Initiative for Managing Adverse Events of Immunotherapy Leads to Clinical Practice Changes at MD Anderson

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The inaugural MD Anderson Clinical Education Symposium on Immunotherapy Toxicity Management (IOTOX) welcomed more than 250 international attendees, both virtually and in person at The University of Texas MD Anderson Cancer Center in Houston on December 3, 2022. The symposium focused on bringing the worldwide oncologic community together to exchange knowledge on immunotherapy toxicity and to promote further collaboration among and between cancer centers to improve patient care and outcomes.

“In 2011, MD Anderson had a few hundred patients on immune checkpoint inhibitors treatment plans. Now, 11 years later, we’re looking at more than 4,000 patients.”

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As the volume of patients on immune checkpoint inhibitors has rapidly increased over the years, immunotherapy toxicity has become a mounting obstacle, said Sarah Fayle, MS, MA, Director, Division of Internal Medicine Administration at MD Anderson, who provided an overview of the clinical practice changes taking place as part of the MD Anderson IOTOX initiative. As a result, IOTOX care is currently recognized as an institutional priority at MD Anderson.

“In 2011, MD Anderson had a few hundred patients on immune checkpoint inhibitors treatment plans,” she noted. “Now, 11 years later, we’re looking at more than 4,000 patients.”

Additionally, based on trends measured over the past decade, the projected volume of patients receiving immune checkpoint inhibitors will increase by an additional one-third by 2025. “So, it’s clear this is an extremely important issue,” Ms. Fayle added.

Optimizing Clinical Practice

“For more than a decade, immunotherapy has revolutionized cancer treatment,” said Ellen Manzullo, MD, Deputy Division Head of Internal Medicine at MD Anderson. “But while we’re providing high efficacy and achieving cancer response and remission, immunotherapy is often limited by immune-related toxicities, leading to increased morbidity and mortality. The management of these toxicities has been a major obstacle for clinicians, and it requires a multi- and interdisciplinary approach to provide comprehensive care.”

“The management of immune-related toxicities has been a major obstacle for clinicians, and it requires a multi- and interdisciplinary approach to provide comprehensive care.”

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As the largest tertiary cancer center in the country, MD Anderson currently faces the same challenges as the rest of the world. Given its high and ever-growing volume of patients on immunotherapy, coupled with specialized clinical care teams managing organ toxicities, the institution has recognized the urgent and critical need to optimize clinical practice. To create the IOTOX initiative at MD Anderson, they needed leadership, patient education, physician education, standardized management, EPIC optimization, and a comprehensive website, Ms. Fayle explained.

To address how best to treat patients with immunotherapy-related toxicities, the Internal Medicine Division collaborated with the Cancer Medicine Division (along with other divisions at MD Anderson) to create the IOTOX Working Group, which leads the MD Anderson IOTOX initiative. The IOTOX initiative was launched in 2019, with the working group assembled shortly thereafter in 2020.

Patient and Provider IOTOX Resources

On the MD Anderson external website, patient education materials have been developed on 15 different organ toxicities associated with immunotherapy. “These resources are available to patients but also to anyone who’s interested in understanding immunotherapy-related toxicity,” Ms. Fayle noted.

The website also offers a lecture series calendar, a patient wallet card, and detailed guidelines with accompanying educational videos. These resources are automatically released to patients via MyChart when a toxicity treatment plan is initiated.

The patient IOTOX alert wallet card is automatically released to patients on initiation of immune checkpoint inhibitors, providing them with a self-alert while also serving as a communication tool between community physicians and MD Anderson oncologists.

A monthly IOTOX Educational Lecture Series provides continuing medical education for providers, allows for knowledge exchange in the management of immunotherapy toxicities among medical teams, and provides a challenging case discussion forum within the MD Anderson network and with external academic members.

“We have a group discussion on literature review, and it’s allowed us to create a library of recorded presentations on our guideline recommendations,” Ms. Fayle stated.

The IOTOX Publication and Clinical Trial Database offers a summary of immunotherapy toxicity–related publications from MD Anderson groups (more than 229 collected in the past 3 years) and a registration of active immunotherapy toxicities–related prospective clinical trials. This provides a platform to identify appropriate specialists with expertise in available studies within the institution.

On the internal IOTOX webpage, guidelines are available on 15 organ toxicities. Of them, three have moved into algorithm status and have been officially released from MD Anderson for public use (gastrointestinal, kidney, and endocrine toxicities). There are plans to move the remaining 12 to the external website in the coming years.

“At MD Anderson, all of our guidelines are considered internal until they move to an external capacity,” Ms. Fayle explained. “At that point, anyone in the public can download them from our external website.”

Additionally, an IOTOX web app reflects all of MD Anderson’s current guidelines and algorithms in an easily accessible format, in which a provider can indicate the status of a patient and receive next steps regarding the said guidelines.

IOTOX EPIC optimization has been established and offers the following features:

  • Ambulatory and inpatient evaluation SmartSets, which offer a standardized comprehensive evaluation package for each organ toxicity
  • EPIC “express lanes” with a prepackaged organ toxicity clinic workflow that allows providers to move a patient quickly through the process
  • “Smart phrases” to standardize documentation on evaluation
  • An IOTOX eCONSULT request form that creates an autopopulated referral sheet for streamlined referral requests

Follow-up after hospital discharge, which establishes an EPIC workflow for 2 weeks after hospital discharge for patients who are moving from inpatient to outpatient while minimizing immunotherapy toxicities–related readmission.

Additional Highlights From the IOTOX Symposium

Highlights from the 1-day program also included two keynote speeches. Douglas Johnson, MD, Associate Professor and Clinical Director of Melanoma at Vanderbilt University Medical Center, provided an overview of approaches to the clinical management of immune-related adverse events. Dr. Johnson’s research focuses on optimizing and extending the use of novel immune and targeted therapies in different cancers to identify markers of response and resistance. Julie Brahmer, MD, Director of Thoracic Oncology at Johns Hopkins Kimmel Cancer Center, spoke on current challenges in the treatment of immune-related adverse events, as well as future directions in terms of research and therapies.

The symposium featured more than 30 speakers and session moderators who discussed common and rare immune-related adverse events—providing comprehensive reviews of more than 10 organ systems and their associated toxicities related to immunotherapy—as well as multidisciplinary management strategies.

Yinghong (Mimi) Wang, MD, PhD, Associate Professor of Gastroenterology, Hepatology & Nutrition at MD Anderson, and Chair of the MD Anderson IOTOX working group, commented on the success of the symposium in its ability to disseminate knowledge and experience with the rest of the oncology community.

“From this educational event, our institutional IOTOX management strategy has received high recognition as the pioneer in this field among attendees, especially the guest speakers who serve as chairs and key members of ASCO, NCCN [National Comprehensive Cancer Network], SITC [Society for Immunotherapy of Cancer], and ESMO [European Society for Medical Oncology],” Dr. Wang said. “We feel compelled and honored to share our new IOTOX management model and the other accomplishments in optimizing clinical practice at both scientific and operational levels from our institutional IOTOX working group over the past 3 years, with the rest of the community around the world.” 

DISCLOSURE: Ms. Fayle and Dr. Manzullo reported no conflicts of interest. Dr. Wang has served as a consultant to Sorriso Pharmaceuticals, Mabquest, Sanarentero, AzurRx, and Illya Pharma and has received research grant funding from Gateway, Adopt a Scientist, Moonshot, Health and Environmental Sciences Institute, and Sabin Fellowship.


The inaugural Immunotherapy Organ Toxicity (IOTOX) Education Symposium took place at The University of Texas MD Anderson Cancer Center in Houston on December 3, 2022. This new symposium provided a comprehensive review of more than 10 organ systems and associated toxicities related to immunotherapy. The event was joined by 5 external guest speakers who are nationally recognized as immunotherapy organ toxicity guideline authors, as well as more than 30 MD Anderson speakers and session moderators, all of whom have a great deal of knowledge and experience with patients experiencing these toxicities. It brought the worldwide oncologic community together to exchange knowledge on immunotherapy organ toxicity and promoted future collaborations among and between academic centers to further improve patient care and outcomes. For more information about IOTOX, visit

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.