Assessment and Monitoring of Patients Receiving Chemotherapy for Multiple Myeloma: Strategies to Improve Outcomes
the ONA take:
With the approval of numerous novel agents by the US Food and Drug Administration (FDA) for the treatment of patients with multiple myeloma in only the last few years, clinician awareness of these new drugs and common adverse events is essential to manage patients effectively. For example, neuropathy is common with bortezomib and ixazomib, while infusion reactions are frequently reported with daratumumab and elotuzumab.
Despite the use of these effective new therapies, remission and relapse often occur, leading to clonal evolution, drug resistance, and drug-resistant disease. Therefore, it is imperative for clinicians to closely monitor patients for response to therapy and evaluate for biochemical and symptomatic disease progression to reduce the risk for developing myeloma-related complications.
To prevent and manage common disease-related complications, such as skeletal-related events, renal impairment, infection, peripheral neuropathy, and venous thromboemboli, clinicians should include supportive care for their patients. To prevent skeletal-related events and renal impairment, all patients should receive bisphosphonates monthly for at least 12 months and adequate fluid intake, respectively. To reduce the risk of infection, all patients with multiple myeloma should receive seasonal inactivated influenza vaccination and a polyvalent pneumococcal vaccine every 5 years. In terms of venous thromboemboli, it is recommended that hospitalized patients receive enoxaparin or dalteparin and those with a high risk of thrombosis receive warfarin, enoxaparin, or direct oral anticoagulants.
Clinicians can also provide care plans, calendars, or other tools to help patients understand and adhere to treatment and allow the patient to participate in their own care to improve survivorship.
Blood and Lymphatic Cancer: Targets and Therapy
Abstract: Improved understanding as to the biology of multiple myeloma (MM) and the bone marrow microenvironment has led to the development of new drugs to treat MM. This explosion of new and highly effective drugs has led to dramatic advances in the management of MM and underscores the need for supportive care. Impressive and deep response rates to chemotherapy, monoclonal antibodies, and small molecule drugs provide hope of a cure or prolonged remission for the majority of individuals. For most patients, long-term, continuous therapy is often required to suppress the malignant plasma cell clone, thus requiring clinicians to become more astute in assessment, monitoring, and intervention of side effects as well as monitoring response to therapy. Appropriate diagnosis and monitoring strategies are essential to ensure that patients receive the appropriate chemotherapy and supportive therapy at relapse, and that side effects are appropriately managed to allow for continued therapy and adherence to the regimen. Multiple drugs with complex regimens are currently available with varying side effect profiles. Knowledge of the drugs used to treat MM and the common adverse events will allow for preventative strategies to mitigate adverse events and prompt intervention. The purpose of this paper is to review updates in the diagnosis and management of MM, and to provide strategies for assessment and monitoring of patients receiving chemotherapy for MM.
Keywords: multiple myeloma, treatment, symptoms, assessment, monitoring, symptom management, targeted therapies
Multiple myeloma (MM) is an incurable, but highly treatable cancer characterized by an overproliferation of bone marrow plasma cells, which leads to the production of a monoclonal protein. Through a series of genetic changes, genetic mutations, and cellular alterations, the normal plasma cell turns malignant. Cancerous plasma cells overproduce clonal immunoglobulin (Ig) proteins which cause organ destruction. Although the genetic makeup of the tumor itself and patient symptoms at presentation are heterogeneous, common signs and symptoms of MM exist at diagnosis. Known as “CRAB” criteria, the pneumonic stands for hyperCalcemia, Renal insufficiency, Anemia, and Bone damage. The incidence of these at diagnosis is as follows: anemia 73%, bone pain 68%, renal insufficiency 19%, and hypercalcemia 13%.1 To delay worsening of existing organ damage, or to prevent future organ damage, prompt treatment of the malignant plasma cells with chemotherapy is warranted.
As of 2012, it is estimated that 65,000 individuals are living with MM globally and comprise ~2% of all cancer types.2 The incidence of MM is expected to increase over the next decade. The etiology of MM is unknown, but the risk is associated with increasing age, obesity, and race. MM is more prevalent in individuals over the age of 65 and is nearly two times higher in African–American individuals and men. Obesity and high body mass index further increases the risk to develop monoclonal gammopathy of undetermined significance (MGUS) and potential MM.3