Drs Fatima Cardoso, Hope Rugo, Rebecca Dent, and Zoe Quandt discuss a multidisciplinary approach in managing immunotherapy side effects to optimize patient care in metastatic breastcancer.
or other oral agents are very helpful in combination with famotidine or ranitidine. I think they can help quite a bit.That's an interesting question. One big question that comes up for us often, which I'd love your opinions on, is, when can you re-treat? We have patients who have had immune toxicities and recovered, but they are very high risk so you really want to give the checkpoint inhibitor. You always have to balance the potential benefits if somebody's not responding.
The only other thing is I find that with some of the toxicities, like skin toxicity, sometimes people need a break. They're not severe, but patients are getting irritating and they've got a long duration of treatment. You've got those great success stories of many years. I had this patient. She had gastritis and nonspecific GI stuff. I was convinced that she was adrenal insufficient. Her biochemistry was off. I just couldn't get her to feel better. I gave her a break and I put her on steroids. She was like a new woman.
At that time, her eosinophils were 10,000. With this remarkable finding, I thought we could go ahead and treat her with steroids and did not have to obtain a colonoscopy first. Indeed, with steroids she completely recovered, and her eosinophils returned to normal. We had a slight delay in time to surgery and a slow taper off of the steroids. We did not rechallenge her with immunotherapy.
These decisions can be really challenging. It does appear that we see more immune toxicity in patients treated in the early-stage setting than in patients treated for metastatic disease, probably because of the relative immunosuppression of metastatic disease or other issues that we don't understand as well. It doesn't appear to be PD-L1 expression alone. There's something else going on, because in the metastatic setting we're treating patients in the first-line setting.
On further discussion, she was taking some multivitamins given by a friend. She was like,"Oh no, they're all natural." I said,"Stop them, get a scan, get your blood work." A week later, her liver function tests were trending down to 50% what they had been.
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