Managing Chronic Immune-Related Adverse Events in ICI-Treated Patients in the Community
The development of immune checkpoint inhibitors (ICIs) was a watershed event that has allowed for increased patient survival in a broad range of tumor types in multiple treatment settings. However, modulation of the immune response during ICI treatment can result in immune-related adverse events (irAEs), which sometimes occur even after the treatment has concluded. This has created a relatively large population of cancer survivors who have a long-term risk of irAEs. To address the emerging needs of these patients, the Society for Immunotherapy of Cancer convened an expert panel, and Dr Tessa Flores and colleagues recently published their recommendations for the monitoring and treatment of cancer survivors who have received ICI therapy. Follow-up of these patients often falls on oncologists in the community and could eventually transfer to settings outside the oncology space. In this context, awareness and communication of irAE fundamentals across treatment disciplines is essential for effective patient care.
Understanding Chronic irAEs
The authors define chronic irAEs as toxicities persisting beyond 3 months of stopping ICIs and categorize them as either chronic active (ongoing inflammation/autoimmunity) or chronic inactive (permanent tissue damage). Endocrine-related damage represents the most common chronic inactive irAE, often requiring lifelong hormone replacement therapy and potentially causing fertility challenges. Per the authors’ analyses, 83% of endocrine-related irAEs become chronic in patients receiving adjuvant anti-programmed death-1 therapy (PD-1). Long-term sequelae can also affect salivary glands, musculoskeletal tissues, peripheral nerves, and coronary arteries.
The recommendations include more-frequent monitoring during the first 3–6 months post-ICI, followed by laboratory work, physical examination, and review of systems every 6–12 months, with this level of surveillance ranging 2–5 years. However, some experts advocate for indefinite monitoring at this frequency.
Most of the experts agree that management of chronic inactive irAEs can transition from oncology to relevant specialists or primary care physicians (PCPs). Simple conditions like chronic hypothyroidism may be managed by PCPs, while complex cases such as myasthenia gravis or advanced renal insufficiency require specialist follow-up. Management of delayed or reemergent irAEs follows similar paradigms to acute irAEs, though the authors agree that decisions regarding systemic immune-modulating agents should involve the treating oncologist.
The expert panel stressed that successful care transition of patients outside of expert treatment centers requires clear communication among providers, patient engagement, medication reconciliation, comprehensive care plans documenting ICI treatment details, timely follow-up appointments, and thorough communication of all irAE-related information, including type, grade, management strategies, and resolution status.
High Level
The recommendations from the expert panel may involve dedicated survivorship programs for patients who were treated with ICIs, with structured surveillance protocols, risk-stratified monitoring pathways, and formalized multidisciplinary collaborations integrating endocrinology, rheumatology, and other specialties to restructure long-term irAE care. The experts recommend steroid-sparing immunosuppressive strategies rather than reflexive acute management protocols for chronic active irAEs. These guidelines position academic institutions to lead prospective registry development and multi-institutional research that can establish evidence-based surveillance intervals and care transition criteria for multidisciplinary physicians and PCPs.
Ground Level
On the basis of recommendations from the expert panel, management of chronic irAEs will involve coordination between academic specialists, community oncologists, multidisciplinary physicians, and PCPs. Recommendations include structured surveillance schedules with laboratory testing, physical examinations, and systems reviews, plus clear guidelines to delineate which cases may transfer to primary care vs those requiring ongoing specialist involvement. Care coordination systems will be essential for maintaining and/or improving communication among treating oncologists, specialists, and PCPs, especially when considering systemic immunosuppression for delayed or reemergent irAEs.
