vs immunotherapy.
I would say the time interval is so different from what we're used to using or what we're looking at that we were really learning together. This included an open dialogue, continued discussion over WhatsApp, monitoring people's symptoms, knowing how to taper steroids, learning how to diagnose; how to identify the toxicity, treat the toxicity, monitor it over time, and then decide whether to rechallenge.
It's not a one-time engagement; it's an ongoing relationship that, to be honest, for the most part, we aren't used to having. I think we both have found it quite fruitful and really critical to helping manage patients. Now, some of my colleagues in private practice don't have the same access to multidisciplinary care within one center but similarly have identified their key specialists that they're just used to collaborating with, and I think that makes all the difference.
Cardoso: Hope and Zoe, since you are working in the same institution, what is your experience?
Rugo: It's great that we were able to include Zoe for her comments here because that's what's so important for us. We're used to talking to our consultants about getting a biopsy or complications of cancer, but in this situation, we really needed to have urgent communication with specialists who we might not have previously needed to have that direct line with.
Then we needed to understand who was interested in this area, who had experience with it, and who would be able to give us information about getting the testing and then see the patient in a fairly rapid time period. What was interesting for me was the first patient I had with significant immune toxicity had colitis, and this developed almost 4 months after her last of two doses of checkpoint inhibitor.
www.medscape.com/viewarticle/...
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