HI Kathy-
Great question. When we first began to treat numerous patients with immune checkpoint inhibitors, we found out quickly that it was ideal to have a “go to” person in subspecialty practices. Notably, GI and dermatology were identified as the greatest need at the time (this was going back about 10 years now when ipilimumab was in clinical trials). Honestly, many of the relationships we now have, stemmed from fellows being “assigned” to these patients. I would often have a conversation with these individuals describing these therapies and the need to have a “go to”. Many were very intrigued by the science behind the toxicity and from there, interest and curiosity blossomed. Eventually with use of ICIs by other cancer disease groups and more and more patients were experiencing toxicity, these other groups reached out to us (the Melanoma Team) for our contacts.

Over time, we had established a contact within multiple subspecialties and developed a “List” – this eventually turned into what is now an established “Immunotherapy Severe Toxicity Team”. Often, one of the physicians would reach out to a department head, explain the need for an established contact along with the rationale. This approach,for us, was incredibly helpful.

Regarding your second question- for the most part, if we have a patient with underlying autoimmune issue- depending on what it is, we may or may not reach out. For example, for someone with underlying hypothyroidism, we “take over” the management of TFTs an replacement dosing. I make a point of noting this in the patient progress note and ensure a copy is sent to the patients provider. If it is a case of underlying UC or Crohn’s- then YES, we typically do reach out with the intended plan to co-manage these patients. Ideally, co-management is the best approach, but not always feasible.

Thanks for posting.

PS- I would add one more thing. For community practices, I believe proactive identification of subspecialty providers in the community is CRITICAL to successful outcomes for patients receiving ICIs.

We are similar to Lisa and Krista in that we have identified specialists with an interest in, and experience with, ICI immune related AE’s. This group has blossomed in recent years. It is a great concept to have a whole team identified as is done at Krista’s institution. We are not quite that organized, but it is something to work toward!

In terms of a pre-existing autoimmune condition, it depends on the severity and our comfort level managing the issue. We try to at least notify the managing team so they are aware of potential problems.