THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



Rheumatologists have role to play in ensuring patients get the most out of immunotherapy

Laura Cappelli, MD
Laura Cappelli, MD

The development of immune checkpoint inhibitors (ICI) to fight cancer has given oncologists a powerful tool against a host of malignancies.

But as use of ICIs increases, so does the number of patients experiencing rheumatologic immune-related adverse events. The session Checkpoint Inhibitors: Past, Present and Future will talk about the evaluation and management of the different syndromes that can occur related to this particular form of immunotherapy. The first airing, complete with a live question and answer session, will take place from 3 – 4 p.m. Monday, Nov. 9, and registered attendees can watch a replay through Wednesday, March 11, 2021, with 24/7 online video access.

Jedd Wolchok, MD, Chief of the Immuno-Oncology Service and The Lloyd J. Old Chair in Clinical Investigation, Memorial Sloan Kettering Cancer Center, will provide the perspective from the oncology world. Dr. Wolchok studies innovative immunotherapy strategies and has been principal investigator on many pivotal clinical trials, including the approval of ipilimumab for advanced melanoma. Laura Cappelli, MD, Assistant Professor of Medicine at the Johns Hopkins University School of Medicine, Division of Rheumatology, will share the rheumatologist’s perspective.

This multidisciplinary session will promote the multidisciplinary approach needed to provide care for cancer patients who often present with inflammatory arthritis, polymyalgia rheumatica-like symptoms, myositis, and, more rarely, vasculitis, or eosinophilic fasciitis.

“We are trying to thread the needle of managing their side effects without negatively impacting the immune system response against the tumor,” Dr. Cappelli said. “And that’s what makes it difficult to manage these patients in practice.”

Dr. Wolchok plans on reviewing the use ICIs and highlighting clinical data in terms of anti-cancer activity and toxicity.

ICIs allow the immune system to become more robustly activated in its attempt to control the cancer. ICIs have modest activity as single agents in most cancers, Dr. Wolchok noted, but research shows that ICIs can combine with other ICIs, chemotherapy, or other cancer therapies to provide more patients with favorable clinical outcomes.

“All of this has to be kept in the context of the toxicities, which are very reminiscent of autoimmune disease,” Dr. Wolchok said. “So, the ability to manage those toxicities represents a unique opportunity for oncologists to collaborate with rheumatologists, and also gastroenterologists, endocrinologists and other medical subspecialists who know more about these autoimmune syndromes than oncologists do.”

Rheumatologists can reassure patients that they can help the rheumatologic symptoms without interfering in the cancer treatment. Clinicians hesitated to co-treat patients with immunosuppression when ICIs first started as therapy, but in a span of about five years additional research shows that many patients who develop immune-related adverse events can manage that disease without stopping immunotherapy either temporarily or permanently.

Oncologists also have started to refer patients to rheumatologists earlier in the course of diseases such as inflammatory arthritis, when management of symptoms is easier.

The understanding of connections between cancer and autoimmunity has grown over the years, Dr. Cappelli said, especially as it relates to tumor immunology and whether responses to tumors could contribute to the development of autoimmune disease. And an ongoing trial looking at the use of nivolumab for cancer in patients with preexisting autoimmune disease is helping gather important prospective safety data for rheumatology patients in case they develop cancer and need checkpoint inhibitors.

“There are a lot of ways that we in rheumatology intersect with our oncology colleagues, and immune checkpoint inhibitors have brought to the foreground what we’re clinically dealing with,” Dr. Cappelli said. “But I think from a research standpoint, there are many connections between cancer and autoimmunity that are ripe for exploration.”

Dr. Cappelli also will discuss one of the more severe complications of ICIs, myositis. Patients who develop myositis from ICIs also have a chance to develop myasthenia gravis or myocarditis, both potentially life-threating manifestations. Rheumatologists need to know how to evaluate for both for ICI patients referred for myositis.