Managing toxicities of immune checkpoint inhibitors

Immune checkpoint inhibitors are an integral part of cancer therapy following the demonstration of substantial responses across multiple tumour types. These agents induce T-cell activation against cancer cells that have achieved immune escape. Tipping the balance of immune homeostasis can however produce undesired autoimmunity, thus giving rise to a myriad of immune-related adverse events (irAEs) that can affect every organ. Although, mostly mild and manageable, potentially life threatening irAEs may occur and require prompt recognition and management. The incidence and severity of irAEs is likely to increase with combination immunotherapies. Clinical presentations of these irAEs are varied in onset, type and severity, often leading to delays in presentation, diagnosis and appropriate management. As immuno-oncology becomes integrated into the broader anti-cancer treatment paradigm, clinicians will be required to rapidly recognise and manage a wide range of irAEs. We provide a summary of the patterns of onset, key clinical, pathologic and radiologic features of irAEs and management guidelines. Successful management of irAEs requires education for the patient, their carers and other health personnel, good patient-physician communication and multidisciplinary input from the medical oncologist and other specialist.