Cancer immunotherapy that targets immune checkpoints represent a major advance for oncology but rheumatologists will be integral to managing the autoimmune related adverse events seen in patients, an expert has told delegates.
Speaking to the limbic following his talk on the scientific mechanisms and clinical features of checkpoint inhibitors for the rheumatologist Clifton O. Bingham, Professor of Medicine at the John Hopkins Arthritis Center said musculoskeletal and rheumatic immune related adverse events were not the most common seen with cancer immunotherapy but were certainly under-recognised.
“Dermatoses, colitis, pneumonitis, thyroiditis are higher in terms of their numbers but the rheumatic manifestations are under-appreciated and we don’t have a good feel for the true impact of what these are going to be,” he said.
Professor Bingham explained that the mechanism behind the adverse reactions to checkpoint inhibitors involved the up-regulation of T cells.
“When you inhibit the checkpoints the reason they work for cancer is that they are allowing T cells to more effectively kill the cancer. But T cells mediate inflammatory processes that occur all over the body, in every organ, the joints, the salivary glands and blood vessels,” he said.
Prepare to practice on a different time scale
According to Professor Bingham managing patients experiencing adverse reactions to checkpoint inhibitors is complicated because decisions have to be made quickly.
The oncologists are interested in controlling symptoms so that the patient can continue to receive potentially life saving therapy.
“We don’t have the time we would normally have to wait for things to work… the approach has to be a little more aggressive and it’s scary for rheumatologists to think about using TNF inhibitors and IL-6 inhibitors in people who have active cancer,” he explained.
But while this is a challenge for the rheumatologist it’s also an opportunity, says Bingham.
“In seeing these adverse events we have an opportunity to learn about the biology of our normal rheumatic diseases that may help us improve and find strategies to deal with our traditional patients,” he said.
What is clear is that rheumatologists will need to work more closely with their specialist colleagues, ranging from the oncologist to the gastroenterologist, to the endocrinologist.
“Rheumatologists are uniquely positioned as adverse events rarely occur in isolation. Someone could have thyroiditis and pneumonitis and arthritis at the same time, or sequentially.
“Who better to deal with a consolation of autoimmune phenomena in multiple organs than a rheumatologist.“
Click on the link to view Professor Bingham’s slides: Bingham