Immune activation signatures associated with fatigue in cancer patients undergoing immune checkpoint inhibitor therapy

Fatigue is a common and often debilitating adverse event among patients receiving immune checkpoint inhibitor (ICI) therapy, yet its underlying immunologic mechanisms remain poorly defined. We prospectively collected clinical data and blood samples from patients with solid tumors receiving ICI therapy. Patients were prospectively surveyed at month 2, 4, or 6 on treatment to assess for the presence and severity of fatigue as compared to treatment baseline. We analyzed peripheral lymphocyte populations by Cytometry by Time-of-Flight (CyTOF) and peripheral levels of 39 cytokines with a Luminex multiplex assay to identify dynamic immune changes associated with ICI-related fatigue. Of 53 patients enrolled, 31 (58.5%) reported worsening fatigue during ICI therapy. Patients reporting fatigue exhibited broad early-treatment elevations in circulating cytokines, with the most prominent increases observed in the Th1-associated cytokine cluster including IFN-γ, IL-2, and IL-12. In parallel, several clusters of cytotoxic effector CD8+ T cells expanded significantly from baseline in the fatigued group. Fatigue was not associated with objective tumor response or with the development of other clinically meaningful immune-related adverse events (irAEs). In a pan-tumor cohort treated with ICIs, increases in clusters of cytotoxic effector CD8+ T cells in parallel with related Th1-associated cytokines were associated with ICI-related fatigue, implicating fatigue as a potential marker of immune activation in this population.