Immune checkpoint inhibitors (ICI) have revolutionized management of advanced malignancies, but predispose to toxicities such as immune-mediated diarrhea and colitis (IMDC). Systematic management strategy including early evaluation, diagnosis, treatment and close follow up of IMDC ensures high efficacy of clinical remission and reduces the delay and interruption of cancer treatment. We evaluate the quality outcomes of cancer patients in regards to IMDC and cancer after implementation of an institutional practice change following a standardized algorithm by a dedicated toxicity GI service among inpatients in a tertiary cancer hospital.
This is a retrospective quality improvement study comparing outcomes of inpatients admitted with IMDC among years 2017 and 2019. IMDC practice algorithm was implemented in 10/2017.
Our sample includes 59 and 67 patients admitted for IMDC in 2017 and 2019 respectively. Genitourinary cancer is the most frequent cancer type (36%) followed by melanoma (23%). Baseline IMDC characteristics are shown in Table-1. We found no significant differences in duration, number of ICI treatments or time from ICI exposure to IMDC as well as clinical severity of IMDC in both groups. Patients admitted in 2019 had significantly higher rates of GI consultation (82% vs 53%, p< 0.001), endoscopic evaluation (70% vs 49%,
P=0.01) and acceptance of GI medical management recommendations (55% vs 34%, P=0.015). Same group of patients more frequently received SIT as opposed to 2017 during their index hospital admission (41% vs 21%, P=0.039) which notably translated into significantly lower days to clinical remission (4 vs 10, P=0.046), hospital re-admissions (25% vs 51%, P=0.002) and recurrence of IMDC (24% vs 49%, P=0.002). Patients in 2019 had higher portion of close post discharge GI follow up compared to 2017 (50% vs 32%, P=0.038), and the dedicated IMDC GI specialist follow up contributed to better overall survival ( P=0.003, Figure-1). Conclusion:
Early evaluation, aggressive treatment and close post hospital follow up by a dedicated toxicity GI service is associated with earlier clinical remission, lower re-admissions, lower recurrence and better overall survival among inpateints with IMDC through a systematic management algorithm. We speculate the substantial improvement in quality of care and outcome of these complex cancer patients with the early involvement of an expert service specialized in this field.
GI follow up vs not Hazard ratio: 0.473 (0.285 - 0.783)
P = 0.003 Table 1::
IMDC related characteristics in patients treated for colitis in 2017 and 2019 (N=126). ICI: immune checkpoint inhibitor, IMDC: immune mediated diarrhea and colitis; IQR: interquartile range; IV: intravenous