Introduction: Immune checkpoint therapies are novel cancer agents, which have been associated with the development of endocrine toxicities. ESMO and SfE endorsed management guidelines have been helpful for the early recognition of these toxicities, but in clinical practice, having early access to specialist endocrine advice improves the decision making and effective use of these agents when toxicities occur. In response to need we developed an easily accessible interdisciplinary support team to provide prompt guidance for oncologists using immunotherapies. An electronic email based referral was set up in March 2018 to provide high quality support to the oncology team, with the aim of having a dedicated specialist team with rapid response time.
Methods: We conducted a retrospective audit of the management of endocrine toxicities at our centre from 2014 to 2019. All patients treated with Immune checkpoint therapy (CTLA4, PD1, PDL1) were included for the audit, while patients with pre-existing endocrine diagnosis or incomplete clinical outcome data were excluded from the final analysis. Time to endocrine advice was noted before and after March 2018.
Results: Out of 356 patients included in the final audit 87 patients were identified to have endocrine toxicities (approx. 25%). Thyroid dysfunction was the most endocrinopathy, seen in 19.6% of total cases, followed by hypophysitis (4.2%). There were 2 cases of Graves disease and 2 new type 1DM. Most patients with toxicities were found to have Common Terminology Criteria for Adverse Events (CTCAE) toxicity grade 1 or 2 (87.3%) while 11 (12.6%) cases had grade 3 toxicity or above. Between 2014 to Feb 2018, the mean time to endocrine advice/ assessment was 9.7 days in cases with CTCAE toxicity grade 1 or 2, while this improved to 3.7 days after March 2018. Time to clinical input and urgent inperson review in CTCAE grade 3 or 4 was found have improved from 73 days to 20 days after the referral link was set up, with all patients receiving a virtual plan within 24 hours.
Conclusion: Simple governance steps of setting up 1. A Local Management Guideline, and 2. A virtually supported e-referral system, enabled improvement in the quality of care of endocrine toxicities. This did not need substantial additional resource and the majority of patients could continue uninterrupted immunotherapy.
18 - 21 May 2019
European Society of Endocrinology