Nova Scotia Health Authority
MRN #:0001563691Acct #:28210797HCN #:999125858TEST, TEST T123 TEST STREET, MONCTON, NB X9X-9X9DOB:1966-Jun-06Phone:PMI:PROVINCIAL MEDICAL INSURANCEWCB:NSCC CONSULTATION REPORTInfectious Disease ClinicQEII Health Sciences CentreVISIT DATE: 2016-Nov-28Dear Primary Care Practitioner: I wanted to bring to your attention that our mutual patient is receiving an immune checkpoint inhibitor (CPI) as part of his/her cancer treatment and as such is at risk for immune-related toxicities which may be life threatening and require urgent assessment and management. Side effects from CPIs are different from those typically encountered with chemotherapy or targeted therapies. CPIs can result in dysregulation of the immune system and result in signs and symptoms very similar to autoimmune disorders. Emergence of toxicities can occur at any time during or up to 1 year after treatment. Toxicity can result in inflammation of any tissue or organ system, but some of the most common systems affected include (but are not limited to): GASTROINTESTINAL (colitis, ileitis, pancreatitis)LUNGS (pneumonitis)LIVER (hepatitis)RENAL (interstitial nephritis)ENDOCRINE (thyroid dysfunction, diabetes, adrenal insufficiency, hypophysitis) CUTANEOUS (rash, Stevens-Johnson Syndrome)OPHTHALMOLOGIC (inflammation of any ocular structure)NEUROLOGIC (encephalitis, Guillain-Barre Syndrome, Myasthenia Gravis, neuropathy)MUSCULOSKELETAL (arthritis, myositis)CARDIAC (pericarditis, myocarditis) Immune-mediated toxicities can be organ or life threatening and absolutely requires prompt coordination with a medical oncologist. They often require treatment with high dose steroids. **If you suspect that this patient is presenting with an immune related toxicity, please call the hospital Locating Department (CBRCC 902-567-8000; QEII 902-473-2000) and ask for the patient's primary medical oncologist/hematologist/gynecology oncologist. If after hours or on the weekend, please ask for the medical/hematology/gynecology oncologist on-call and/or send the patient to the emergency room. Your patient has been provided a CPI Alert Card to provide to ED staff upon presentation. Thank you for your support in the care of this patient. -----------------------------------------------------------------------------------------------------------------------------------------IMMUNE CHECKPOINT INHIBITOR (CPI) INFORMATION PRIMARY CARE PRACTITIONER FEEDBACK **Please complete and return to the Nova Scotia Cancer Care Program via fax at (902) 473-6412** 1. Does the information contained within this CPI letter provide you with the necessary level of detail to provide care for your cancer patients? ____ Right amount of detail ____ Too much detail____ Not enough detailIf you've checked off too much or too little, please explain why: 2. Use of this CPI letter will provide me with the information I need to provide appropriate care for my patients presenting with treatment related side effects. ____ Strongly Agree ____ Agree____ Disagree____ Strongly DisagreeIf you've checked off disagree or strongly disagree, please explain why: 3. Is there anything else you would like to tell us? If you have any questions about the CPI letter please contact Joy Tarasuk, Manager Oncology Clinical Programs, Nova Scotia Cancer Care Program at (902) 473- 5845. DICTATED BUT NOT READIf changes are required, they will be made and an updated report will be sent.If you require immediate clarification, please contact the attending physiciandirectly.__________________________________________DBNR Signer Test, MDAttending StaffDept. of NeurologyOffice Tel: 902-473-2568 Office Fax: 902-425-5007cc: Unknown Physician <PCP> ................
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