immunotherapy complications & nutritional challenges · the royal marsden an example of...
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The Royal Marsden
Immunotherapy.June2019 1
Immunotherapy Complications & Nutritional Challenges
Lucy Eldridge
Dietetic Team Leader, Royal Marsden NHS Foundation Trust
Chair of BDA Oncology Specialist Group
June 2019
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The Royal Marsden
Outline of session
1. What is immunotherapy
2. What are the side effects of immunotherapy
3. GI toxicity
4. Case study
5. Future recommendations
Immunotherapy.June20192
Best Supportive
Care
Surgery
Chemotherapy
Immunotherapy
Radiotherapy
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Immunotherapy.June20193
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Nutrition is part of the cancer pathway
– Malnutrition can occur at any
stage
– Good nutrition has a role
throughout the pathway
– Arends J, et al. Clin Nutr 2017;36:11–48
Nutrition is important.Dec184
Arends et al, 2016
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The Royal Marsden
Prevalence of overt malnutrition by cancer site: PreMiO study
Malnutrition defined as MNA score <17 (N=1925); M0 = stage I–III, M1 = stage IV
Muscaritoli M, et al. Oncotarget 2017;8:79884–96.
5
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The Royal Marsden
Weight loss & symptom burden at diagnosis
151 new patients (122 GI & 29 Lung) – symptom burden at diagnosis
33% lost ≥10% body weight in 6/12 prior to presentation
Khalid U, et al. Support Care Cancer 2007;15:39–46.
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The Royal Marsden
Fearon K, et al. Lancet Oncol 2011;12:489–95.
7
Cancer Cachexia
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Identification of nutritional issues is vital
Nutrition is
important.Dec18
8
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The Royal Marsden
What is immunotherapy?
• Cancer immunotherapy—treatments that harness and enhance the innate powers of the immune system to fight cancer (Cancer Research, 2019)
• Immune checkpoint inhibitor therapies are a novel group of monoclonal antibodies with a proven effectiveness in a wide range of malignancies:
• Melanoma
• Renal cell carcinoma
• Non-small-cell lung cancer
• Urothelial carcinoma
• Hodgkin lymphoma
• Under investigation at present is their use in:
• Gastrointestinal
• Head and neck
Immunotherapy.June20199
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Immunotherapy.June201910
www.roche.com
1. Mutations in cancer cells
cause the release of
antigens
2. Immune cells that
specialise in locating the
antigens & taking to T cells
3. T cells become primed by
the antigens & so begins
the immune response
against cancer cells
4. T cells travel back to the
tumour
5. T cells infiltrate the
tumour to attack it
6. T cells recognise the
cancer cell due to the
antigens
7. T cells destroy the cancer
cells leading to cell death
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The Royal Marsden
An example of immunotherapy treatment: Nivolumab
• a fully human IgG4 PD-1 immune checkpoint inhibitor
antibody
• a type of immunotherapy drug designed to target the PD-1
Protein receptor.
• Cancer cells send a signal to the PD-1 via the PD-L1 molecule,
tricking the T-cell into recognizing the cancer cell as normal.
• Designed to disrupt that signal &
expose the cancer cell to the immune
system.
Immunotherapy.June201911
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The Royal Marsden
Which patient will respond? (Cogdill et al, 2017)
Immunotherapy.June201912
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The Royal Marsden
Toxicity related to immunotherapy
Immune cell rich
barrier tissues:
– Lungs: pneumonitis
– Gut: Colitis
– Skin: rashes
– Many other –itises
High dose steroids
Infliximab
Autoimmune prone
tissues:
– Endocrine system:
Subclinical hypothyroidism
Fulminant type 1 DM
Hypoadrenalism
Immunotherapy.June201913
Immune checkpoint therapy: bystander tissue damage (immune cell
rich), tissues prone to auto immune attack
Josephs , 2018
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The Royal Marsden
Management of toxicities from immunotherapy: ESMO Clinical Practice Guidelines for diagnosis, treatment
and follow-up†
Haanen et al. Ann Oncol. 2017;28(suppl_4):iv119-iv142. doi:10.1093/annonc/mdx225
Toxicity related to immunotherapy
Immunotherapy.June201914
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From: Management of toxicities from immunotherapy: ESMO Clinical Practice Guidelines for
diagnosis, treatment and follow-upHaanen et al Ann Oncol. 2018;29(Supplement_4):iv264-iv266. doi:10.1093/annonc/mdy162
Gastrointestinal toxicity guide (ESMO, 2018)Immunotherapy.June201915
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The Royal Marsden
Grading of Diarrhoea & Colitis (Marin-Acevedo et al, 2018 & Haanen et al, 2018)
Immunotherapy.June201916
Gra
deDiarrhoea Colitis Suggested diet but
?evidence
1 Increase of <4 stools per
day (over baseline (OB))
Asymptomatic
(pathological or
radiographic findings
only
To avoid high fibre &
lactose for 2 weeks
2 Increase of 4-6 stools per
day OB; not interfering with
activities of daily living
(ADL)
Abdominal pain; mucus
or blood in stool
As above for 3 days –
if no improvement
follow the advice for
G3
3 Increase of ≥7 stools per
day OB; incontinence;
hospitalisation; interfering
with ADL
Abdominal pain; fever;
change in bowel habits
with ileus; peritoneal
signs
Refer to
gastroenterology & rv
diet: NBM/clear fluids/
PN
4 Life threatening
consequences (eg.
Hemodynamic collapse)
Life threatening
consequences (eg.
Perforation, bleeding,
ischemia, necrosis,
toxic megacolon)
As above
5 Death Death
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The Royal Marsden Immunotherapy.June201917
Jo’s story
– 51 year old man
– Diagnosed 2009 Stage IV Mucosal melanoma
– Surgery
– 2012 metastatic disease liver & lungs
– Treated with Temozolomide
– May 2013 commenced CHECKMATE037 trial
– March 2015 continues Nivolumab two-weekly
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The Royal Marsden
Nivolumab
• a fully human IgG4 PD-1 immune checkpoint inhibitor
antibody
• a type of immunotherapy drug designed to target the PD-1
Protein receptor.
• Cancer cells send a signal to the PD-1 via the PD-L1 molecule,
tricking the T-cell into recognizing the cancer cell as normal.
• Designed to disrupt that signal &
expose the cancer cell to the immune
system.
Immunotherapy.June201918
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The Royal Marsden
Aug 2016 diagnosed with immune related colitis
Admitted due to:
1) Admitted with grade 3 colitis secondary to immunotherapy • Severe abdominal pain• Change in bowel habits
2) Portal vein thrombosis
3) Deranged LFTs - improving
4) Steroid induced hyperglycemia - started on Insulotard
5) Thrombocytopaenia
6) Leg weakness - likely steroid induced proximal myopathy
Immunotherapy.June201919
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Dietetic Input
– Early Sept 2016
• First met due to Steroid
Induced Diabetes
• Lost 10kg due to
diarrhoea related colitis
• Asked to keep a food &
bowel diary
• Self restricting some
fibre
• History of IBS which he
self managed
• Given refined sugar
advice
– Diet History
– BF Rice Krispies & milk
– Toast & butter
– L Soup, ham sandwich, plain low fat yogurt
– EM Fish & cream potato
– banana
Immunotherapy.June201920
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The Royal Marsden
Dietetic Input
30th Sept
• commenced on PN due to D+ to allow for bowel rest• Required a bespoke bag due to Mg needs and to reduce Na
7th Oct• reduced PN due to concerns over LFT’s (note: were deranged from
admission)
• advised Soft diet & concentrated supplements
• Steroids increased due to colitis
Immunotherapy.June201921
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The Royal Marsden
PN and immunotherapy colitis
Limited evidence although included in algorithms such as the ESMO
guidelines (2018)
A review of IBD & acute colitis literature suggests:
• PN fails to show benefits compared to enteral feeding
• Increased adverse effects with PN
• Increased length of stay
• Increased costs
(Pham et al, 2015; Seo et al, 1999; Triantafillidis et al, 2013)
Immunotherapy.June201922
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The Royal Marsden
Dietetic Input
October 2016
• Muscle atrophy increases
• emphasis on high protein foods
• doesn’t want any supplements
• cautious about food
Immunotherapy.June201923
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Energy Requirements
– A 80kg patient would require
2000 – 2400kcals
Nutritional Support November 201624
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The Royal Marsden
Increasing fat energy intake
Food Kcals
1 tablespoon olive oil 135
1 tablespoon clotted cream 115
1 tablespoon peanut butter 130
1 tablespoon mayonnaise 100
1 tablespoon French dressing 70
1 teaspoon butter 75
1 tablespoon Greek yogurt 45
Nutritional Support November 201625
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Fat:CHO Ratio’s
Nutritional Support November 201626
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Protein Requirements
– A 80kg patient would
require 80 – 120g
protein per day
(potential 160g/day)
Nutritional Support November 201627
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Oral Nutritional interventions
Nutritional Support November 201628
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The Royal Marsden
Dietetic Input
Oct 16 – June 17
• Remained an In patient, social issues, requires high input.
• Intensive rehabilitation – due to muscle atrophy secondary to steroid
use for colitis
June 2017
• Eating well
• Bowels opening 3-5 times a day but not indicative of malabsorbtion
• Further weight loss
Immunotherapy.June201929
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The Royal Marsden
Dietetic Input
Early July 2017
Discussions between teams re PN – differing opinions.
Consideration for surgical intervention
Ended up on PN and following a “light diet”
Mid July 2017
Open total Colectomy & end-ileostomy
Weaned off PN
Eating & drinking well
Given salt advise
Immunotherapy.June201930
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The Royal Marsden
Today – October 2018
• Latest MRI shows no evidence of relapse or active disease
• Finally home – a year in hospital & a further year in rehabilitation
Nutritionally
• Weight stable
• Normal appetite
• Some diarrhoea but manageable
Immunotherapy.June201931
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The Royal Marsden
Reflections….
• Complex series of events: • compromised nutritional status, • steroid induced diabetes & muscle atrophy, • impact of immunotherapy on body composition combined with colitis
• Low fibre guidance is not conclusive – in the literature guidance is vague especially for moderate to severe colitis• Descriptions used for fibre restrictions need clarity:
• Light, soft, low etc.
• Melanoma is not routinely on a dietitians radar
Immunotherapy.June201932
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The Royal Marsden
What food means…
Nutrition is important.Dec1833
Harmful
Hope
Control
Comfort
FearEnjoyment
Anxiety
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The Royal Marsden
Coming soon…
• It is recognized that there is a need for national guidelines for GI toxicity. A group of gastroenterologists have formed a working party led by Dr Nick Powell.
• He has invited the Oncology Special Interest Group (BDA) to add a dietary component to the guidelines
• They also acknowledge the need for nutrition research and opportunities are being explored
Immunotherapy.June201934
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The Royal Marsden
Recommendations (awaiting publishing, 2019):
1. Aim should be to maintain nutritional status
2. Screening with a cancer specific validated screening tool.
3. All those at risk of malnutrition and or those with Grade 3 diarrhoea, that is impacting on their weight and or nutritional status, must referred to an Registered Dietitian with expertise in oncology.
4. The aim would be to meet energy and protein needs as defined by Arends et al, 2016, ideally through a balanced oral dietary approach.
5. To follow the guidance for IBD (Forbes et al, 2017), that is to eat a varied diet to meet their energy and nutrient requirements, including dietary fibre
6. Where oral intake cannot be maintained consideration must be made for enteral or parenteral nutrition.
Immunotherapy.June201935
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The Royal Marsden
Ideas for research
• the use of pre & probiotics;
• use of PN to allow bowel rest;
• use of modified diets including elemental, a low
FODMAPS diet
• manipulation of dietary fibre intake.
Immunotherapy.June201936
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The Royal Marsden
Probiotics & Immunotherapy
Preliminary study from MD Anderson looked at the link between immunotherapy, the gut
microbiome, and diet in people with cancer (113 participants)
• Completed a lifestyle survey on their diet, medication, and use of supplements.
• Analysed their fecal samples to build up a picture of each individual gut microbiome.
• Tracked treatment progress.
Results:
1. Taking over-the-counter probiotic supplements correlated with a 70 percent lower
chance of responding to checkpoint inhibitor immunotherapy. Almost half (42 percent)
of the participants reported taking such supplements.
2. Dietary choices appeared to have an impact. People who ate a high-fiber diet were five times
as likely to respond to immunotherapy and had more bacteria linked to a positive response.
https://www.medicalnewstoday.com/articles/324886.php
Immunotherapy.June201937
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The Royal Marsden
Probiotics
This is a very small study the guidance at present is:
Not to take probiotics whilst on immunotherapy
Immunotherapy.June201938
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The Royal Marsden
Conclusions
• Need for an MDT approach
• Gain greater understanding of the nutritional needs of
each individual – most with GI symptoms would benefit
from some form of nutritional guidance from a qualified
health professional
• Lack of evidence/agreement regarding the appropriate
nutritional intervention
Immunotherapy.June201939