Toxicities of novel antineoplastic therapies

Recent innovation and discovery in oncologic and pharmaceutical industry have led to many new efficacious cancer therapeutics. In the past decade, the US Food and Drug Administration approved, at an accelerated pace, over a hundred novel agents in oncologic alone. These rapid advances present important challenges to emergency physicians, relating to knowledge about the timing, sequence, duration, and treatment of disease processes, as well as prompt identification of the risk profiles of new cancer therapies that may present with acute toxicities, in oncologic centers and non-oncologic centers as well. In the presence of a large gap between the emergency medicine literature and these rapid advances in oncologic, emergency physicians are not well acquainted with the diagnosis and management of the emerging adverse effects of the new cancer therapeutics. In this chapter, we discuss these issues, offering suggestions for diagnosis and management in the emergency department setting. In particular, we address differentiation syndrome, sinusoidal occlusion syndrome, QT prolongation, infusion-related reactions, cytokine release syndrome due to chimeric antigen receptor (CAR)-T-cell therapy, immune effector cell-associated neurotoxicity syndrome, and immune-related adverse events associated with immune checkpoint inhibitor therapy (affecting multiple organ systems and hemophagocytic lymphohistiocytosis). Novel cancer therapies offer the promise to improve outcomes and survival of cancer patients, at the price of unique toxicities that can be devastating, and emergency physicians are at the front line to intervene and mitigate these problems.