Partnering With Local Hospitals to Manage CRS and ICANS From Bispecific Antibodies

Ralph V. Boccia, MD, FACP, founder of The Center for Cancer and Blood Disorders, clinical associate professor at MedStar Georgetown University Hospital, and medical director of the International Oncology Network Clinical Research Program, discussed how partnerships with local hospitals can support outpatient administration of bispecific antibodies and what training emergency department and inpatient teams need to manage cytokine release syndrome (CRS) and immune effector cell–associated neurotoxicity syndrome (ICANS).

Boccia explained that most hospitals are reluctant to admit patients for observation, estimating that more than 90% of hematologists and oncologists lack a hospital willing to do so. Instead, his practice manages toxicities in the clinic when safe and sends patients to the hospital when needed, then joins the hospital care team. He emphasized educating emergency department, hospitalist, intensive care, and pharmacy staff, and ensuring tocilizumab (Actemra) is available to reverse CRS, comparing the approach to how oncologists have long managed neutropenic fever and immune-related adverse events.

Transcript:

Boccia: Historically, hospitals in this country, because of diagnosis-related groups, do not like to admit patients for observation, and depending on the cost of these very expensive drugs, they don’t want to incur the cost of the drugs themselves. Some of my colleagues are fortunate enough to practice in areas where the hospitals want to partner and be a part of this, but that’s unique. In my role as chief medical officer for ION, the International Oncology Network, I have exposure to hematologists and oncologists across the country, and we have enough meetings that we share our experiences. Probably more than 90% of hematologists and oncologists don’t have a hospital that is willing to admit their patients for observation.

What we have always done is practice in a way where we give any form of therapy as an outpatient if we feel we can do so safely. As medical oncologists and hematologists, we have known for years that the drugs we give can cause toxicities and adverse effects, and we have to be prepared to deal with them. The way we deal with them is either we bring patients into the clinic and manage them there, if that’s safe and the right thing to do, or we send them to the hospital and become a part of the hospital care team. Then you have to educate the different hospital staffs: the emergency department, the hospitalist internal medicine services, the intensive care unit, and the pharmacists. As long as you get them on board and you have tocilizumab to reverse the effects of CRS, that’s the way we do it.

That’s the same way we’ve been doing things all along. A patient on cytotoxic chemotherapy can get a neutropenic fever. They go to the hospital, and we share in the care there. This is no different. Yes, we have tocilizumab, whereas for sepsis we’re not usually using tocilizumab, but you have the tools to treat the toxicities of the therapies you’re using at the time. We’re now flooded with immuno-oncology drugs and immune-related adverse events, and we learned how to deal with those over the last 10 years. Now we’re learning how to deal with CRS, ICANS, non-ICANS neurologic effects, and some of the autoimmune effects. Those are things we’re building into the repertoire and teaching our colleagues, and they’re learning themselves. If we have to admit a patient, the hospital teams get to share in that care, and they learn as well.