Heather Greene, a nurse practitioner at West Cancer Center, discusses the toxicities that are associated with VEGF TKIs and checkpoint inhibitors in metastatic renal cell carcinoma (mRCC).

For patients on VEGF TKIs, providers should be aware of the possibility of grade 3 hypertension, which would require a patient to stop therapy. Grade 1/2 diarrhea is also common, though it can be managed fairly well, explains Greene. If it becomes a higher grade, it can interfere with the patient’s course of treatment. With regard to immune checkpoint inhibitors, providers have to be alert to patients who are reporting vague symptoms, says Greene. That way, physicians can ensure that it’s not an underlying low-grade immune toxicity that would require intervention and management before hospitalization and intravenous steroids.

The first step in managing these toxicities is patient education, adds Greene. Patients should understand what to look for, so that they can alert their providers to a potential concern. Beyond education, patients should be comfortable going to their provider and informing them if they’re experiencing diarrhea at home, if their joints are hurting, and if they’re more tired than usual. Moreover, if they're gaining weight, or having coordination issues.

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Toxicities Associated With VEGF TKIs and Checkpoint Inhibitors in mRCC

Heather Greene, a nurse practitioner at West Cancer Center, discusses common treatment-related toxicities in metastatic renal cell carcinoma (RCC).

In terms of anti-VEGF tyrosine kinase inhibitors (TKIs), healthcare providers should be aware of potential diarrhea, hypertension, palmar-plantar erythrodysesthesia, as well as skin and hair depigmentation, says Greene. Patients who are receiving mTOR inhibitors should be aware of the potential for pneumonitis and stomatitis. In terms of immune checkpoint inhibitors, there are a variety of adverse events that can result from treatment. Ensuring that patients are being screened and monitored for the vast array of toxicities that can occur with that drug class is important.

However, screening for potential toxicities with immunotherapies is an area of debate, adds Greene. In 2018, ASCO and NCCN guidelines were released for the management of immune-related adverse events; however, healthcare providers still do not have guidelines in terms of screening. Screening patients with underlying myasthenia gravis for some of the more severe neurologic toxicities has been a topic of discussion, notes Greene, and for some of the expected endocrine toxicities, there are ways to screen for patients who may not be good candidates for immune checkpoint inhibitors.

Common Treatment-Related Toxicities in mRCC

Heather Greene, a nurse practitioner at West Cancer Center, discusses the most common immune-related adverse events (AEs) in patients with non—small cell lung cancer (NSCLC), and whether or not these AEs vary between agents.

Immune-related AEs can occur anywhere in the body, but they typically manifest on the skin and in the gastrointestinal tract and endocrine system. Rare side effects include pneumonitis and nephritis. It can be difficult to differentiate between immune-related AEs and other symptoms, notes Greene.

Immune-related AEs tend to be lumped together as immune checkpoint inhibitors. We tend to focus on the PD-1/PD-L1 AEs which are generally the same, says Greene. They tend to have the same side effect profiles. There is however some increase in toxicity when PD-L1 inhibitors are combined with CTLA-4 inhibitors.

Heather Greene, a nurse practitioner at West Cancer Center, discusses the most common immune-related adverse events (AEs) in patients with non–small cell lung cancer (NSCLC), and whether or not these AEs vary between agents.

Heather Greene, NP

Articles

Toxicities Associated With VEGF TKIs and Checkpoint Inhibitors in mRCC

Common Treatment-Related Toxicities in mRCC

Heather Greene on Immune-Related Adverse Events in Patients With NSCLC