Although using immunotherapy to treat melanoma typically results in fewer side effects that are less severe than those associated with other forms of cancer treatment, some side effects still can occur, and some can be severe. Not everyone will experience the same side effects with immunotherapy, and some people may not experience any side effects at all. Symptoms can vary in severity and differ according to the type of immunotherapy (see Table 1).
Many side effects can be managed with over-the-counter medications. However, if your symptoms are severe, it is important to contact your health care professional immediately.
With immunotherapy, side effects can indicate that your immune system is too active and could put you at risk for an autoimmune disorder. If treated early, these symptoms can be corrected with corticosteroid medications and your treatment can be resumed at a later date.
Your doctor may be able to adjust the immunotherapy medication to prevent future autoimmunity if the symptoms are noted early enough. So, it is important for you to communicate with your doctor’s office frequently so they can help monitor you and your symptoms. Seek treatment immediately for any medical emergencies, including high fever, severe abdominal pain or shortness of breath.
Common side effects associated with immunotherapy include the following.
Immune-mediated Adverse Reactions
Immune-mediated adverse reactions have not been a commonly reported side effect of immunotherapy, but they can occur with certain types of immunotherapy medications.
This type of reaction, which occurs when the immune system is overstimulated by the treatment, may cause inflammation, swelling or redness, which may or may not be painful. Some organs may become inflamed, which can lead to hepatitis (liver), dermatitis (skin) and enterocolitis (small intestine, colon). It can also damage the nerves and endocrine glands. One of the more common side effects with the checkpoint inhibitors and cytokines is a change in the function of the thyroid gland. This can sometimes be corrected with thyroid replacement medication. Your doctor will likely monitor your thyroid function through a blood test.
Talk to your doctor about how to recognize an immune-mediated adverse reaction, as some side effects may not produce obvious symptoms you can feel. These reactions will need to be confirmed through blood tests. It is important to tell your doctor if you think you may have this reaction so that you can receive treatment as soon as possible to avoid any life-threatening complications.
Fatigue
Fatigue is the most common side effect reported in multiple immunotherapies. Fatigue and feeling tired are often found in the class of therapies known as checkpoint inhibitors, cytokines and oncolytic virus therapy.
The fatigue associated with cancer is different than simply feeling tired because you haven’t had enough rest. Fatigue from cancer or its treatment may cause you to feel physically, emotionally or mentally tired and exhausted. If you begin to miss work, spend less time with friends and family, sleep more, have difficulty remembering things or can’t think clearly, talk with your doctor or nurse.
An evaluation of your fatigue level throughout your treatment and recovery, including doing a distress screening, is recommended.
Flu-like Symptoms
Flu-like symptoms, such as fever, chills, aches, headache, drowsiness, nausea, vomiting, loss of appetite and low blood cell counts, can occur if your treatment includes cytokines or oncolytic virus therapy. These symptoms can range from mild to severe.
To manage flu-like symptoms, get enough rest. Ask your doctor if you can take acetaminophen. Consider taking any oral treatments at bedtime to help minimize symptoms, if your doctor approves. If a cough develops, drink plenty of water and other fluids to keep your throat moist.
Diarrhea
Diarrhea is a common side effect with the checkpoint inhibitor class of immunotherapies for melanoma, specifically PD-1 and CTLA-4 inhibitors.
The symptoms can vary in severity and duration. It is important to talk with your health care team about what to expect with this side effect, how long it may last and when to consider emergency treatment. Diarrhea can lead to severe dehydration and electrolyte imbalance, but also could be a symptom that your immune system is going into overdrive.
Tips to manage diarrhea include drinking clear liquids, avoiding milk products, eating low-fiber foods, eating frequent small meals, choosing foods that are high in potassium, avoiding foods that can irritate your digestive tract and trying probiotics.
Call your health care team if you experience symptoms that interfere with your daily activities, such as severe abdominal cramping, or that cause you to fear leaving your home.
Mild Skin Reactions
Mild skin reactions, such as bumpy or itchy red rashes, can occur. These reactions are some of the most common side effects of checkpoint inhibitors.
Other skin problems include yellowing or other changes in skin color, blistering, hives, pale patches and flushing or redness.
Although these symptoms are rarely severe, they can be very uncomfortable. Depending on the type of itching, a corticosteroid or numbing medicine may be recommended by your doctor. If the itching affects your sleep, your doctor may prescribe an antihistamine, such as cetirizine (Zyrtec) or diphenhydramine (Benadryl). Medicated creams may be prescribed to help you manage itchy skin or rashes. In some cases of rash, antibiotics may be prescribed.
Contact your doctor at the first sign of a reaction because early treatment may improve your symptoms.
Depression
Depression is a common side effect of cancer and its treatment. In addition to affecting your mood, depression can affect your behavior and ability to think and concentrate, as well as be associated with physical symptoms, including fatigue, loss of appetite, difficulty falling asleep or extreme tiredness. Depression can be serious and include suicidal thoughts or other psychiatric disorders. Call your doctor’s office if you notice any mood changes that develop during your treatment.
Discuss any concerns you have about any potential side effects with your doctor before starting treatment. Communication with your health care team is crucial in managing all side effects during immunotherapy. Once you start treatment, ask your doctor about whom to contact if you have urgent questions about side effects, especially after normal office hours.
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