Abstract
About this talk
Background: Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy and are now being integrated into public oncology care in low- and middle-income countries (LMICs) such as Pakistan [1]. Their adverse effects are different from those of cytotoxic chemotherapy. Immune-related adverse events (irAEs) can occur in almost any organ, most frequently affecting the skin, gastrointestinal tract, liver, endocrine glands, and lungs. Side effects may appear weeks to months after starting treatment. Some can be fatal if untreated, such as severe colitis, pneumonitis, or adrenal crisis. In the crowded oncology wards of LMICs, the first doctor to see a patient who is deteriorating is often a resident, with no immediate access to endocrine testing, sophisticated imaging or immunotherapy experts on site.
Objective: To present a practical, resident-led framework that adapts international irAE guidance (American Society of Clinical Oncology [ASCO], European Society for Medical Oncology [ESMO], National Comprehensive Cancer Network [NCCN]) to settings where diagnostic and specialist resources are limited.
The framework, derived from frontline experience within inpatients/outpatients oncology, emergency escalation, and multidisciplinary team (MDT) planning, is split into four sections. (1) Pre-treatment screening checklist using commonly available tests, including hepatic, renal, glucose, and thyroid function tests (where available), oxygen saturation, and a documented history of symptoms. (2) Symptom-triggered recognition, with grading using the Common Terminology Criteria for Adverse Events (CTCAE) and clear thresholds for when a resident should withhold treatment, start corticosteroids, and escalate to the senior on call. (3) A systematic approach to patient/attendant counseling including clear signposting, a written alert card, and guidance regarding timely return; this is important to ensure that patients can return quickly if they have traveled far and presented to a non-oncology clinic first. (4) Working across sectors with partner institutions to achieve Sustainable Development Goal (SDG) 3 (Good Health and Well-being) and SDG 17 (Partnerships for the Goals) by ensuring there are pathways to tertiary centers.
Evaluation: This system can be used to facilitate a local pilot and audit. Time to diagnosis from symptom onset, time to senior review, percentage of patients with documentation of baseline and alert card, and unplanned admissions for irAEs. Not patient outcome data.
Conclusion: Delivery of safe immunotherapy in LMICs is as much about identifying, communicating, and referring patients at the front line as about ensuring the availability of medications. A straightforward, auditable, resident‐driven approach may bridge the gap between guideline suggestions and practical solutions to enhance patient care. This can serve as a template for collaboration between public-sector hospitals and international partners.
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