Oncology Nursing Practice Patterns in Multiple Myeloma

APRIL 30, 2009
Christina T. Loguidice
In an educational symposium session entitled “Oncology Nursing Practice Patterns in Multiple Myeloma,” sponsored by Millennium Pharmaceuticals, Jonathan Kaufman, MD, Emory University School of Medicine, provided an overview of this plasma cell cancer and discussed some of the novel therapeutics that have considerably improved survival. Dr Kaufman noted that the median patient age at multiple myeloma diagnosis is 70 years and that the disease has a higher prevalence in African Americans (2:1 ratio), who also tend to present 10 years earlier than other patients.

While the cause of the disease is unknown, the higher incidence in this patient population suggests that genetic factors may contribute to its development. Treatment generally includes a bone marrow transplant and chemotherapy, though some patients may not be eligible for transplant. Dr Kaufman reviewed drugs that could be used in various multiple myeloma patient populations, including those with newly diagnosed multiple myeloma or relapsed myeloma after autologous transplant. Some of the pharmacotherapies he reviewed included thialidomide, lenalidomide, bortezomib, dexamethasone, and combination therapies. While patients treated with these agents experience better quality of life and improved survival, Dr Kaufman noted that more clinical trials are essential for further advancement. He recommended nurses become aware of the various multiple myeloma trials and encourage their patients to enroll. While Dr Kaufman did not note any trials in particular, here are some you may consider:

Bevacizumab, Lenalidomide, and Dexamethasone in Treating Patients with Relapsed or Refractory Stage II or Stage III Multiple Myeloma (NCT00410605)
Study type: Interventional
Age/Gender Requirements: 18 years and older (male/female)
Sponsor: University of Wisconsin, Madison; National Cancer Institute
Link: http://clinicaltrials.gov/ct2/show/NCT00410605?term=multiple+myeloma&rank=6

Melphalan, Prednisone, and Thalidomide or Lenalidomide in Treating Patients with Newly Diagnosed Multiple Myeloma (NCT00602641)
Study type: Interventional
Age/Gender Requirements: 18 years and older (male/female)
Sponsor: Eastern Cooperative Oncology Group; National Cancer Institute
Link: http://clinicaltrials.gov/ct2/show/NCT00602641?term=multiple+myeloma&rank=10

Temsirolimus and Dexamethasone in Treating Patients with Recurrent or Refractory Multiple Myeloma (NCT00693433)
Study type: Interventional
Age/Gender Requirements: 18 years and older (male/female)
Sponsor: VA Medical Center-West Los Angeles
Link: http://clinicaltrials.gov/ct2/show/NCT00693433?term=multiple+myeloma&rank=17

Managing the side effects of novel agents
Although novel agents have led to considerable improvements in caring for patients with multiple myeloma, they can result in considerable side effects. Beth Faiman, MSN, RN, Cleveland Clinic Taussig Cancer Center, reviewed some of these side effects and provided practical tips on managing them. The most common side effects are gastrointestinal (eg, constipation, diarrhea, nausea, vomiting, and weight loss) and steroid-related effects (eg, constitutional symptoms). In rare cases, potentially fatal side effects (eg, pulmonary embolism) also have been observed. These life-threatening complications were discussed by Joseph D. Tariman, PhC, MN, RN, University of Washington School of Nursing.

Faiman noted that diarrhea can occur 24 to 48 hours after each dose of bortezomib and lenalidomide is administered. Nurses can recommend many nonpharmacologic therapies to alleviate diarrhea in their patients, including increased fluid intake and avoiding fiber and caffeine or carbonated beverages. She noted that antidiarrheal agents should be used with caution and that intravenous hydration may be necessary in more extreme cases. In patients with grade 3 toxicity, dose reduction is warranted. She also indicated that a stool culture should be taken to check for Clostridium difficile.

Faiman also reviewed various nonpharmacologic and pharmacologic treatments for nausea and vomiting. Nonpharmacologic therapies may include diet modification, avoiding exercise, getting fresh air, and wearing loose clothing. Faiman noted that antiemetics should be selected based on how strongly the novel agents stimulate nausea and vomiting, and that intravenous hydration may be required to prevent dehydration.

Steroid-related side effects
Nurses also need to monitor their patients for side effects related to steroids, which are used as single agents (eg, dexamethasone) or as part of a combination therapy (eg, prednisone, prednisolone) in patients with multiple myeloma. Steroids can affect all systems in the body, resulting in constitutional symptoms, leukocytosis, steroid myopathy, muscle cramping, osteonecrosis, osteoporosis, and edema. Faiman noted that effective management requires careful monitoring, educating patient and caretakers on what to expect during treatment, appropriate prophylaxis, and pharmacologic and nonpharmacologic treatments as appropriate.

Life-threatening complications

Peripheral neuropathy
Tariman noted that peripheral neuropathy is being observed with greater frequency in patients with multiple myeloma for two reasons: (1) the availability and use of more neurotoxic drugs and (2) patients are living longer and receiving multiple chemotherapy regimens. Thalidomide and bortezomib are both known to result in this complication, which can range from mild/moderate to severe. Symptoms of mild (grade 1)/moderate (grade 2) peripheral neuropathy include temporary numbness, tingling, paraesthesias, sensitivity to touch, and muscle weakness. Severe peripheral neuropathy (grade 3) symptoms include burning pain, muscle wasting, paralysis, and organ failure. Tariman emphasized the importance of using a peripheral neuropathy assessment tool in practice. Peripheral neuropathy is managed by reducing drug doses. Tariman also noted success with use of amino acids.

Thromboembolic events
Tariman reported a higher risk for deep venous thrombosis and pulmobary embolism in patients treated with conventional chemotherapies plus novel therapies such as thalidomide and lenalidomide. Signs and symptoms of deep venous thrombosis may include slight fever, tachycardia, erythemia, cyanosis, dull ache, Homan’s sign (35% patients), and distension of the superficial venous collateral vessels. Pulmonary embolism may result in anxiety, sudden shortness of breath, worsening chest discomfort, rapid pulse and heart rate, low-grade fever, and wheezing. Thromboembolic event prophylaxis includes mechanical measures, such as antiembolism stockings, and steroid-dose reduction.

Myelosuppression is a condition in which bone marrow activity is decreased, resulting in fewer red blood cells, white blood cells, and platelets. Patients should be educated on signs and symptoms of this disorder, which can include fatigue, shortness of breath, increased incidence of infections, and susceptibility to bruising and bleeding. Management includes growth-factor therapy, dose reduction (as appropriate), and transfusion (as indicated).

Take-home message
Strategies for management of multiple myeloma remained stagnant until the development of several novel agents, which have resulted in major advances in the care of patients with this disease. As with all treatments, however, there will be side effects, some of which can be fatal; thus, patients should be educated on these side effects and closely monitored. Any observed or reported side effects, including those that are not life threatening, require prompt intervention. Rapid response to side effects increases patient compliance and improves time to progression, progression-free survival, and overall survival.

Kaufman, Faiman, and Tariman reported a financial/interest relationship with Millennium Pharmaceuticals.

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