Pre-treatment evaluation and diagnostic tests to consider in all patients prior to initiating checkpoint inhibitor therapy

Routine pre-treatment screening
History ♦ Detailed questioning for autoimmune, infectious disease, endocrine and organ-specific disease history ♦ History of base line bowel habit (frequency of bowel movements, usual stool consistency)Blood tests ♦ CBC ♦ CMP ♦ TSH ♦ HbA1c ♦ Free T4 ♦ Total CK ♦ Infectious disease screen: HBsAg, HBsAb, HBcAb, hCAb, CMV antibody, T-spot test, HIV antibody, HIV antigen (p24)a ♦ Fasting lipid profileDermatologic examination ♦ Full skin and mucosal exam, taking note of the extent and type of lesions presentPulmonary tests ♦ Baseline oxygen saturation on room air and during ambulationCardiac tests ♦ ECG ♦ Troponin I or T: baseline and weekly for 6 weeksb
Additional screening tests recommended in patients with pre-existing organ disease/at risk of organ-specific toxicity
Endocrine tests ♦ 8 am cortisol ♦ 8 am ACTHCardiac tests ♦ Brain natriuretic peptide (BNP) or N-terminal pro B-type natriuretic peptide (NT pro-BNP)Pulmonary tests ♦ PFTsc ♦ 6MWTc

In certain settings, some of these tests may not be readily available. Until their use is firmly supported by evidence, individual physician judgment is recommended

aThese tests become very relevant if patients develop irAEs and require immunosuppressive treatment such as steroids and/or anti-TNFα treatment

bGiven the rarity of cardiac toxicity, this may not be cost-effective as a routine test. . Baseline troponin should be measured although the follow up interval for re-testing is not determined. Any suspicious cardiopulmonary symptoms warrant repeat troponin and natriuretic testing in this population

cGiven the rarity of pulmonary toxicity, pre-treatment PFTs and 6MWTs should considered in patients with pre-existing lung disease (chronic obstructive pulmonary disease, interstitial lung disease, sarcoidosis, pulmonary fibrosis etc.) and may not be feasible in all patients

ACTH, Adrenocorticotropic hormone; CBC, Complete blood count; CMP, Complete metabolic panel; CMV, Cytomegalovirus; CK, Creatine kinase; ECG, Electrocardiogram; HbA1c, Glycosylated hemoglobin; HBsAg, Hepatitis B surface antigen; HBsAb, Hepatitis B surface antibody; HBcAb, Hepatitis B core antibody; HCAb, Hepatitis C antibody; HIV, Human Immunodeficiency Virus; PFTs, Pulmonary function tests; TSH, Thyroid-stimulating hormone; T4, Thyroxine; 6MWT, 6 min walk test