Optimization of immune-related adverse event management in a thoracic oncology clinic.

Abstract

261 Background: Improved awareness and management of immune checkpoint inhibitor (ICI) related adverse events (IRAEs) is a mandate for best practice given widespread use of ICIs in clinic. IRAE grading is standardized by the Common Terminology Criteria for Adverse Events (CTCAE); management has been standardized in recently published consensus guidelines. In the thoracic oncology clinic at the Beth Israel Deaconess Medical Center grading and management of IRAEs has been inconsistent. Methods: A retrospective review of 98 patients receiving ICIs in the thoracic oncology clinic from March 2015-April 2018 was conducted with a focus on IRAE grading and management. Oncologists were surveyed regarding barriers to grading, management, and subspecialty referral for IRAEs. We aimed to improve documentation of IRAE grading to 75% as well as the rate of specialist referral for grade 3-4 IRAEs. As an intervention we implemented a macro to document IRAE CTCAE grade and management. Additionally, our team created a pathway for specialist referral for patients with grade 3-4 IRAEs. Results: Upon review of 98 patient charts, 38 patients developed 58 IRAEs of which 36% were grade 1-2, 17% were grade 3, 0% were grade 4 and 47% were ungraded. The most commonly affected organs were skin (25%), thyroid (25%) and lung (11%). 53% of active IRAEs were formally graded in the oncologist’s assessment, only 6% of resolved IRAEs were documented in the subsequent oncologic history. A total of 11 patients were hospitalized for IRAEs, 7 of which had undocumented severity; 40% of grade 3 IRAEs were hospitalized. 14 specialist referrals were made, most with undocumented severity; 30% of patients with grade 3 IRAEs were referred. Overall, 18 patients required steroids, of these 40% were ungraded, and 19 had immunotherapy stopped or held, of these 45% were ungraded. Conclusions: While the presence of IRAEs is consistently documented, documentation of severity and subsequent management are inconsistent- including amongst those patients requiring hospitalization, specialty referral and/or treatment modification. Further data will be reported regarding utilization of the macro, documentation of IRAE grading and management as well as specialist referral rate.