The Role of Nurses in the Management of Adverse Events in Patients Receiving First-Line Axitinib Plus Immuno-Oncology Agents for Advanced Renal Cell Carcinoma - Beyond the Abstract

The US Food and Drug Administration's approval of the combination axitinib plus pembrolizumab in 2019 marked the emergence of the use of combination IO/TKI agents in the front-line setting for the treatment of people with aRCC. , With the emergence of IO/TKI combinations comes the complexity of potential overlapping treatment-related adverse events (TRAEs). Effective management of TRAEs is needed to optimize treatment adherence and duration, and consequently improve clinical outcomes while preserving quality of life of patients receiving these efficacious treatment approaches.

Potential TRAEs

Receptor tyrosine kinases are involved in the growth and division of different cells within the body. By inhibiting VEGF-R TKIs, growth of new blood vessels slows down, thus hindering the ability of cancer cells to obtain the necessary nutrients and oxygen required to grow. The most common and clinically relevant TRAEs associated with antiangiogenic agents, such as TKIs, are diarrhea, fatigue, hypertension, nausea, and hand-foot syndrome. In contrast, TRAEs associated with IO agents are typically mediated by the immune system. Despite the differences in the mechanism of action between the two treatment classes, overlapping toxicities are often observed. Common (>10%) TRAEs that are overlapping and may be IO- or axitinib-related include hypothyroidism and hyperthyroidism, rash/inflammatory dermatitis and pruritus, diarrhea, increased alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST), nausea, arthralgia, and general disorders such as fatigue.⁴

This ever-evolving complexity of treatment options for patients with cancer diagnoses over the last few decades has led to the establishment of a multidisciplinary approach to patient care and management. Up to 2 of every 3 patients has an underlying comorbidity that may need to be managed in addition to their cancer diagnosis. The goal of multidisciplinary teams is to provide multiple perspective on diagnosis, aid treating physicians to remain on top of updates to clinical guidelines, and specialized treatment management based on expertise. One key individual, and often considered the glue in clinical practices serving as a messenger and important care provider to patients, is the nurse.

Role of Nurses

The role of nurses in oncology has evolved and expanded over the years. Nurse-led patient care and AE management has become a staple in current clinical practice given they are often the health care provider that spends the most time with a patient. Through collaborative efforts, oncology nurses have formulated immunotherapy management guidelines and recommendations for AEs management, as well as patient-directed materials to help improve treatment tolerability. Parreira and colleagues have expanded on these guidelines to include TKI/IO AE management recommendations.

Recommendations for Nurse Management of IO/TKI Adverse Events


Management of Specific TRAEs

It is important to help patients identify AEs early and take appropriate measures to minimize side effects that may impact quality of life and lead to early treatment discontinuation, which could compromise their oncological outcomes. Identifying the AE is the first step in managing therapy. After the event is identified, different recommendations and guidelines for management are available, as they have been previously published.^4,8

In the absence of severe symptoms that require treatment to be held, axitinib treatment interruption for 24-48 hours with patient monitoring may lead to reduced symptoms, if the TRAE is axitinib-related. A previous study demonstrated that axitinib treatment interruption of 5 of the most common AEs associated with axitinib treatment (diarrhea, fatigue, hypertension, nausea, and hand-foot syndrome) found that time to treatment resolution was generally shorter for axitinib monotherapy (≤3 days, except for fatigue) compared with axitinib + IO combinations (4-11 days).⁴ Parreira et al further describe nurse-assisted management of these adverse events (Figure).



Conclusion

Ongoing education of nurses related to regular monitoring/assessment of AEs of aRCC patients receiving TKI inhibitors in combination with immunotherapy should be a priority. By prioritizing regular patient monitoring, healthcare providers can help secure efficient safety management and optimal cancer care for patients facing an aRCC diagnosis.

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