Case 3: Managing Immune-Related Adverse Effects in TNBC

Hope Rugo, MD, FASCO: We’ve talked about this with some other treatments, but when we’re thinking about giving a new therapy to a patient, we always want to balance the risks and benefits. Obviously, this is about 40% of our patients, depending on the group. How do you counsel patients about immune-related adverse events? And then, what is your level of suspicion? Some of these can be hard to pick up, and it does appear to be important to understand them earlier and also to consent patients, in a way, about them. Ian, how do you talk to your patients about that?

Ian Krop, MD, PhD: I think based on the data so far, I would say that for most people, checkpoint inhibitors are well tolerated with relatively mild toxicities. But in a small subset, the toxicities are quite serious and need to be caught and treated appropriately. I think those of us who are breast cancer specialists—if you want to use that word—who haven’t used a lot of checkpoint inhibitors up until recently are learning how to use these therapies.

Fortunately, our colleagues in melanoma and thoracic oncology are very experienced with these. Our breast cancer oncologists reach out to them all the time for advice regarding how to manage the various types of toxicities. I think it’s important that patients and your nursing staff be aware that when a patient calls in with diarrhea, it’s not just, “Take some Imodium, and call me in the morning.”

Hope Rugo, MD, FASCO: Yes. I had a patient recently diagnosed with adrenal insufficiency—or maybe central, because we didn’t get an ACTH [adrenocorticotropic hormone]—who presented feeling lightheaded. The woman was weak and tired, which is your entire practice of patients with metastatic disease who are older. This woman weighs about 110 pounds. When she got admitted, they were calling me from the outside hospital about it. Suddenly I was like, “Oh wait, can you check her cortisol levels?” She had 0 cortisol. So it is important for us to keep that in mind. It’s interesting and can be difficult.

Transcript edited for clarity.