Abstract
The use of immune checkpoint inhibitors (CPIs) for cancer treatment has risen. CPIs cause immune activation, which can adversely cause inflammation in healthy tissues, including joints. Up-to 40% of patients report arthralgia, with CPI-induced inflammatory arthritis occurring in up to 7%. Many require corticosteroids and in severe cases, CPI may be discontinued. Prompt rheumatology assessment is essential for diagnosis and specialist management, potentially reducing corticosteroid burden, and preventing CPI interruption. We aimed to improve access to rheumatology assessment by establishing a dedicated clinical service.
We analysed patients referred to rheumatology at Leeds Teaching Hospitals Trust (LTHT) between 2020-2021 prescribed CPIs (pembrolizumab, ipilimumab, nivolumab, durvalumab, atezolizumab, avelumab, cemiplimab, tremelimumab). Patients under rheumatology with pre-existing inflammatory arthritis were excluded. Patient records were assessed for time taken between initial CPI-related arthralgia documentation to rheumatology referral and clinic review, and whether corticosteroids were started before rheumatologist assessment. In April 2022, we set up a dedicated service for CPI-related arthralgia/arthritis (‘intervention’) via direct patient referral to a rheumatology registrar with two dedicated clinic slots per week. We examined patient records seen between 2022-2024 to evaluate access to specialist care following this intervention. Chi-square tests were used for comparisons.
10 of 15 patients (67%) pre-intervention started corticosteroids from oncology before rheumatology review, with a median delay of 48 days from referral to rheumatology clinic. Post-intervention, only 6/29 (21%) patients started corticosteroids before rheumatology assessment (table 1). The median delay between referral to review in our dedicated service was 19 days, significantly improved from the pre-intervention group(p < 0.05). The delay between documented arthralgia to rheumatology referral from oncology was over 30 days in both groups.
Our dedicated clinical service has improved access to specialist care and significantly reduced delays to rheumatology review. With improved access, we demonstrate a significant reduction in corticosteroid initiation before specialist review, facilitating earlier diagnosis and reducing steroid burden. However, delay between patients reporting arthralgia to rheumatology referral remains >30 days, highlighting the need for improved education for oncologists. These data highlight the value of a direct access clinical pathway in lowering corticosteroid exposure and ensuring prompt rheumatological assessment for these patients.
B. Sethi: None. K. Harnden: None. K. Mankia: None.
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