Recognizing and Monitoring for Adverse Events

Cancer and cancer treatments are known to cause side effects.¹ These side effects, also known as adverse events (AEs), can be different for each patient and may vary by medications and treatments.² Moreover, AEs may be different even among patients who receive the same type of cancer treatment.²

The oncology care team should be aware of the potential for AEs and related symptoms so they can be monitored and prevented or managed appropriately.^1-2

Potential Immune-related Adverse Events

Recent advances in immunotherapy have transformed current cancer treatment; however, clinicians must be vigilant for AEs.^4-5 As more patients with cancer are exposed to immunotherapy, including immune checkpoint inhibitors and chimeric antigen receptor (CAR) T-cell therapies, clinician awareness of the drugs’ associated toxicities and how to best manage them is vital.^4-5

While immunotherapy can treat many types of cancer effectively, it can cause the patient’s immune system to attack healthy cells.⁴ Immune-related AEs (irAEs) can occur at any time during treatment and even after stopping immunotherapy.⁴ Common irAEs depend on the type of immunotherapy administered.^4-5

Immune Checkpoint Inhibitors

Immune checkpoint inhibitors are the current standard of care for the treatment of several types of cancer, including solid-organ and hematologic malignancies.⁵ Use of immune checkpoint inhibitors has increased in recent years; in 2023, approximately 56% of patients with cancer in the US were eligible for treatment.⁶ Development of new immune checkpoint inhibitors continues, making this a rapidly changing field.⁵

CAR T-cell Therapy

CAR T-cell therapy works by returning adjusted immune cells back into the body to attack cancer cells.⁴ Common irAEs of CAR T-cell therapy generally result from immune system changes involving more than one part of the body.⁴

Immunomodulators

Other types of immunotherapy may be associated with AEs.⁴ Common AEs may include, but are not limited to: cough, respiratory issues, diarrhea, constipation, pain, sweating, headache, confusion, jaundice, seizures, sensitivity to light, weight changes, alopecia or hirsutism, tachycardia, hepatomegaly and splenomegaly.⁴ While most AEs will resolve or can be treated effectively, some are serious and require immediate medical attention.⁴

Bispecific Antibodies

Bispecific antibodies have unique toxicity profiles depending on their therapeutic target and format.⁷ Some require slow dosage escalation and close inpatient monitoring for adverse effects such as cytokine release syndrome and immune effector cell-associated neurotoxicity syndrome during treatment initiation.⁷ In addition, on-target off-tumor toxicities may also occur, including B-cell depletion and cytopenias. Other adverse events include infections, cardiovascular complications, venous thromboembolism, and hemophagocytic lymphohistiocytosis.⁷

Antibody-Drug Conjugates

Antibody-drug conjugates (ADCs) which are made up of a monoclonal antibody linked to a cytotoxic payload, increase target selectivity and widen the therapeutic window of traditional chemotherapy.⁸However, construct-specific features, such as properties of the payload, drug-to-antibody ratio, and linker stability can contribute to toxicity.⁸ Clinical manifestations of off-target effects include neutropenia, thrombocytopenia, peripheral neuropathy, interstitial lung disease, hepatotoxicity, ocular toxicity, and other AEs.^8,9

Best Practices for Monitoring for Adverse Events

Close monitoring, patient education and supportive care are vital elements of AE monitoring.^1-4 Providers should discuss with patients the type of immunotherapy being used, treatment goals, potential AEs, and signs and symptoms to look for.⁴ The oncology care team can help prevent or treat many AEs related to cancer treatment.⁴ AEs related to immunotherapy can be mild, moderate or life-threatening, and some effects may not appear until months or years later; treatment depends on severity.⁴

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