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The Nurse’s View: Managing Your Patient's Maintenance Therapy for Multiple Myeloma

  • Authors: Beth Faiman, PhD, CNP; Charise Gleason, MSN, NP-BC, AOCNP; Sandra Kurtin, RN, MS, AOCN, ANP-C
  • CE Released: 12/15/2018
  • Valid for credit through: 12/15/2019, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for nurses/nurse practitioners, hematology/oncology specialists, and other care professionals involved in the care of patients with multiple myeloma.

The goal of this activity is to improve knowledge of maintenance therapy and competence caring for patients with multiple myeloma on maintenance therapy.

Upon completion of this activity, participants will:

  • Have increased knowledge regarding the
    • Clinical safety and efficacy of agents recommended for use as maintenance therapy for multiple myeloma
  • Have greater competence related to
    • Preventing and managing treatment-related adverse effects in patients with multiple myeloma receiving maintenance therapy
    • Counseling and educating patients receiving maintenance therapy as part of the management of multiple myeloma


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  • Beth Faiman, PhD, CNP

    Nurse Practitioner
    Multiple Myeloma Program
    Taussig Cancer Institute, Cleveland Clinic
    Cleveland, Ohio


    Disclosure: Beth Faiman, PhD, CNP, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Amgen Inc.; Bristol-Myers Squibb Company; Celgene Corporation; Takeda Pharmaceuticals North America, Inc.
    Served as a speaker or a member of a speakers bureau for: Amgen Inc.; Bristol-Myers Squibb Company; Celgene Corporation; Takeda Pharmaceuticals North America, Inc.
    Received grants for clinical research from: Carevive Systems, Inc.


  • Charise Gleason, MSN, NP-BC, AOCNP

    Chief of Advance Practice Providers Department of Hematology
    and Medical Oncology
    Emory University School of Medicine Nurse Practitioner
    Bone Marrow and Stem Cell Transplant Center
    Winship Cancer Institute of Emory University
    Atlanta, Georgia

    The opinions expressed are those of Ms Charise Gleason and do not necessarily reflect the views of Emory University or Emory Healthcare. Ms Gleason’s participation in this activity does not constitute or imply endorsement by Emory University or Emory Healthcare.


    Disclosure: Charise Gleason, MSN, NP-BC, AOCNP, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Takeda Pharmaceuticals North America, Inc.

  • Sandra Kurtin, RN, MS, AOCN, ANP-C

    Assistant Professor of Clinical Medicine
    Assistant Professor of Nursing
    The University of Arizona Cancer Center
    Tucson, Arizona


    Disclosure: Sandra Kurtin, RN, MS, AOCN, ANP-C, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: Celgene Corporation; Pharmacyclics, Inc.; Takeda Pharmaceuticals North America, Inc.
    Served as a speaker or a member of a speakers bureau for: AbbVie Inc.; Genentech, Inc.


  • Sara Fagerlie, PhD, CHCP

    Scientific Director, Medscape, LLC


    Disclosure: Sara Fagerlie, PhD, CHCP, has disclosed no relevant financial relationships.

  • Melinda Tanzola, PhD

    Scientific Director, Medscape, LLC


    Disclosure: Melinda Tanzola, PhD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

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  • Awarded 0.50 contact hour(s) of continuing nursing education for RNs and APNs; 0.50 contact hours are in the area of pharmacology.

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The Nurse’s View: Managing Your Patient's Maintenance Therapy for Multiple Myeloma

Authors: Beth Faiman, PhD, CNP; Charise Gleason, MSN, NP-BC, AOCNP; Sandra Kurtin, RN, MS, AOCN, ANP-CFaculty and Disclosures

CE Released: 12/15/2018

Valid for credit through: 12/15/2019, 11:59 PM EST




[START 21818 - 262449_01_RT_Faiman_101818 (37 min).m4a]

Beth Faiman, PhD, MSN, CNP, AOCN: [00:00:06] Hello. I am Beth Faiman from the Cleveland Clinic. Welcome to this program titled The Nurse View: Managing Your Patient's Maintenance Therapy from Multiple Myeloma. Joining me today are Charise Gleason from the Winship Cancer Institute at Emory University and Sandra Kurtin from the University of Arizona. Welcome.


Sandra E. Kurtin, RN, MS, AOCN: [00:00:25] Thank you.


Charise Gleason, MSN, NP-BC, AOCNP: [00:00:25] Thank you.


Dr Faiman: [00:00:26] This program will include a discussion of off-label treatments and investigational agents not approved by the FDA for use in the United States and data that were presented in abstract form. This data should be considered preliminary until published in a peer-reviewed journal.


[00:00:45] Let us talk about maintenance. Maintenance is a very important component of multiple myeloma therapy. Basically, when patients are diagnosed with multiple myeloma, I think of it in bucket. First, that individual has induction therapy and then whether or not that individual decides to pursue transplant, they might go on to consolidation or stem cell transplant, which we will talk about, and then we go on to maintenance therapy. The last part of that bucket is the treatment of relapsed disease, which will not necessarily be covered in this topic today, but I think it is important for you to be understanding of.


[00:01:22] Supportive care occurs throughout, and that will be covered at the end. Continuous therapy is when that individual may not undergo stem cell transplant, but that continuous therapy is ongoing whether or not that patient participates in transplant.


[00:01:37] I just wanted to mention a couple of studies first that illustrates what we give to patients if they do not undergo transplant. Before I do that, I just wanted to ask the both of you do you have patients in your practice that do not undergo stem cell transplant? Charise?


Ms Gleason: [00:01:53] No, we absolutely do. We keep with the very similar upfront treatment of lenalidomide, bortezomib, and dex. Typically, if they are not a transplant candidate, we are going to modify that just like you saw in the studies.


Dr Faiman: [00:02:06] Sandy?


Ms Kurtin: [00:02:07] I would agree with that. I think there are different reasons that patients may or may not go to transplant.


Dr Faiman: [00:02:13] What are some of those reasons?


Ms Kurtin: [00:02:15] Some of it is personal choice still today, some of it is financial. Of course, a lot of it is comorbidities. They just are not eligible, and we know that they are likely to have more treatment-related morbidity or mortality.


Dr Faiman: [00:02:33]<<delete 2:34-2:51>> In my practice, I might have somebody that is in their 40s, but because they are the main breadwinner for the family, they are not up for a transplant. You just keep that in mind for down the road. When their situation changes or that 80-year-old that just is not willing to do transplant. For those people that do not up for upfront transplant, we generally recommend a 3-drug induction regimen.


[00:02:59] There are 2 studies <<delete 2:59-3:05>>though that really support the use of non-transplant. One of them is the first trial. That was a study in which patients were randomized non-transplant eligible patients. An international study, 1600 patients were randomized to receive either lenalidomide and dexamethasone until disease progression or unacceptable toxicity.


[00:03:24] The second group was melphalan, prednisone, and thalidomide for a fixed duration of cycles vs lenalidomide and dexamethasone for a fixed duration. Just with all oral therapy in patients that could not have a transplant, we saw that continuous lenalidomide/dexamethasone in that 535 patients, they did quite well. There was a progression-free survival advantage. For somebody that wants to work full time or is older, does not necessarily want to go through transplant, that continuous therapy without staffing really made a difference.


[00:03:58] The more compelling data is with 3 drugs, and that is really where we are in myeloma today. This was a study with 3 drugs, bortezomib, lenalidomide, and dexamethasone. The second group was randomized to receive just lenalidomide and dex. What we saw in that study is that the patients that had 3 drugs did better in terms of progression-free survival vs 2.<<delete 4:21-4:40>> The nice thing about this study is that patients only had bortezomib for 8 cycles. It was 6 to 8 cycles depending on toxicity in most cases, but is this something that you use in your real world, lenalidomide?


Ms Kurtin: [00:04:35] Absolutely. We do.


Dr Faiman: [00:04:37] Perfect. That is something to keep in mind. The evolution of maintenance therapy is ongoing. Basically, I think in my practice like yours, we think of risk stratification. I think, Charise, you are going to present some data on the importance of knowing your patient's risk. There are a lot of single-agent maintenance as well as combinations. I think it is important to emphasize the role of nurses. What do we do? We encourage our patients to stay on therapy. We put together calendars so they adhere to therapy. A lot of these drugs are oral. The nurses have a very important role.


[00:05:15] I know you can probably share, Sandy, your patients will come to you and say why I am still taking this. What do you answer to them?


Ms Kurtin: [00:05:22] I think it gets back to understanding the disease itself. <<delete 5:24-6:08>>We understand that we can make those certain free light chains look normal on a computer screen. We can have their heavy-chained - - their immunoglobulin levels be normal on a screen. We know there is this layer in the person that we cannot see on a screen. If left unchecked, it will rear its ugly head...


Dr Faiman: [00:05:52] In that clonal evolution.


Ms Kurtin: [00:05:53] Exactly. That disease is going to change evolution become more resistant to therapy but inevitably relapse.


Dr Faiman: [00:06:02] I would like to dive in to some of the therapies that we use for maintenance and why. Again, remember, multiple myeloma is a cancer of the bone marrow plasma cell. <<delete 6:11-6:29>> What do plasma cells need to do? They survive. They are part of our humoral immune system, our innate immunity. They are meant to survive, and they can become resistant. Sometimes, depending on the biology of the disease, we need to get a little bit creative with the medicines that are given.


[00:06:29] Just real quick, cycling back. Patients are diagnosed with multiple myeloma. How are they diagnosed, Charise? The CRAB. Maybe, you want to go with the SLiM CRAB. Mention that real quickly.


Ms Gleason: [00:06:41] We are looking for symptoms because we have these patients that we watch. Are we having changes in the bones? Are we seeing a lesion on an MRI, for instance? Are we seeing anemia? Are we seeing renal changes? Are we seeing a calcium elevation with that? We look for some other things that we are looking at. Are there LDH and...


Dr Faiman: [00:07:05] The risk disease markers...


Ms Gleason: [00:07:07] Yes, for that. We have those patients that we are watching, but then you have those patients that come in and they are already symptomatic. We all see that in all of our practices. It is a different conversation. I think it is worth having than we had 15 years ago with our patients. From the start, we are talking about this continuous therapy moving forward into maintenance. We are setting that...


Dr Faiman: [00:07:29] ...that diagnosis you set that stage.


Ms Gleason: [00:07:30] Patients will expect that almost likely always be on something.


Dr Faiman: [00:07:35] Sandy, we were just talking about setting expectations for treatment at diagnosis. This is incurable but very treatable in many cases. You have that discussion, too, as well.


Ms Kurtin: [00:07:47] Absolutely. You have to set expectations that this is a lifelong - - I mean, once they are diagnosed, they are going to be on some type of therapy in most cases forever. Having that conversation is critically important. I would just add to the whole new SLiM CRAB and the myeloma defining events that the goal with that is really not to wait until they have organ damage - - the advantage of not waiting until they are renal compromised or extended bone compromised, I think a great advance in science.


Dr Faiman: [00:08:27] Just for you in the audience that might not be familiar. SLiM CRAB is the 2014 diagnostic criteria for myeloma, the serum-free light chain elevation. A meta-analysis showed that if patients had a ratio of Kappa Lambda greater than 100, then they will more likely to develop symptoms of the disease like Charise mentioned - - bone anemia, renal insufficiency. It was recommended they start treatment. Bone marrow plasma cells greater than 60% is also part of the new revised criteria because those individuals had a higher risk in the treatment. The last 1 is an MRI with greater than 1 focal lesion greater than 5 millimeters. I always think of centimeters.


Ms Kurtin: [00:09:10] It is always big.


Dr Faiman: [00:09:11] A big lesion. That would be real big lesion. Those are the reasons why patients would be treated. Charise, I would like you to go into take us through what a typical patients at Emory University is. They come in with symptomatic myeloma. Does that individual go through transplant? Is that recommended for most?


Ms Gleason: [00:09:30] Yes, it is. For any new patient coming in, we are going to look at that. Are they a transplant candidate or not? For today, since we are really talking about that maintenance post-transplant, I am going to focus more on those patients that are transplant eligible.


Dr Faiman: [00:09:45] What are some of the trials that you have...


Ms Gleason: [00:09:49] In the maintenance setting? Three really come to mind when we think about this era of maintenance. You think of CALGB. We think of the IFM trial from the French group and we think of the Italian group, their studies. These were trials that looked at lenalidomide vs placebo or lenalidomide vs observation. What we know overall is that the meta-analysis showed that these patients do have an overall survival benefit. I think that really shaped most of us in our practices.


[00:10:22] You do need to think about some things about these trials. There are some differences. One, there are differences in induction therapy. The IFM, for instance, had a consolidation piece to it. The CALGB had an area where they looked at the median survival and then patients could actually roll over from...


Dr Faiman: [00:10:41] That was the US trial, correct?


Ms Gleason: [00:10:42] That was the US trial <<delete 10:44-10:46>>that did that as well. I think these are conversations that come in when we are talking about our patients, to our patients about the importance of going on maintenance. The other piece that did not take into consideration in these trials were risk stratification, which we are going to talk about more later.


[00:11:01] All patients went in and what we did see is patients with an ISS stage 3, for instance, did not have the same benefit. You think of those patients - - those are your higher risk patients typically. The other piece that we can talk about is the secondary or primary malignancies that came out. Patients, they want to know that. We have to talk about when we are having that conversation about maintenance.


[00:11:25] We did see these other malignancies. Overall, the data shows us that the risk of progressive myeloma is still greater than a secondary.


Dr Faiman: [00:11:34] I have a question for you. When you talk about risk stratification, is that done on bone marrow biopsy? How do we define somebody's risk for high risk vs low risk for myeloma?


Ms Gleason: [00:11:45] Typically, it is the cytogenetics, that biology of the disease. We are looking for those high-risk factors. Do they have deletion of 17p? Do we see a 4;14 or 14;16. A complex karyotype tells us this disease is going to behave differently.


Dr Faiman: [00:12:01] We have a paragraph of...


Ms Gleason: [00:12:03] A whole detail.


Ms Kurtin: [00:12:05] 1q. I mean, there are some newer ones that have evolved.


Ms Gleason: [00:12:08] There are. We did not use to look for the 1q. I think for a while, that thought was this is an acquired like you can with the 17p. You can have it upfront or acquire. I think many of us were not just looking. Now that we are looking...


Ms Kurtin: [00:12:21] It is up to the panels [crosstalk] those other panels because we use both metaphase cytogenetics in fish because these are fully matured plasma cells. You will perhaps miss certain things on metaphase cytogenetics. I think that science has evolved enough so we know what that panel should look like. It helps us define that risk.


Dr Faiman: [00:12:46] Sandy, I think LDH is now in the revised international staging system as an important factor. It is not even a real high LDH. It is just outside of the normal range which is interesting because we do have patients that LDH can be elevated for a number of reasons - - in myeloma, patients that confer a poor prognosis unfortunately.


Ms Kurtin: [00:13:08] Sometimes, that is a clue that you see before you really began to see the changes in their other parameters, particularly these people that have been on therapy a long time. Of course, it is part of our metabolic panel, which is unfortunate, but you have to order it...


Dr Faiman: [00:13:25] Separately. Same in our institution, too. We talked about lenalidomide maintenance and Charise shared the data that shows lenalidomide maintenance after transplant makes a different. In my 2 studies upfront, we saw that without a transplant staying on lenalidomide was a good idea. What about bortezomib? That has been FDA-approved since 2003. What are your thoughts on that, Sandy?


Ms Kurtin: [00:13:52] You know that we have a lot of historic data in bortezomib, and it is part of proteasome inhibitor and immunomodulatory agent and a steroid. That 3-drug regimen upfront is really I think the standard of care for everybody. It is being looked at in the maintenance setting. I think the critical addition that the bortezomib studies offer is that they are found to be effective in people with this high-risk cytogenetics. Things like 17p and 4;14, where this drug has shown improvement.


[00:14:36] There was a recent published retrospective analysis out of Duke, 102 patients really looking at people that have received bortezomib in the maintenance setting. There really was no difference in people with normal cytogenetics and people with this high-risk cytogenetics in terms of progression-free survival. That is a big advancement.


Dr Faiman: [00:15:02] Absolutely. The HOVON data showed that the bortezomib can overcome some of the poor prognostics of that 17p. Our tumor suppressor gene should not be deleted. You should have it intact and working. We do have some data in bortezomib. I know in my practice after transplant, if it took 3 drugs to get them into remission and then they go onto transplant and they have not quite achieved that complete response, that adaptive response we want, there is a study that you all are very well aware of, the Dana Farber IFM study that shows MRD negativity makes a difference. How do you get to MRD-negative? Those less than a million cells, by more therapy and deeper therapy.


[00:15:49] It really was not a transplant. It was the depth of therapy that made people stay in remission longer. Again, it was with bortezomib and len/dex. Those really are backbone of myeloma therapy I think.


Dr Faiman: [00:16:01] What about ixazomib? Ixazomib is a nice oral proteasome inhibitor to take in 3 pills per month. It is nice.


Ms Kurtin: [00:16:10] Ixazomib came on the stage as the second proteasome inhibitor that we have available. It is an oral therapy which offers certainly an advantage to certain patients. I think you emulate the prior data from similar drugs. That has now been looked at extending out the TOURMALINE trial in this randomized phase 3 ixazomib vs placebo much like the len maintenance trial post-transplant. These data looked very promising in terms of progression-free survival for these patients. <<delete 16:56-17:28>>We are likely to hear more about this at ASH coming up at a couple of months here.


Dr Faiman: [00:16:59] I think they met their progression-free survival endpoint. It is just nice to have all these options. All of us were around in the 1990s when we had melphalan and prednisone or alkaline and prednisone whatever. We also had...


Ms Kurtin: [00:17:15] Some of us worked in the '80s when we used a lot of thalidomide. [crosstalk]


Dr Faiman: [00:17:20] We have bad infusional [crosstalk].


Ms Kurtin: [00:17:23] We are so thrilled to have come a long way.


Dr Faiman: [00:17:24] We are just thrilled to have come a long way. Let us think of that patient. FISH is the technique where we fish out in the bone marrow a fluorescent in situ hybridization, this abnormal gene X. We have the cytogenetics for those of you that are watching this at home, the abnormal cytogenetics is that 1 test on the bone marrow that looks at just the genetics once they are cultured out of those cells. It is the genetics of the cancer cells not the patient's genetics and their makeup.


[00:17:53] The FISH is when we fish out certain abnormalities that Charise had mentioned like the deletion 17p. It is a tumor suppressor gene, 11;14, 14;16, and Sandy mentioned the 1q addition. We will not go into other detail about that risk, but I think it is important to frame i in the context of these new drugs so that patients that did not get into an awesome remission, you do not necessarily need to dip in that remission if they are able to work and enjoy life and travel. What about the patient that has really high-risk cytogenetics? Charise, are you doing anything at Emory that might be something we would like to know about?


Ms Gleason: [00:18:33] We are. I think we learned, here, we take this patient to transplant and by the time we are restaging them at Day 100, their disease was taking off. We started looking at our patients and started restaging a little bit earlier. Somebody who falls into 1 of those categories, we actually look at their disease status about 60 days post-transplant.


[00:18:54] We published a paper in 2014 that looked at our data using the 3-drug maintenance. We went back to that lenalidomide, bortezomib, dexamethasone, and we took these high-risk patients, restaged them at Day 60 and put them on this regimen. We will look back at our patients' experience. At 3 years out, we had about 93% overall survival rate, which you just were not seeing before.


[00:19:17] We are committing to patients to 3 years of 3-drug regimen which you do have to dose adjust. It is more of that RBD light therapy. You are seeing this. We have more drugs available to us, so we are tailoring that even more.

<<delete 19:33-20:24>>

Dr Faiman: [00:19:34] What about the other monoclonals antibodies, elotuzumab, daratumumab? Do you use any of those?


Ms Gleason: [00:19:38] We do. We use daratumumab. We are able to use it in combination with pomalidomide. Maybe, if you did not get that VGPR upfront with that RVD, you are going to look for something a little different or maybe, you did even get them to transplant after that first induction you had to use multiple drugs. You know you have to go to a different type of maintenance for these patients.


[00:20:00] The caveat to this is somebody who has a 4;14 and everything else looks normal. You can frequently get by with just a proteasome inhibitor. The data looks pretty good on that. Those patients do not have quite as aggressive of maintenance. Again, you are seeing such nice responses with just patients’ years out now with high-risk disease.


Dr Faiman: [00:20:24] Sandy, how important is it for your patients to know their genetic makeup? Is that something you routinely discuss and how can nurses feel comfortable in the community to have this information?


Ms Kurtin: [00:20:37] You talked about buckets early on. I used the analogy of the worry bucket and the good bucket. How many things are in the worry bucket? Some of the things that go in that worry bucket are these chromosomal abnormalities which are in this later that we cannot get to. Even with the transplant, we cannot quite close it, put a lid on it.


[00:21:01] These are exactly the terms I use for patients. I explain to them what they have in the worry bucket, and that may be this high-risk cytogenetics. It might be their uncontrolled diabetes that needs to get under controlled. It might be that they still smoke and I need to quit, have them quit. Those are the worry buckets.


[00:21:20] Over here is the good bucket, which is you are otherwise healthy, fabulous. We have that conversation. I think that is something that realistically nurses can play an important role in describing to the patient is understand what the worry bucket items are. What do we have available to us overcome those specific things. I think what is ultimately critical about that is in oncology at least in my experience, the myeloma population is highly motivated, engaged. They compare notes. They attend support groups and probably are equivalent to what we think about it in the solid tumor world as the breast cancer population.


[00:22:09] They are going to talk to each other and say why are you getting that and I am getting this? We need to be able to explain that there is a scientific rationale behind that.


Dr Faiman: [00:22:21] Your myeloma is not my myeloma.


Ms Kurtin: [00:22:23] Exactly.


Dr Faiman: [00:22:23] It is 1 diagnosis, but it is so heterogeneous. There are so many different types of people. That is what we think about with maintenance. We think of patient preference. The ideal maintenance therapy I think should be easy to administer, relatively well tolerated, and it should not affect the quality of life. I think that is so important that quality of life continue to be evaluated.


[00:22:48] From my quality of life screens, I do not do a fancy tool. I just ask them the top few things. Are you happy with your happy? Is there anything you would change in your life? What are the side effects of this that bother you? In patient selection, we have already highlighted the risk profile. It is super important and the tolerance is important. What are some of the discussions you have as patients are on? One more step, what are the strategies that you use to make sure that they know what they are taking? I use calendars, electronic reminders with smartphones for refills and stuff. Do you use the same things to emphasize the importance of staying on it and reminders?


Ms Gleason: [00:23:32] We do. We use the calendars and the electronic reminders as well on phones. I think it is a conversation, too, when you are talking about maintenance in that induction phase upfront. You have to push through. We are in the maintenance for long-term. It is going to be there, but you do not want it to be the forefront of the life in the same way. We want you to get back to normal activities, working, family events, doing those things that make you happy. How do we keep you on this maintenance but manage the side effects? If we are not talking to our patients about side effects, then they are going to stop taking the drug. I think that it is really important to consider their quality of life, how is this impacting them, and continue to monitor throughout for the side effects and know that we can adjust doses.


Ms Kurtin: [00:24:18] I think that is critical. My other tool is what I call the truth squad, which are the caregivers or other friends or family that - - because I think the other challenge that we have and part of this engagement that these patients have with each other and online sites is that sometimes, when they do need to have a drug holiday or a treatment interruption because the toxicity is really impairing their quality of life is they are afraid to stop at all even if for a short period of time. That does not really help you keep them on over a longer period. If we let those things get to severe, we are not going to be able to complete that duration of therapy. There is a lot of finessing and tailoring that is required to be able to do that.


Dr Faiman: [00:25:12] I think 1 of the things is the elephant in the room. Sometimes, what is brought to the forefront is the financial toxicity. These patients are survivors. They are losing time at work. When you are not working off, in times, there is no money, no insurance. I use the resources at the Leukemia and Lymphoma Society, Patient Assistance Foundation, HealthWell Foundation. There is quite a few out there. Do you have social workers available to help out as well at your institutions?


Ms Gleason: [00:25:41] We do. I am fortunate I am at an academic center. Like you, we have those tools available to us. We have social workers. We have nutritionists that we can bring in when they have dietary issues and things like that. Our nurses work really hard to make sure that they are helping patients get that financial assistance. Sometimes, it forces us to change the therapy if we cannot get that for them or if it is just too expensive.


Dr Faiman: [00:26:05] The pharmacies, the specialty pharmacies I think are useful, too. <<delete 26:10-26:14>>Most of the drug companies really want that patient to get the drug that is the best for them, too. Let us just step back a minute and talk about how you monitor your patients. The International Myeloma Working Group has set forth criteria for diagnosis as well as NTCN. That says we should do a CBC, CMP, SPEP, UPEP. LDH looks at risk stratification. How often are you in your practice, Sandy, monitoring myeloma labs and imaging? Is it monthly? I know from my experience, it is usually monthly and then after transplant, it can go up to every 3 months.


Ms Kurtin: [00:26:52] That is pretty much what we do. I think it gets back to the tempo of their disease and how it is behaving and what that risk profile looks like. In those higher risk patients, we tend to stick with the monthly monitoring. If they are not quite getting where we want them to be, they are here and they are stuck and they are doing this, we keep up that more frequent monitoring.


[00:27:20] We are not doing bone marrows that often obviously, but checking their blood because that is easy to do. The other thing is they want to know. It is all about having that conversation with them because they want to know what their numbers are. But then, there are those people that are much further out and they have met that depth of response, and you know they are in a good - - maybe, they are MRD-negative and then we are willing to spread that out a little bit further.


Dr Faiman: [00:27:51] Do you get a lot of treatment fatigue? I think when I am thinking about the side effects - - so for len maintenance, we will talk about diarrhea and GI and fatigue. Bortezomib, we worry about peripheral neuropathy is an issue which is an issue which is less now that we have the subQ formulation, and that is so nice. Usually, the onset is 4 to 6 months for the neuropathy, but if they did not get it by then, then most individuals will be okay. What about treatment fatigue? Do you do plan holidays or how do you have those discussions, Charise?


Ms Gleason: [00:28:22] We do especially for a patient who is a multi-drug maintenance regimen. Again, it is that monitoring of side effects. We will have patients that want to plan their holidays. Sometimes, the best thing we can do is able to take a month off and reassess. Patients will say holidays are coming up? How do you take that month off during the holidays? You need to do that. We would rather do that to keep a patient on therapy because you do not want them sprinkling. I stop. I start. I stop. I start. Planning the holidays are alright. We have that conversation, too, because patients are worried what happens if I stop for a month. Probably, disease was going to do what it was going to do anyhow in 1 month off. It is going to make things take off for you.


Ms Kurtin: [00:29:08] We have that conversation all the time that if we have taken you off drug for 2 weeks or 3 weeks or 4 weeks even and you progress or you have a biochemical relapse even, that was likely on its way.


Ms Gleason: [00:29:23] Sometimes, just restarting the medication can bring [crosstalk].


Dr Faiman: [00:29:28] I think one of the things I see a lot, a part of my dissertation research during PhD was lenalidomide-related diarrhea. It was my hypothesis that there was an autoimmune component because I noticed that patients that had diarrhea live longer, and that was a call to keep people on treatment longer. I use a lot of cholestyramine with myeloma patients. Any other strategies for managing diarrhea other then dose reduction because we want to keep control of the myeloma cells. The maintenance should be 10 or 15 milligrams according to the FDA indication daily. Any other strategies for diarrhea in lenalidomide?


Ms Gleason: [00:30:07] We do the same things that you discussed, fluids making sure monitoring the electrolytes...


Dr Faiman: [00:30:15] Periodic stool samples to make sure they did not have C diff or secondary...


Ms Gleason: [00:30:21] It is important to make sure they are up-to-date on their colonoscopies because we never want to just...


Dr Faiman: [00:30:28] The other thing I wanted to bring about in patients on maintenance would be supportive care. How do you protect them against infections or what are some of the things that you would like to discuss with the patients that are important. You talk about health maintenance, maintaining healthy behaviors to keep that worry bucket less full, stay healthy, stop smoking and do not start. What about health maintenance screenings or what are some of the things that you...


Ms Kurtin: [00:30:53] If they have any comorbidities at all, we really try to keep them connected to those other providers because we cannot be experts in diabetes and cardiovascular disease. I mean, we could be but that science is changing just as rapidly. You want to make sure that their everything is as much in balance as it can be. Maintaining those connections, making sure they do have a primary care physician. I am always shocked when you get into the computer and it says PCP in my name. No, I am not your PCP.


[00:31:29] If there are things that we have caused from their myeloma therapy, I feel like you broke it, you fix it or unless you try to help fix it. We do have to understand enough the mechanism of what is happening to be able to treat it. We know there are certain things - - anybody on the proteasome inhibitor needs an antiviral.

<<delete  31:52-32:05>> Really, anybody on...


Dr Faiman: [00:31:54 ] Shingles prevention.


Ms Kurtin: [00:31:54] ...on therapy needs an antiviral.


Dr Faiman: [00:31:59] Influenza, pneumococcal.


Ms Kurtin: [00:32:01] Exactly.


Dr Faiman: [00:32:02] Go to the


Ms Kurtin: [00:32:05] They need to be immunized. No live vaccines obviously. Those are all very important conversations to have particularly in the maintenance where you really - - their disease hopefully is under control and well-controlled. They need to be as well as they can be.


Dr Faiman: [00:32:24] Bone-modifying agents, how long do patients stay on bone strengtheners in your practice because the new recommendations from Dr Anderson in the JCO 2018 papers say that everybody with myeloma, regardless of bone disease, should be on it. How long do you use it in your practice?


Ms Gleason: [00:32:44] Typically, we use it monthly upfront and then about that year after or after transplant, we go down to every 3 months. We are stopping by 5 years. I know some people...


Dr Faiman: [00:32:58] Quarterly, we do, sometimes.


Ms Gleason: [00:32:59] It depends on how they are tolerating that as well - - again, dental exams, making sure that they are not having any issues. If there is any question, we hold it.


Dr Faiman: [00:33:09] Talking to the truth squad helps.


Ms Kurtin: [00:33:12] Yes.


Dr Faiman: [00:33:12] Finding out the quality of life, involving the caregiver is important. What if they do not have a caregiver? Do you have people that do not have that member that comes with them who just march in there on their own?


Ms Kurtin: [00:33:25] Those are the other group of people that we cannot transplant because the caregiver is prerequisite. You have to have a caregiver to get a transplant. We have actually had a couple of patients, believe it or not, who hired a healthcare provider to be a caregiver just so that they could get a transplant and then get through that phase.


Dr Faiman: [00:33:48] It is real-world stuff.


Ms Kurtin: [00:33:49] That is the reality.


Dr Faiman: [00:33:50] For maintenance myeloma, I think and I believe that you are pretty much in alignment with this is that it is important to involve family members and caregivers. Quality of life is so important so talk about side effects, common side effects such as GI, muscle cramping, peripheral neuropathy where they get that numbness and tingling and trying to select the right regimen for the patient.


[00:34:13] If they have high-risk cytogenetics, maybe, they do not want to transplant right now. You know that they are going to have to stay on some form of therapy, maybe even a maintenance therapy. What are some of the things just to conclude that you tell your patients when to get in touch with the treatment team? What are some big side effects?


Ms Gleason: [00:34:31] I think communication throughout is just key. We want patients to talk to us. Do not wait to that next visit if you are having issues, GI side effects, fevers, chronic infections especially this time of year. We are...


Ms Kurtin: [00:34:45] Give us a call.


Ms Gleason: [00:34:46] ...changes in those things you discussed with the neuropathy, things that just do not feel right to you. We want to hear about it.


Dr Faiman: [00:34:54] The usual fevers of over 100.4.


Ms Kurtin: [00:34:55] I basically say rather than focusing on a list, if there is something that is different and you do not feel good and it is persistent, just call us and we will say no big deal. Do this or hey, come on down, or go to the emergency room. We try to avoid getting to that point. This is where it is important to have the other people. I think the other really big thing to me about communication is something I call consistency of message, which is where hopefully what you say and then what I say as to say, if you are the physician and then I maybe the nurse practitioner and now, you are the nurse, hopefully that storyline is more the same than different. We are all having these conversations based on the science and reinforcing these key points so that people get those reinforcements regardless of who they talk to in the team.


Dr Faiman: [00:35:53] Very important. Thank you so much for participating in this learning activity. I love this Nurses' View series, and I hope you love it, too. I want to thank you for participating in this activity. Please continue on to answer the questions that follow and complete the evaluation. I hope you have a good day.

 [END 21818 - 262449_01_RT_Faiman_101818 (37 min).m4a]

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