VIDEO: Common small cell lung cancer treatment-related toxicities

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So, treatment-related toxicities can be different depending on the regimen, and I’ll broadly bucket them. In the cytotoxics I think are really the ones we have the most experience with because cytotoxics have been the backbone of our treatment in oncology — really in all of the fields of oncology has been cytotoxics for decades.

Cytotoxics we’re familiar with cytopenias, fatigue — nausea, thankfully, is not nearly the issue it used to be, but it still can be. Broadly speaking, patients end up with less energy, less appetite. Depending on the regimen, patients get alopecia, which I do think we should have a bit more attention to how that impacts patients emotionally and at least addressing that — warning them of that. I tell patients, "Hey, in 2 to 3 weeks, expect your hair to start falling out, and it can often fall out in clumps."

This can be really emotionally challenging for patients. They don’t anticipate that now all of a sudden their hair is coming out in clumps. It also is, I think, the way people picture someone with cancer — how they look — and now they kind of start looking like that, that really enhances all of that emotional expectation around the diagnosis. And I think the emotional journey of a patient with a cancer is important for us to be aware of and to kind of speak to and warn them about that alopecia. You know, but the other things I mentioned — the cytopenias, the fatigue — these are all things that we’ve monitored for decades now and I think most are pretty comfortable with. The immunotherapy drugs have a whole different toxicity profile.

Thankfully, most patients actually do really well on these checkpoint inhibitors without much in the way of side effects. Fatigue can happen. It’s not nearly to the same degree as what we see with the cytotoxics. But the other things to be really aware of are effects on adrenals. I’ve seen patients that suddenly become like a type 1 diabetic. I mean, these are really very different toxicities that can come up and really need to be addressed urgently.

More commonly, we see rash, we see diarrhea, we can see pneumonitis. Nephritis is something to be aware of. So, if creatinine is increasing, do they need to see nephrology? Do you need to consider the checkpoint inhibitor as the potential cause of that? And things like confusion, altered mental status, you know — these are not common, but they can come up and you need to be aware of this as a potential toxicity.

If this comes up and there is no other identifiable cause, then sometimes the checkpoint inhibitor might be causing it. Now with some of the newer drugs, these bispecific, trispecific T-cell engagers, we see cytokine release syndrome — that’s typically in the first infusion but can be in the second as well.

In the majority of patients, this is mild, but it can be severe. Those patients need to be managed, you know, with steroids, with IV fluids, and potentially with escalated medications or even pressors in the worst cases. Right now, these patients on trials are managed in the hospital for the first dose and often for the second dose as well. I guess the one other thing in the bispecific trials, we can see neurologic toxicities as well. That's kind of the two big ones, the cytokine release syndrome and neurologic toxicities.

But as these drugs are developed, you know, there may be other toxicities that we need to be aware of — but broadly speaking, those are kind of the buckets I’d put those in.