Monitoring Immunotherapy's Side Effects in Genitourinary Cancers

While immunotherapy agents are generally well-tolerated, it is important that patients with genitourinary cancers know what kind of side effects to look out for, and when they should contact their health care providers about them. While patients may be hesitant to tell their doctors about these side effects, in fear of being taken off treatment, Xiao X. Wei, M.D., MAS, said that should not be the case.

“It’s important for oncologists to tell their patients that most of these side effects are reversible, especially if they are treated early with steroids and potentially other agents, if necessary,” Wei, instructor of medicine at the Harvard Medical School, Dana-Farber Cancer Institute, said in an interview with OncLive, a sister publication of CURE.

“A lot of times we can resume therapy — that is assuming that the severity is not very high, or the heart and other vital organs are not affected.”

Agents in the kidney cancer space include Cabometyx (cabozantinib) and checkpoint inhibitors such as Opdivo (nivolumab). Bladder cancer has also seen an explosion of PD-1 and PD-L1 inhibitors in the past year or so, with the approval of agents such as Tecentriq (atezolizumab) and Keytruda (pembrolizumab).

PD-1 and PD-L1 inhibitors are generally well-tolerated, so most patients face little or no issues with the drugs. However, there are still some things to look out for.

“The faster we act, the better the outcome. Immune-related toxicities can affect any organ, but the organs that are commonly affected are the skin, gastrointestinal tract, liver and the endocrine system,” Wei said.

So, patients should notify their providers if they notice any skin changes or if they have diarrhea.

And while there is currently no way for clinicians to predict which individual patients are more prone to side effects, previous studies have shown that combination immunotherapy regimens — such as getting Opdivo and Yervoy (ipilimumab) together – are associated with more side effects.

“Although the combination of ipilimumab and nivolumab, for example, has a higher efficacy, it also has a higher toxicity associated with it,” Wei said. “That is definitely a concern.”

The combination is associated with more severe toxicities that can lead to colitis, pneumonitis, myocarditis and neurological complications.

“These are things that patients and clinicians need to know about when considering combination treatments,” Wei said.

While the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO) have all put out guidelines regarding the management of these side effects, symptoms should still be treated depending on the person’s disease type, treatment regimen and individual health status.

“There are no prospective data per se on high-level evidence on how to best treat side effects, though ASCO, NCCN and ESMO guidelines have given us tools to work with … every patient is different, and we have to employ our clinical judgement,” Wei said.