Nurses on the front lines of immunotherapy

A patient writes, “The Astros will win the World Series next year,” in bold print as Jaquelin Velasquez watches. The clinical nurse in Lymphoma and Myeloma isn’t interested in the accuracy of this prediction. She’s looking for signs of a serious side effect of immunotherapy.

“If a patient’s handwriting deteriorates, it’s a red flag that they’re developing neurotoxicity,” Velasquez says. She explains that the handwriting test is part of a neurological assessment developed at MD Anderson for patients receiving CAR T-cell therapy.

“Neurotoxicity can be fatal if we don’t intervene early and reverse the effects,” she says. 

Velasquez has cared for immunotherapy patients since the first CAR T-cell therapy clinical trial here in 2015. The therapy involves the removal of a patient’s own T cells, which are then reengineered to find and destroy cancer proteins or targets. Next the cells are infused back into the patient’s body, where they attack the cancer cells. While there’s been great success with this type of treatment, it comes with a unique profile of toxicities that can be life-threatening.

Making immunotherapy a safer treatment option

Velasquez is one of many clinical, advanced practice and research nurses throughout MD Anderson who collaborate across the institution and the nation to identify and manage toxicity in patients treated with immunotherapy and thus bring a higher level of safety to this innovative treatment option.

“On the front line of patient care, our nurses have been instrumental in helping us deliver immunotherapies in a safe fashion,” says Partow Kebriaei, M.D., a professor of Stem Cell Transplantation and Cellular Therapy. “Since the beginning, they’ve really led the charge in creating educational resources and collaborating with physicians and pharmacists to develop the ground rules for toxicity management and patient safety.”

Leading through innovation

Advanced practice registered nurse Sherry Adkins has seen the side effects of CAR T-cell therapy first-hand. She describes cytokine release syndrome as being similar to a severe case of the flu with high fever, fatigue and body aches. Cytokine release syndrome also can develop into a high-grade syndrome associated with life-threatening consequences. In addition to deteriorating handwriting, neurological toxicities may include confusion, difficulty speaking and seizures. 

In her work managing CAR T clinical trials, Adkins contributed to a multidisciplinary team that composed guidelines for handling those side effects, which usually are reversible if caught early.

The guidelines include a system for grading toxicities, as well as treatment plans for side effects depending upon their severity.

Partnering with informatics, Adkins and her nursing colleagues further refined the process for toxicity management by creating an automated documentation tool, or “flowsheet,” for immunotherapy-related toxicities in a patient’s electronic health record.

This allowed for standardized documentation, data reporting and tracking of immune-related toxicities.

In addition, Adkins collaborated with Informatics to create a mobile app that automates the process for grading toxicities related to CAR T therapy. Her goal is to make it as simple as possible for all clinicians to accurately grade and manage side effects.

“Clinicians have said they feel more confident in the assessment and grading of toxicities,” says Adkins, adding that physicians find the app helpful when they get a call in the middle of the night.

“They can access the app right then and there to ensure the right intervention is implemented at the right time.”

An evolving role in immunotherapy treatment

As immunotherapy treatments rapidly evolve, so do the roles of nurses.

After being involved with clinical trials and seeing Yescarta therapy become FDA-approved for CAR T patients last year, registered nurse Misha Hawkins applied her expertise to a newly created position at MD Anderson: cell therapy coordinator for lymphoma. Since then, she’s managed about 50 patients from pre- to post-treatment, keeping detailed documentation on each person.

“For 99% of infusions that happen on inpatient units, I’m here to assist the nurses and monitor patients if they start having side effects,” she says. “As nurses, we’re the eyes and ears for the physicians when they can’t be in the room, so being able to accurately describe and assess what’s happening is very critical to the care and safety of the patient.”

The documentation Hawkins records not only helps current patients, but it may help future patients, as well. She’s working with an interdisciplinary team to review the data and determine what factors cause some patients to have serious side effects, while others may experience mild or no effects.

Continuous immunotherapy education

Most MD Anderson nurses now are required to take some form of immunotherapy training.

“As immunotherapy becomes available to treat more cancer types and more patients, it’s critical for everyone to be educated on the latest developments and best practices,” says Joaquin Buitrago, a nurse educator who has pioneered nursing immunotherapy education.

Buitrago is constantly updating immunotherapy curriculum as new information comes out. He recently played a key role in ensuring nurses were properly trained as MD Anderson became the first stand-alone immune effector cell program to be accredited by the Foundation for the Accreditation of Cellular Therapy. Now, Buitrago is excited to add a new training to the curriculum – this time, focusing on life after cancer, as many immunotherapy patients are nearing the five-year survivorship milestone.

“It’s exciting to be part of a team that’s making groundbreaking advancements in cancer care,” says Buitrago. “There are no limits for nurses.”

A longer version of this story originally appeared in Messenger, MD Anderson’s quarterly publication for employees, volunteers, retirees and their families.

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