Shared Decision Making
Deciding that treatment is necessary is the most pressing initial decision post-diagnosis. Since all treatments have side effects, treatment must be medically necessary and the benefits of treatment must outweigh unwanted side effects. The provider and the patient should make individualized decisions together regarding treatment. The treatment should be based on the medical situation, but also patient preference. Treatment will change through the course of the disease, and thus these questions should be revisited over time.
The Nurse Leadership Board recommends the Agency for Health Care Research and Quality’s (AHRQ) SHARE Approach.
The 5 steps to SHARE:
- Seek your patient’s participation
- Help your patient explore and compare treatment options
- Assess your patient’s values and preferences
- Reach a decision with your patient
- Evaluate your patient’s decision
Sequencing of Treatment
A number of medical factors will be taken into consideration when identifying therapy options such as patient fitness, eligibility for a stem cell transplant, genetic biomarkers and prior therapy history. The IMWG is a valuable resource for treatment guidelines.
- IMWG Consensus Statement on treatment for those eligible for transplant
- IMWG Consensus Statement on treatment for those not eligible for transplant
- IMWG Consensus Statement on treatment of those with high-risk cytogenetics
- Risk Classification based on genetic biomarkers
- An Overview of Currently Approved Myeloma Drugs summarized here:
Source: Faiman B, et al. J Adv Pract Oncol. 2016:7(suppl 1):17-29. Joseph Mikhael, MD, Med https://www.medscape.com/viewarticle/882042. NCCN Guidelines. Multiple Myeloma. V2.2019.
“High Dose Therapy (HDT) with autologous stem cell rescue" is the standard of care for myeloma patients who are fit enough to undergo the procedure. The procedure has come to be known simply as “transplant”. The intent is to provide high dose chemotherapy to ablate the myeloma clone. Stem cells are “transplanted” to help a person recover from the collateral damage from the chemotherapy. In myeloma, the transplant procedure is safest for patients when their own stem cells are harvested and used as the replacement cells, referred to as “autologous” stem cell transplant (ASCT). ASCT is the standard approach in myeloma. An “Allogenic” transplant is when donor cells are used.
The IMWG has established a consensus statement regarding the treatment approach for transplant candidates, as well as a consensus statement on the current status of allogeneic stem-cell transplantation for myeloma. The phases of the transplant timeline are as follows:
|Phase 1: Pre-Transplant||Phase 2: Peri-Transplant||Phase 3: Post-Transplant|
|End||Stem cell collection||Engraftment|
There are a number of nursing considerations leading up to, during and following the transplant procedure that should be taken into account:
- Nursing considerations for transplant-related drugs
- Immunizations are essential for infection prevention. One sample post-transplant vaccination schedule is provided, but schedules may vary by institution as well as patient health status and prior immunity. Live vaccines are not recommended.
- Managing post-transplant symptoms including fatigue, anxiety, and depression
- Car-T Cell Therapy Update: Separating Hype from Hope
- The Potential of Car-T Therapy and the Patient Journey – a white paper by the Nurse Leadership Board
For those not eligible for transplant, the IMWG provides a consensus statement regarding management, treatment and care of non-transplant eligible patients.
Optimizing Quality of Life
Validated self-report tools benefit the advanced practitioner in assessing the impact of myeloma and treatment on quality of life. They are one tool in individualizing supportive care to the patient’s specific needs.
The following resources can assist in measuring patient Quality of Life:
- International Psycho-Oncology Society (IPOS)
- International Society of Quality of Life Research (ISOQOL)
- European Organization for Research and Treatment of Cancer (EORTC)
- Patient Reported Outcomes version of the National Cancer Institute Common Terminology Criteria for Adverse Events (PRO-CTCAE)
- Patient-Reported Outcome Measurement Information System (PROMIS)
- International Consortium for Health Outcomes Measurement (ICHOM)
Adherence to treatment by the myeloma patient is important, given the expectation of long-term survival with myeloma and the development of numerous oral agents used in treatment. The advanced practitioner is better able to support the myeloma patient if the barriers to adherence and resources available to the patient are understood. The Nurse Leadership Board’s white paper The Current Therapeutic Landscape and the Patient Experience discusses barriers to care and strategies for overcoming them. The IMF provides an up-to-date list of Pharmaceutical Assistance Programs for Novel Agents Approved for Myeloma.
Maintenance, or continuous therapy, is treatment that is ongoing in order to sustain or improve the response from prior therapy. Maintenance can often last for multiple years and often includes Revlimid (lenalidomide). The tradeoffs of potential benefits, side-effects, and cost should be discussed by the practitioner and the patient before proceeding. The IMWG has provided a consensus statement on maintenance therapy.
When relapse is suspected, typically, a full set of lab tests similar to those done at diagnosis will be performed. This may include a bone marrow test and imaging, and genetic testing with FISH and/or cytogenetics to re-assess the risk status. Kidney, heart, lung, or other testing (including biopsy) may be required as well.
Numerous treatment options are available for relapse:
|FDA-Approved Myeloma Therapies||Common Combinations|
|Velcade (bortezomib)-V (SQ admin)||VRD, Vd|
|Revlimid (lenalidomide)-R||VRD, Rd|
|Kyprolis (carfilzomib)-K||KRd, Kd, K|
|Pomalyst (pomalidomide)-P||Pd, DPd, EPd, PCd|
|Darzalex (daratumumab)-D||DRd, DVd, DPd, D-VMP|
|Empliciti (elotuzumab)-E||ERd, EPd|
|Farydak (panobinostat)||Panobinostat + Vd|
|Xpovio (selinexor)||Selinexor + d|
|Doxorubicin||Liposomal doxorubicin + V|
Source: Faiman B, et al. J Adv Pract Oncol. 2016:7(suppl 1):17-29.
Dexamethasone(d) and other steroids are an important part of myeloma treatment combinations.
Clinical trial participation should be considered an option during all phases of treatment, including relapse. Learn more by visiting NLB Resource: Clinical Trials.
The patient and caregiver should be familiar with the members of their treatment team.
A teleconference by members of the Nurse Leadership Board provides guidance to patients on how to talk with their healthcare team: How to Talk with Your Healthcare Team about What’s Best for You.
This publication discusses the option of autologous stem cell transplant (ASCT) for the treatment of myeloma.
Advance Practitioner's Guide to Multiple Myeloma
JADPRO Vol. 7 | Supplement 1 | March 2016
- The Continuum of Care in Multiple Myeloma Redefined: Challenges and Opportunities
- Sequencing of Treatment and Integration of Clinical Trials
- Palliative Care in Multiple Myeloma
- New Agents in the Treatment of Multiple Myeloma
- Monoclonal Antibodies in the Treatment of Multiple Myeloma
- Updates in the Diagnosis and Monitoring of Multiple Myeloma
- Adherence, Persistence, and Treatment Fatigue in Multiple Myeloma
- Resources for Patients and Caregivers With Multiple Myeloma and Their Providers
- Multiple Myeloma Treatment Options for Newly Diagnosed, Relapsed, and Refractory Disease
Clinical Journal of Oncology Nursing
Supplement Vol. 17 Num. 6 | December 2013
Hematopoietic Stem Cell Transplantation and Multiple Myeloma
Seminars in Oncology Nursing
Vol. 33 issue 3 | August 2017
Comprised of oncology-certified nurses, the Nurse Leadership Board has extensive knowledge of the multiple myeloma treatment and care landscape. These resources were developed by their team.
Last Medical Review: August 1, 2019