Monitoring Endocrine Complications of Immunotherapies: A QI Initiative

The advent of immunotherapy has revolutionized cancer therapy and their use has increased vastly over the past decade. Immune checkpoint inhibitors (ICI) can trigger immune-related adverse events (irAEs) affecting multiple organs. About 10% of patients receiving ICIs develop endocrine irAE and some of them, such as adrenal insufficiency and diabetic ketoacidosis can be life threatening. Many institutions do not have standardized protocols to screen for, diagnose and manage these life-threatening adverse effects. We aimed to increase awareness of these endocrine complications, develop a standardized institutional screening protocol, increase the comfort levels of oncologists diagnosing them and streamline the referral process to endocrinology for prompt management.

Methods:

After institutional IRB approval, we surveyed our oncology providers (attendings, nurse practitioners, fellows) with 13 questions assessing their knowledge, comfort levels in diagnosing and managing endocrine irAEs. We created a referral order specifically for oncology related endocrinopathies in our electronic medical records system. In addition, we developed institutional screening protocol for diagnosing endocrine irAEs based on the current society guidelines. This also included indications for referral to endocrinology & how to interpret endocrine labs. We met with oncology physicians, nurse practitioners & fellows respectively in three separate sessions to introduce the protocol and referral order set. The protocol was further disseminated on the oncology division’s website & via e-mail.

Results:

A total of 27 participants responded to the survey. Of them 10 (37%) were attending physicians, 8 (30%) nurse practitioners and 9 (33%) were fellows. Only a minority of the respondents stated that they are comfortable diagnosing (26%) and managing (15%) immunotherapy related adrenal dysfunction whereas more respondents were comfortable diagnosing (55%) and managing (56%) thyroid dysfunction. The majority (67%) of the respondents knew which immunotherapies commonly are implicated in hypophysitis but only 42% of them were aware of the next steps of its management. Only a small portion of respondents were aware of the common immunotherapies that lead to thyroid dysfunction (26%) and its natural history (35%).

In the 3 months following our intervention more patients were referred to the endocrine clinic for endocrinopathy related to immune checkpoint inhibitors use compared to before. A follow up survey will be sent out to the participants in April 2022.

Discussion/Conclusion:

Unlike other irAEs, endocrine irAEs tend to be irreversible necessitating lifelong treatment. There is usually a delay in diagnosis due to their rarity and vague symptom, especially if there is concomitant use of chemotherapy, steroids and/or opioids. If untreated, they lead to increased hospitalizations and death. This can indeed raise the healthcare costs. A standardized and practical screening protocol with regular testing can help diagnose these patients promptly, seek specialized care if needed and reduce healthcare related costs.