Advances in multiple myeloma treatment over the past decade have transformed the prognosis for many patients, but the same treatment advances require oncology nurses to be more aware of potential side effects of medications and to play a greater role in monitoring and educating patients about them.
“I work day in and day out with multiple myeloma patients, and have seen a major transformation in the last five to ten years,” said Beth Faiman, RN, MSN, CNP, a nurse practitioner in the Multiple Myeloma Program at the Cleveland Clinic Foundation. “For patients diagnosed ten years ago, survival was only about two years, and the best we could offer them was palliative care. But today patients are surviving much longer with the newer treatment options, and this means we need to reassess our role as nurses caring for such patients and be more aware of potential side effects of newer medications and how to ameliorate them.
“We must be willing to take a leadership role in educating patients about them and monitoring their response.”
Ms. Faiman is an active author, presenter, and educator on multiple myeloma and sits on the Nursing Leadership Board for the International Myeloma Foundation. She has also contributed two chapters to a new textbook from the Oncology Nursing Society on the topic, Multiple Myeloma: A Textbook for Nurses” (ISBN: 1890504939).
Lenalidomide, Thalidomide, Bortezomib
In addition to chemotherapy followed by stem cell transplants in young patients, three major drugs have become the mainstays of treatment: lenalidomide, thalidomide, and bortezomib. Alone or combined with other drugs, these agents have dramatically changed the prognosis for patients, Ms. Faiman pointed out.
“Patients are living longer, but understanding and helping manage the side effects of treatment present a unique challenge for nurses. The first step is educating nurses about what they should be looking for, and the second is how they should respond.”
As is the situation for many drugs, the most common side effects associated with myeloma treatment are gastrointestinal, such as constipation, diarrhea, nausea, vomiting, and weight loss. Ms. Faiman noted that diarrhea can occur within the first 24 to 48 hours after each dose of bortezomib and lenalidomide, but there are many nonpharmacological options nurses can recommend, such as increasing fluid intake and avoiding fiber and caffeine or carbonated drinks.
Antidiarrheal agents should be used with caution, however, and intravenous hydration may be necessary for extreme cases, she continued. In some patients with severe symptoms, dose reduction is warranted. A stool culture should be also taken in patients to check for Clostridium difficile bacteria.
Steroids also come with a range of potential side effects. Those used most often to treat myeloma include dexamethasone, prednisone, and prednisolone, either individually or in combination with other drugs. Steroids can affect the entire body and cause leukocytosis, steroid myopathy, muscle cramping, osteonecrosis, osteoporosis, or edema, and effective management requires both careful clinical monitoring of patients and educating them and their caretakers about the symptoms and what pharmacological and nonpharmalogical measures can help ease them.
Blood clotting issues are a major concern with most myeloma patients, Ms. Faiman noted. “All of the treatments currently in use can cause blood clotting, but especially thalidomide. Regular blood tests are necessary to watch for increased biomarkers of clotting issues.”
These include monitoring platelet and leukocyte counts, as well as hemoglobin levels, all of which are associated with an increased risk of cancer-associated venous thromboembolisms.
For eligible patients with elevated biomarkers, blood thinners can be given, or treatment can be withheld or reduced until levels fall—at the very least, all multiple myeloma (MM) patients should be taking daily aspirin, she said.
One of the most common side effects—and one that patients are often hesitant to mention—is peripheral neuropathy, which is characterized by tingling, numbness, or pain in the extremities. Nurses need to question patients about whether they are having any of the symptoms at every session, Ms. Faiman said.
“Around 85 percent of MM patients experience peripheral neuropathy, and it can get worse with time, but many MM patients don't link symptoms to treatment or are afraid that saying anything about it might mean that they will have to stop taking their medication. It's up to us to ask because we can withhold treatment for a while or lower the dose, and that seems to help. Patients need to know that this will not compromise treating their disease, which is their biggest fear.”
Bortezomib can delay progression of myeloma when combined with the synthetic steroid dexamethasone, she explained. Administered intravenously twice a week, the drug is also associated with an increase in peripheral neuropathy, typically within the first four months, but by the end of treatment, most patients will have even mild neuropathy.
‘Monitor and Educate’
The Nurse Leadership Board of the Multiple Myeloma Foundation published guidelines in 2008 to help nurses recognize, educate, and help ameliorate side effects from treatment. The guidelines detail specific protocols and procedures that nurses can use to help myeloma patients optimize their treatments, manage side effects, and receive the support they need.
“With nurses educating patients regarding signs of potential side effects and coordinating appropriate medical management, we believe more patients will stay on their medications and continue to reap the full benefit of their therapies,” Ms. Faiman said.
“If patients have more than two risk factors for clotting or cardiovascular risk, they need to be put on low molecular weight heparin. But as nurses we need to be aware of these things in order to educate, support, and help patients with their treatment regimen.”
Needed: Long-Term Care Plan
“If I could emphasize only one thing,” Ms. Faiman summed up, “it is that patients today need a long-term care plan. It used to be that patients lived only two years after developing the disease, but now it's up to 10 years, and even longer. Because they will be on these medications, they need a plan to protect their kidneys, their bones, and have other health maintenance routines.
“Often when someone gets diagnosed with cancer and starts treatment, they forget about other health issues, such as exercise and cholesterol levels. We need to impress on them the importance of taking care of themselves, not just making sure they are taking their meds.”
Book for Nurses from International Myeloma Foundation & Oncology Nursing Society
The Nurse Leadership Board of the International Myeloma Foundation (IMF) has published a book with guidelines designed to help nurses manage care for myeloma patients. The book, a news release notes, is the first written and edited by expert myeloma nurses for other nurses, with each chapter written by one of several members of the Nurse Leadership Board.
“Oncology nurses are closely involved in their patients' care, play an active role in educating patients before and during their therapies, and offer support and solutions when problems arise,” said the book's editor, Joseph D. Tariman, PHC, MN, APRN-BC, OCN, predoctoral fellow in the Biobehavioral Nursing Research Program at the University of Washington.
“As nurse leaders with the IMF, we felt it was important to share our knowledge and experience in this book to empower other nurses to help their myeloma patients. The guidelines and advice shared in this book will provide nurses with important new tools to enhance their myeloma patients' treatment.”
The Nurse Leadership Board is a partnership between the IMF and 20 oncology nurses from leading centers treating myeloma in the United States. The 287-page book, the authors note, builds on previously published treatment guidelines to provide a vehicle for expert myeloma nurses to formally share their knowledge and experience with other oncology nurses and community-based colleagues who may see few myeloma cases each year.
Multiple Myeloma: A Textbook for Nurses ($54, ISBN 978-1-89054-93-9) is available from the ONS—further information is available at http://esource.ons.org/ProductDetails.aspx?sku=INPU0598
Choosing to Specialize in Myeloma
Beth Faiman said her decision to focus on helping to improve the care of multiple myeloma patients began when she first encountered such individuals in nursing school in the mid-1990s, when treatment options were limited and life expectancy was low: “I found that I gravitated toward these patients, and in 1999 decided to specialize in MM care. Dr. Mohamad Hussein was then the specialist at Cleveland Clinic, and I recognized his passion for these patients. He became my mentor and a great influence on my specialization in the field.”
Ms. Faiman is currently working toward a PhD, in order to get even more actively involved in myeloma research, she said.