Immune checkpoint inhibition (ICI) to treat cancer is a radical innovation that requires equally radical toxicity management.1 Using ICI to intentionally overactivate T cells against cancer can, at times, result in unintentional attack of normal, healthy tissues. These inflammatory effects are known as immune-related adverse events, or irAEs. Unlike the predictable toxicity profile of traditional chemotherapy, irAEs are unpredictable, resulting in poor recognition and delayed treatment. I spend my time in clinical practice educating patients on immunotherapy and managing irAEs in a medical oncology clinic that treats people with skin cancer. My passion is to advocate for awareness of irAEs by pharmacists in every setting. In this feature, I will argue for the pharmacist as the health care professional best suited for immunotherapy education.
What makes a pharmacist valuable to a patient? This might seem like an almost comically existential question in the context of immunotherapy and irAEs. But bear with me for a few moments. I learned early in life that I wanted to be a pharmacist. My mother, a nurse, would share with me statistics about the most trusted professions, and year after year, three consistently rose to the top: Nurse. Physician. Pharmacist. Trusted. Pharmacists across the nation remain one of the most consistent faces of health care for millions. Before specializing in oncology, I spent years in a retail pharmacy. Those pharmacists appreciate the value of the human factor. They know patients by name. They see them on a regular basis. They are personally invested in them. It is not lost on myself and my health-system pharmacist colleagues that when we first describe our profession to friends and family, the image conjured in their mind’s eye is likely akin to the person they know and love behind the counter at their local pharmacy. I often think about this type of patient-pharmacist relationship, and why its cultivation in other settings where we practice pharmacy is still important.
Although our professional trajectories as pharmacists lead us down varying paths, our mutual goals are the same: Ensure drug safety; Maximize patient outcomes. But I fear that, in the pursuit of these goals, pharmacists in many settings including health-systems may forget to give proper focus to the human factor. We spend countless hours managing medication safety, ensuring access, probing for drug interactions, making therapeutic recommendations, and documenting interventions. These important tasks result in us being glued to a screen. The result? Face-to-face patient contact may become neglected to save time.
My message to you is that this type of distant patient care is less than ideal when it comes to responsible education and management on irAEs. Handouts, while helpful, are only a tool. And let’s be honest—most of them end up in the trash, whether we like it or not. Thus, my approach to ICI education is deeply focused on the human factor, and the importance of relationship building. An irAE can be a terrifying, life-threatening experience for the unacquainted. We must ensure that patients are well prepared to communicate with us to help efficiently manage immune toxicities. Healthy People 2030 places an emphasis on health literacy—not only that of the individual, but an organization’s responsibility to “equitably enable patients to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”2 We must help our patients be more than just spectators in the sport of their own health, especially when it comes to irAEs; they must be active participants—team members. As the expert in both medication and drug toxicity management, the pharmacist is the ideal health care professional to educate patients and other health disciplines on appropriate identification and management of irAEs. As someone who does this daily, I offer to you three guiding principles that have helped me solidify the role of the pharmacist as the de facto immunotherapy educator at my organization.
Invest early in a patient-pharmacist relationship.
Whenever possible, I meet with each patient before starting immunotherapy and spend time walking through its “foot off the brakes” mechanism, timeline, risks, potential irAEs, how to manage low-grade irAEs, and when to call for help. The short time we spend building rapport and educating in the earliest stages pays off in dividends when patients quickly notify the team of signs or symptoms concerning for an irAE.
Speak in simple terms and relate to past experiences.
As the discussion begins, it is important to use language that is simple, easily understood, and actionable. Be relatable. Ask about the patient’s life. Discuss past experiences with cancer treatment – whether for themselves, or for loved ones – and how these may differ from the experience they might have with ICI. A similar approach can be taken with other health care professionals who have experience with chemotherapy, but minimal experience with immunotherapy.
Be transparent to build mutual trust for prompt action.
There is a confidence established by sitting with someone and being honest about cancer treatment that simply cannot be replicated any other way. Talking through baseline knowledge, and what I call “red alert zones” for what symptoms warrant a call to the clinic (i.e., grade 2 or worse), provides a rational structure to patient and caregiver communication. Patients and caregivers come to appreciate we “have their back”, if and when they have an irAE. This results in early recognition and improved compliance during irAE treatment.
Once again, I ask—what makes a pharmacist valuable to a patient? I would argue that it is the human factor. Patients want to be able to learn what they need to know about complex topics like irAEs from the drug experts, in simple terms. But more importantly, they want to know that we are there for them, and care. We all want drug safety and optimal outcomes with ICI. But perhaps the best way to achieve those goals is to take a few minutes to listen and educate. In the end, it is no more than we would want done for us if we found ourselves fighting cancer with immunotherapy.
- Robert C. A decade of immune-checkpoint inhibitors in cancer therapy. Nat Commun. 2020; 11(1):3801.
- Santana S, Brach C, Harris L, et al. Updating Health Literacy for Healthy People 2030: Defining Its Importance for a New Decade in Public Health. J Public Health Manag Pract. 2021; 27(Suppl 6):S258-S264.