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leading the way managing multiple myeloma for the long term

Leading the Way: Managing Multiple Myeloma for the Long -Term

Accredited by Medical Education Resources

Supported by The International Myeloma Foundation

Grant Funding Provided by Celgene Corporation and Millennium – The Takeda Oncology Company

welcome and introductions

Welcome and Introductions

Beth Faiman, MSN, APRN-BC, AOCN

Cleveland Clinic Taussig Cancer Institute

Cleveland, OH

slide3

ONS Disclaimer

Meeting space has been assigned to provide a satellite symposium supported by the International Myeloma Foundation via an unrestricted educational grant during the Oncology Nursing Society’s (ONS) 34th Annual Congress, April 30 to May 3, 2009, in San Antonio, TX. The Oncology Nursing Society’s assignment of meeting space does not imply product endorsement, nor does the Oncology Nursing Society assume any responsibility for the educational content of the symposium.

symposium accreditation
Symposium Accreditation
  • This continuing education activity provides 2.0 contact hours.
  • Medical Education Resources is an approved provider of continuing nursing education by the Colorado Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Please complete the CE Certificate Registration and Program Evaluation Form found in your guidebook and return it to the registration desk.
additional accreditation
Additional Accreditation

Additional 3.8 CEU accreditation opportunity –

Clinical Journal of Oncology Nursing (CJON) June 2008 supplement publication of the International Myeloma Foundation’s (IMF) Nurse Leadership Board (NLB) ‘Consensus Statements’ located at your table

faculty
Chair:

Beth Faiman, MSN, APRN-BC, AOCN

Cleveland Clinic Taussig Cancer Institute

Cleveland, OH

Faculty

Faculty:

Joseph D. Tariman, PhC, MN, APRN-BC, OCN

University of Washington

Seattle, WA

Sandra Rome, RN, MN, AOCN

Cedars-Sinai Medical Center

Los Angeles, CA

Tiffany Richards, MS, ANP, AOCNP

MD Anderson Cancer Center

Houston, TX

learning objectives
Learning Objectives
  • Describe updated data on novel agents used in the management of patients with multiple myeloma (MM)
  • Discuss critical issues in nursing management and medical implications of major side effect management with novel therapies in MM.
  • Understand the value of Survivorship Care planning, education and care.
  • Describe known and potential late side effects of MM and its treatment.
  • Identify ways to improve quality of care.
multiple myeloma a current perspective
Multiple Myeloma: A Current Perspective
  • Etiology of multiple myeloma (MM).
  • Epidemiology of MM.
  • Current and novel therapies in the management of MM.
what is multiple myeloma
What Is Multiple Myeloma?
  • Cancer of plasma cells.
  • Healthy plasma cells produce antibodies or immunoglobulins.
    • Part of our humoral immunity, they are released in response to foreign body invasion.
  • Myeloma cells produce abnormal immunoglobulin.
    • Overproduce monoclonal protein or paraprotein.
    • Ineffective immunoglobulins.
    • Leads to decreased bone marrow function.
    • Destruction of bone tissue.

San Miguel JF, et al. Pathogenesis of Multiple Myeloma: Rationale for New and Novel Therapies. Clinical Care Options:http://clinicaloptions.com/Oncology/Treatment%20Updates/Myeloma/Modules/Pathophysiology/Pages/Page%203.aspx.

slide11

Myeloma Cells Are Distinguished From Normal Plasma Cells by the Presence of Large Nuclei That Are Often Eccentric

Vescio R. Multiple Myeloma & Amyloidosis Program,Jonsson Comprehensive Cancer Center/Cedars–Sinai Medical Center, 2005.

multiple myeloma abnormal proliferation of malignant plasma cells

Multiple Myeloma: Abnormal Proliferation of Malignant Plasma Cells

Kyle and Rajkumar, N Engl J Med 2004;351:1860-1873

multiple myeloma epidemiology
Multiple Myeloma: Epidemiology
  • Second most common hematological malignancy.
  • Incidence and rates:
    • 1% of all cancers
    • US incidence: 19,900 new cases per year
    • US prevalence: 100,000 patients
    • Deaths: estimated 10,790 per year
  • More than 80% of affected patients >age 60.
  • Affects slightly more men than women (1.6:1).

Merck Manual Professional. 2005; George ED, et al. Am Fam Phys. 1999;59(7):1401-1405.

clinical manifestations of multiple myeloma
Clinical Manifestations of Multiple Myeloma
  • Overproliferation of plasma cells can cause:
    • Risk of infection
    • Osteolytic bone lesions
    • Hypercalcemia
    • Bone marrow suppression (pancytopenia)
    • Renal complication risk
  • Production of monoclonal M proteins causes:
    • Decreased levels of normal immunoglobulins
    • Hyperviscosity

http://myeloma.org/pdfs/ph07-eng_f2.pdf

major symptoms at diagnosis
Major Symptoms at Diagnosis
  • Bone pain - 58%
  • Fatigue - 32%
  • Weight loss - 24%
  • Paresthesias - 5%
  • Asymptomatic - 11%

Kyle RA. Mayo Clin Proc 2003;78:21

common sites for bone involvement
Common Sites for Bone Involvement

Skull

Spine

Thoracic

Lumbar

Vertebrae

Pelvis

Long bones

Spinal cord – compression can occur

http://www.emedicine.com/Radio/topic460.htm#section~Introduction

criteria for diagnosis of multiple myeloma
Criteria for Diagnosis of Multiple Myeloma
  • Monoclonal plasma cells present in the bone marrow ≥10%, and/or presence of a documented plasmacytoma.

+

  • Presence of M component in serum and/or urine.*+
  • One or more of the following (CRAB criteria):
    • Calcium elevation (serum calcium >11.5 mg/dL)
    • Renal insufficiency (serum creatinine >2 mg/dL)
    • Anemia (hemoglobin <10 g/dL or 2 g/dL <normal)
    • Bone disease (lytic lesions or osteopenia)
  • *Monoclonal M spike on electrophoresis IgG >3.5 g/dL, IgA >2 g/dL, light chain >1 g/dL in 24-hour urine sample.

Durie et al for the International Myeloma Working Group. Leukemia. 2006:1-7.

diagnostic evaluation of multiple myeloma
Diagnostic Evaluation of Multiple Myeloma

Alb = albumin; CBC = complete blood count; Creat = creatinine; Hgb = hemoglobin; MRI = magnetic resonance imaging; WBC = white blood cell.

Abella. Oncology News International. 2007;16:27;Barlogie et al. In: Williams Hematology. 7th ed. 2006:1501; Durie et al. Hematol J. 2003;4:379; MMRF. Multiple Myeloma: Disease Overview. 2006. www.multiplemyeloma.org; Rajkumar et al. Blood. 2005;106(3):812.

durie salmon staging system for multiple myeloma
Durie-Salmon Staging System for Multiple Myeloma

Subclassification criteria:

A Normal renal function (serum creatinine level <2.0 mg/dL)

B Abnormal renal function (serum creatinine level 2.0 mg/dL)

Durie and Salmon, Cancer 1975;36(9):842-854

international staging system for symptomatic multiple myeloma
International Staging System for Symptomatic Multiple Myeloma

2M=serum 2 microglobulin in mg/dL; ALB=serum albumin in g/dL

Greipp PR, et al. Blood 2005; 102: 190a

challenges in mm management
Challenges in MM Management
  • Currently incurable in most patients.
  • Long-term complete responses are rare.
  • Median survival with standard therapy is about 3 years.
  • Autologous stem cell transplant may prolong progression free survival, but it’s not curative.
  • Treatment of relapse:
    • No standard therapy.
    • Existing options inadequate.

New treatment options needed.

NCCN Practice Guidelines; Rajkumar et al. Mayo Clin Proc. 2002;77:813-822.

mm treatment options
MM Treatment Options
  • Conventional chemotherapy:
    • Melphalan
    • Doxorubicin
    • Cyclophosphamide
  • Steroid therapy:
    • Dexamethasone
    • Prednisone
  • Novel therapeutics:
    • Thalidomide
    • Lenalidomide
    • Bortezomib
  • Stem cell transplantation:
    • Autologous
    • Allogenic
  • Radiation therapy

Thalomid® Prescribing Information, Revlimid® Prescribing Information; Velcade® Prescribing Information

update on novel therapies

Update on Novel Therapies

Joseph Tariman, PhC, MN, APRN-BC, OCNUniversity of Washington Seattle, WA

nccn review categories
NCCN Review Categories

*Combinations recently reviewed by NCCN

Generic Name Trade Name

Bortezomib Velcade

Lenalidomide Revlimid

Thalidomide Thalomid

NCCN Categories of Evidence and Consensus:

1 High-level evidence, uniform consensus

2A Lower-level evidence, uniform consensus

2B Lower-level evidence, non-uniform consensus

NCCN Clinical Practice Guidelines in Oncology, v2 2009

recent and ongoing clinical studies
Recent and Ongoing Clinical Studies
  • Transplant-eligible patients
    • Bortezomib/Thalidomide/Dexamethasone (VTD) vs Thalidomide/Dexamethasone (TD)
    • Bortezomib/dexamethasone
    • Lenalidomide/low-dose Dexamethasone (Rd)
  • Transplant-ineligible patients
    • VISTA: Bortezomib/Melphalan/Prednisone (VMP) vs Melphalan/Prednisone (MP)
    • Lenalidomide/low-dose Dexamethasone (Rd)
  • New combinations and early studies
    • Transplant-eligible patients
      • Bortezomib/Lenalidomide/Dexamethasone
      • Bortezomib/Lenalidomide/Dexamethasone vs Bortezomib/Dexamethasone
    • Transplant-ineligible patients
      • MTP vs MPR (Phase III)
      • VMP vs Bortezomib/Thalidomide/Prednisone (VTP) (Phase III)
    • Early studies
      • Bortezomib/Vorinostat (Phase I)
vtd vs td in patients who are transplant eligible
VTD vs. TD in Patients Who Are Transplant Eligible

Phase III Bortezomib-Thalidomide-Dexamethasone (VTD) vs Thalidomide-Dexamethasone (TD) Prior to Stem Cell Transplantation (SCT))

  • Study objective
    • VTD vs TD in preparation for autologous stem cell transplantation (ASCT)
  • Study design
    • Randomized trial
    • Three cycles of induction therapy
  • Methods
    • Pts. randomized to either VDT (n=199) or TD (n=200).
    • Stem cells were collected.
    • Consolidation therapy with same treatment to pts.
    • Results drawn from a final analysis of 399 patients.

Cavo et al. Blood 2008 112: Abstract 158

slide27

Conclusions From VTD vs. TD

  • Prophylaxis
    • Acyclovir prophylaxis against reactivation of VZV.
    • TEE prophylaxis with low molecular weight heparin, aspirin, or warfarin; fixed low-dose warfarin is effective.
  • Conclusions:
    • In comparison with TD, 3 21-d cycles of VTD as primary therapy significantly increased CR+nCR rates.
    • These response rates translated into significantly higher CR+nCR after first ASCT in the VTD arm.
    • Combinations of novel induction agents, such as VTD, can have a remarkable impact on both pre- and post-ASCT clinical outcome.

Cavo et al. Blood 2008 112: Abstract 158

bortezomib and dexamethasone prior to asct in transplant eligible patients
Bortezomib and Dexamethasone Prior to ASCT in Transplant-Eligible Patients
  • Phase III, active control, multicenter, open label, randomized
    • Objective: compare the CR rate with vincristine/adriamycin/dexamethasone (VAD) and bortezomib/dexamethasone combinations as induction therapy.
  • Number of severe AE was similar between the arms:

Harousseau et al, Blood 2007 110: Abstract 450.

conclusions from bortezomib and dexamethasone prior to asct
Conclusions From Bortezomib and Dexamethasone Prior to ASCT
  • Post-induction complete remission (CR) was increased by VD compared to VAD.
  • One-year PFS and OS rates were 93% and 97% with VD and 90% and 95% with VAD, respectively.

Harousseau et al, Blood 2007 110: Abstract 450.

vista trial vmp vs mp in transplant ineligible patients
VISTA Trial: VMP vs MP in Transplant-Ineligible Patients

A Phase 3 Study Comparing Bortezomib/Melphalan/Prednisone (VMP) With Melphalan/Prednisone (MP)

  • Study objective:
    • Define the differences in efficacy and outcome between VMP vs MP
  • Study design and method:
    • VMP arm (IV Bortezomib in combination with oral prednisone and oral melphalan) vs MP arm (oral melphalan and prednisone)
  • Primary endpoint:
    • Time to progression (TTP)
  • Secondary endpoints:
    • Progression-free survival (PFS), overall survival (OS), overall response rate (ORR), time to progression (TTP) and duration of response (DOR), andsafety

San Miguel et al Blood 2007 110: Abstract 76; San Miguel et al Blood 2008 112: Abstract 650; Harousseau et al Blood 2008 112: Abstract 650 Mateous et al. Haematologica 2008; 93(4), 560-565

slide31

VISTA Trial: VMP vs. MPMost Common Adverse Events (in ≥30% Patients) receiving VMP (n=60)

Mateos, et al. Haematologica 2008; 93(4) 560-565

vista updated results
VISTA: Updated Results

OS

100

VMP

90

MP

80

70

60

Pts w/o Event (%)

50

40

Median follow-up: 25.9 mosVMP: median OS not reached (75 deaths); 3-yr OS rate: 72%MP: median OS not reached (111 deaths); 3-yr OS rate: 59%

HR = 0.644; P = .0032

30

20

10

0

Months

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

  • VMP associated with ~36% reduced risk of death.
  • 43% of pts in the MP arm who had subsequent therapy received Bortezomib upon disease progression.
  • Pts who received >4 cycles of Bortezomib:
    • 1- and 2-yr OS: 98.5% and 89%, respectively

San Miguel JF, et al. Blood 2008 112: Abstract 650.

slide33

VISTA Trial: VMP vs. MP

These results establish VMP as another option for patients not eligible for SCT.

Conclusions

  • Adverse events
    • 46% with VMP
    • 36% with MP
  • Patients remained on therapy longer with VMP:
    • 46 weeks with VMP
    • 39 weeks with MP
  • Patients had a longer time to next therapy.
  • Patients also had longer treatment-free survival.

San Miguel et al Blood 2007 110: Abstract 76; San Miguel et al. Blood 2008 112: Abstract 650.

slide34
Lenalidomide/Dexamethasone (RD) vs Lenalidomide/Low-Dose Dexamethasone (Rd) in Transplant-Ineligible Patients
  • Randomized multicenter Phase III ECOG E4A03 study
    • RD arm (223 patients)
      • Lenalidomide 25 mg (days 1-21)
      • Dexamethasone 40 mg (days 1-4,9-12,17-20)
    • Rd arm (222 patients)
      • Lenalidomide 25 mg (days 1-21)
      • Dexamethasone 40 mg (days 1,8,15,22)
    • Primary endpoint: response rate at 4 months

Rajkumar et al, Blood 2007 110: Abstract 74

results from lenalidomide dexamethasone rd vs lenalidomide low dose dexamethasone rd
Results From Lenalidomide/Dexamethasone (RD) vs Lenalidomide/Low-Dose Dexamethasone (Rd)

Rajkumar et al, Blood 2007 110: Abstract 74; Jacobus et al., Blood 2008 112: Abstract 1740

results from rd vs rd
Results From RD vs Rd
  • Rd is associated with superior OS compared to RD in NDMM patients.
  • Increased mortality in RD arm is due to disease progression as well as increased toxicity.
    • Prevention of venous thrombotic events is a priority for both combinations.

Rajkumar et al, Blood 2007 110: Abstract 74; Jacobus et al., Blood 2008 112: Abstract 1740

emerging new treatments in early development
Emerging New Treatments in Early Development
  • Single agents are limited in efficacy, likely to be used in combinations.
    • Bortezomib, lenalidomide, and thalidomide are being explored for combination regimens.
  • Combining agents directed at different targets may provide synergistic response without an increase in side effects.

ASH 2008 Highlights for Physicians

bortezomib lenalidomide dexamethasone in patients who are transplant eligible
Bortezomib/Lenalidomide/Dexamethasone in Patients Who Are Transplant Eligible
  • First-line Phase I/II study assesses safety and efficacy (66 patients).
    • Lenalidomide 15 to 25 mg (days 1-14)
    • Bortezomib 1.0 to 1.3 mg/m2 (days 1, 4, 8, 11)
    • Dexamethasone 40/20-mg (cycles 1-4/5-8) (days 1, 2, 4, 5, 8, 9, 11, 12)
    • Up to 8 21-day cycles
  • Manageable toxicities
    • All G3/4 hematological (3-15%)
    • G3 hypophosphatemia (8%)
    • DVT/pulmonary embolism (5% with daily aspirin)
    • No treatment-related mortality
  • Overall response rate was 98% (at maximum planned dose – 100%)
    • VGPR 71%
    • CR/nCR 36%

VRD was efficacious and well-tolerated in NDMM patients.

Richardson et al, Blood 2008 112: Abstract 92

slide39
Bortezomib/Lenalidomide/Dexamethasone vs Bortezomib/Dexamethasone Study in Transplant-Eligible Patients
  • Randomized, multicenter Phase III study ECOG E1A05 (initiated in August 2008)
    • Consolidation therapy for patients after dexamethasone- based induction.
    • VRD regimen
      • Bortezomib 1.3 mg/m2 (days 1, 4, 8, 11)
      • Lenalidomide 15 mg (days 1-14)
      • Dexamethasone 40 mg (days 1, 8, 15)
    • VD regimen
      • Bortezomib 1.3 mg/m2 (days 1, 4, 8, 11)
      • Dexamethasone 40 mg (days 1, 8, 15)
  • Primary endpoint: PFS
    • SCT is deferred until relapse
  • The strategy will further prolong survival.

Fonseca and Rajkumar, Clin Lymphoma and Myeloma 2008 5: 315-317

mpt vs mpr in patients who are transplant ineligible
MPT vs MPR in Patients Who Are Transplant Ineligible
  • Randomized multicenter Phase III ECOG E1A06 study
    • MPT regimen
      • Melphalan (days 1-4)
      • Prednisone (days 1-4)
      • Thalidomide (days 1-28)
    • MPR regimen
      • Melphalan (days 1-4)
      • Prednisone (days 1-4)
      • Lenalidomide (days 1-21)
    • 28 days for up to 12 cycles
    • Primary objective: PFS, OS

http://clinicaltrials.gov/ct2/show/NCT00602641?term=e1a06&rank=1

vmp vs vtp
VMP vs. VTP

Exploring Alkylating (Melphalan) and Immunomodulatory (Thalidomide) Combinations With Bortezomib in Phase III Study in Elderly Transplant-Ineligible Patients

  • Study Design
    • VMP Arm (80 patients):
      • IV Bortezomib 2x weekly for 1 6-week cycle
      • IV Bortezomib 1x weekly for 5 5-week cycles + oral Melphalan/Prednisone 1xd on days 1-4 of each cycle
    • VTP Arm (87 patients):
      • IV Bortezomib 2x weekly for 1 6-week cycle
      • IV Bortezomib 1x weekly for 5 5-week cycles + oral Prednisone 1xd and continuous Thalidomide on days 1-4 of each cycle
  • Primary End Point
    • Overall response rate (ORR)

Mateos et al. Blood 2008 112: Abstract 651

slide42

Conclusions From VMP vs. VTP

6 cycles: 31 weeks of treatment)

  • Incidence of non-hematological AE (especially cardiac) was higher in the VTP arm, resulting in more serious AEs and treatment discontinuations
  • Thalidomide may not be a partner of choice for Bortezomib
    • - Lenalidomide should be explored

Mateos et al. Blood 2008 112: Abstract 651

bortezomib and vorinostat in early clinical studies
Bortezomib and Vorinostat in Early Clinical Studies
  • Vorinostat (Zolinza): a synthetic inhibitor of the histone deacetylases (HDACs)
    • Inhibits cell cycle and survival of cancer cells
    • FDA-approved for some types of lymphoma
  • Study design:
    • Non-randomized, open label, parallel assignment, safety study, treatment, uncontrolled
    • 34 patients with relapsed/refractory MM
  • Objectives:
    • Primary: MTD
    • Secondary: safety and tolerability as measured by disease progression or unacceptable toxicity during each treatment cycle

Weber et al, Blood 2008 112: Abstract 871

vorinostat plus bortezomib conclusions
Vorinostat Plus Bortezomib: Conclusions

Combination of Vorinostat plus Bortezomib is active for treatment of multiple myeloma in the early study.

Weber et al, Blood 2008 112: Abstract 871

slide45

Future Direction of New Therapy Combinations & Protocols of Novel Therapies

  • New combinations of novel therapies may offer personalized targeted therapy by inhibiting specific pathways in myeloma development
    • Bortezomib and Thalidomide have moved from the relapsed/refractory indications to first-line therapy positions
    • Lenalidomide is expected to follow
  • The trend is to use novel drugs and established chemotherapies in combinations
  • MM is perceived as a chronic, long-term disease

ASH 2008 Highlights for Physicians

conclusions
Conclusions
  • Novel combination therapies have great potentials in improving response rate, time to progression, progression-free survival, and overall survival outcomes.
  • Randomized clinical trials are needed to compare which of these novel combinations will offer patients better OS balanced with a good quality of life.
slide47

Management and Treatment of Emergent Side Effects and Defining Long-Term Effects of Multiple Myeloma

Beth Faiman, MSN, APRN-BC, AOCNCleveland Clinic Taussig Cancer Institute Cleveland, OH

five major categories of side effects for novel mm treatments
Five Major Categories of Side Effects for Novel MM Treatments
  • Myelosuppression
  • Thromboembolic events
  • Peripheral neuropathy
  • Gastrointestinal side effects
  • Steroid-associated side effects
  • Challenge for nursing management of emergent side effects:
    • Lack of effective practitioner-based guidelines produces a barrier to providing optimal patient care

IMF-NLB ‘Consensus Statements’ CJON June 2008

myelosuppression definition and symptoms
Myelosuppression: Definition and Symptoms
  • Anemia
  • Fatigue, malaise and SOB

Red BloodCells

Lymphocyte

Monocyte

Marrow

WhiteBloodCells

Eosinophil

  • Neutropenia
  • Increased risk of bacterial, fungal, and viral infections

Basophil

Neutrophil

  • Thrombocytopenia
  • Bruising and bleeding

Platelets

http://www.schneiderchildrenshospital.org/peds_html_fixed/peds/transplant/bonetran.htm; NLB Consensus Recommendations. CJON June 2008

management of myelosuppression
Management of Myelosuppression
  • General recommendations:
    • Monitor signs and symptoms
    • Monitor CBC
    • Educate on signs and symptoms
  • Myelosuppression management:
    • Growth factor therapy
    • Dose reduction as appropriate
    • Transfusion as indicated

Adapted from NLB Consensus Recommendations. CJON June 2008

Thalomid® Prescribing Information, Revlimid® Prescribing Information, Velcade® Prescribing Information. http://ctep.cancer.gov/forms/CTCAEv3.pdf

overview of thromboembolic events
Overview of Thromboembolic Events
  • Cancer patients have a higher risk of TE events (blood clots), which may lead to:
    • Deep vein thrombosis (DVT)
    • Pulmonary embolism (PE)
  • MM patients are at an increased risk for blood clots
    • Patients are at increased risk with high-dose dexamethasone treatment
    • The risk for DVT/PE is further increased in patients treated with novel therapies:
      • Thalidomide
      • Lenalidomide
  • Measures to prevent novel therapy-associated TE events include:
    • Mechanical
    • Myeloma regimen-related
    • Anticoagulant therapy (clot-preventing)

TE events are serious and potentially life-altering and life-threatening.

Adapted from NLB Consensus Recommendations. CJON June 2008. Amir Qaseem et al., 2007, Ann Fam Med; J. B. Segal et al., 2007, Ann Intern Med. http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_WhoIsAtRisk.htm

dvt pe signs symptoms
Slight fever

Tachycardia

Unilateral swelling, erythemia, warm extremity

Cyanosis/cool skin

Distension of superficial venous collateral vessels

DVT/PE: Signs/Symptoms
  • Anxiety
  • Sudden dyspnea
  • Chest discomfort
  • Tachycardia, tachypnea
  • Low-grade fever

PE IS AN EMERGENCY

http://www.nhlbi.nih.gov/health/dci/Diseases/Dvt/DVT_SignsAndSymptoms.html

Adapted from NLB Consensus Recommendations. CJON June 2008

peripheral neuropathy definition signs and symptoms
Signs/symptoms:

Temporary Numbness

Tingling

Parasthesias

Sensitivity to touch

Muscle weakness

Severe symptoms:

Burning pain

Muscle wasting

Paralysis

Organ dysfunction

Peripheral Neuropathy: Definition, Signs, and Symptoms

Damage to the peripheral nervous system, including any injury, inflammation, or degeneration of peripheral nerve fibers

Thalidomide/bortezomib can cause peripheral neuropathy

Adapted from NLB Consensus Recommendations. CJON June 2008; Thalomid® Prescribing Information, Velcade® Prescribing Information; Colson et al., 2004, CJON; S. Lonial, 2007, The American Journal of Hematology/Oncology http://www.ninds.nih.gov/disorders/peripheralneuropathy/detail_peripheralneuropathy.htm

general strategic recommendations for the management of pn
General Strategic Recommendations for the Management of PN
  • Ongoing evaluation
  • Dose and schedule modifications
  • Pharmacological interventions
  • Non-pharmacological interventions
  • Patient education

Pharmaceutical

  • For all patients prior to therapy:
    • B-complex vitamins including B1, B6, B12 (at least 400 mcg)
    • Folic acid 1 mg daily
  • For grades 2 or higher
    • Tricyclic antidepressants
    • Amino acids on an empty stomach
    • Neurontin®, Lyrica®, Cymbalta®
    • Lidoderm® patch 5% to affected area every 12 hours
  • Non-Pharmaceutical
  • Gentle massage of affected areas with cocoa butter, capsaicin cream
  • Home health referral to review safety at home
  • Assistance with ADL
  • Referrals: pain management, neurology, physical/occupational therapy

Adapted from NLB Consensus Recommendations. CJON June 2008; NCCN 2007; NINDS, 2007; Tariman, 2003,Clinical Journal of Oncology Nursing; Visovsky et al., 2007, http://www.ons.org/outcomes/volume2/peripheral/pdf/PEPCardDet_peripheral.pdf.

gastrointestinal side effects of novel therapies
Gastrointestinal Side Effects of Novel Therapies

Thalomid® Prescribing Information, Revlimid® Prescribing Information, Velcade® Prescribing Information

Adapted from NLB Consensus Recommendations. CJON June 2008

management of diarrhea
Management of Diarrhea
  • Non-pharmacologic
    • Increase fluid intake
    • Avoid caffeinated, carbonated, or heavily sugared drinks
    • Dietary changes: avoid fiber
  • Pharmacologic
    • Caution concerning medications or herbal supplements, which can cause diarrhea
    • Antidiarrheal agents:
      • Imodium®
      • Lomotil®
      • Tincture of opium
      • Sandostatin®
    • Intravenous hydration to correct electrolyte imbalance

NLB Consensus Recommendations. CJON 2008; ASCO’s Curriculum Diarrhea 2005; Bush, 2004, Oncology Nursing Forum; Engelking, 2004, Cancer Symptom Management; Mercadante, 2007, Principles & Practice of Palliative Care & Supportive Oncology.

management of nausea and vomiting
Management of Nausea and Vomiting
  • Non-pharmacologic
    • Dietary intolerance and restrictions
    • Avoid exercise and do not lie flat for 2 hrs after eating
    • Fresh air and loose clothing
    • Relaxation, guided imagery, biofeedback, acupuncture
  • Pharmacologic
    • Select anti-emetics based on how strongly the novel agents stimulate N/V and consider type of N/V.
      • Nausea: Ativan®, Compazine®, Decadron®, Pepcid®, Phenergan®, Reglan®, or Zantac®
      • Vomiting: Emend®, Zofran®, Kytril®, Anzemet®, or Aloxi®
    • Intravenous hydration to correct electrolyte imbalance

Adapted from NLB Consensus Recommendations. CJON 2008; ASCO’s Curriculum Nausea and vomiting 2005;

NCI Nausea and vomiting 2007

overview of steroid side effects
Overview of Steroid Side Effects
  • Steroid classes:
    • Glucocorticosteroids
    • Corticosteroids
    • Used as single agents and in combos
      • Dexamethasone, Prednisone, Prednisolone
  • Use of steroids can cause multiple system side effects, such as:
  • Constitutional
  • Psychiatric
  • Immune
  • Musculoskeletal
  • Bone loss
  • Body image
  • Ophthalmic
  • Gastrointestinal
  • Endocrine
  • Cardiovascular
  • Dermatologic

Adapted from NLB Consensus Recommendations. CJON June 2008; Alexanian, Dimopoulos, Delasalle, & Barlogie, 1992

management of steroid dependent side effects constitutional
Management of Steroid-Dependent Side Effects: Constitutional
  • Steroids affect every system
  • Psychological:
    • Mood alterations, let-down effect, insomnia
  • GI: flatulence/hiccoughs
  • Musculoskeltal: proximal myopathy and muscle cramping
  • Bone: osteonecrosis, osteoporosis
  • Endocrine: hyperglycemia, hypogonadism, sexual dysfunction
  • CV: edema

Adapted from NLB Consensus Recommendations. CJON June 2008; Mitchell et al. 2006; Page et al 2006; Badger et al 2006; Cerullo, 2007

overall recommendations for the 5 emergent side effects of novel therapy
Overall Recommendations for the 5 Emergent Side Effects of Novel Therapy
  • Effective management includes:
    • Monitoring patients carefully
    • Educating patients and caregivers about what to expect during treatment
    • Appropriate prophylaxis
    • Pharmacologic and non-pharmacologic interventions
  • Effective management leads to:
    • Increased adherence to therapy
    • Improved quality of life
    • Prevention of serious adverse events that can lead to prolonged hospitalization, and increased morbidity and mortality

Adapted from NLB Consensus Recommendations. CJON June 2008; Ghobrial, et al. (2007) Oncology, 21, 785-792.

Lonial, S. (2007) The American Journal of Hematology/Oncology,6, 194-196.

slide61

Developing a Nurse-Centric Model for a Survivorship Care Plan

Evidence-based data for 5 major long-term side effect issues and their management: creation of clinical practice-based consensus documents

Functional Mobility

Bone Health

Renal Complications

Health Maintenance

Sexuality & Sexual Dysfunction

Outcome: Survivorship Care Plan and Manuscript

functional mobility in multiple myeloma
Functional Mobility in Multiple Myeloma
  • Multiple myeloma is mainly a disease of the bone.
  • Multiple myeloma mostly affects the elderly population, which greatly exacerbates limited motility.
  • Factors contributing to high risk of falls in elderly MM patients:
    • Sensory issues (poor vision and hearing)
    • Age-related co-morbidities
      • Cardiovascular
      • Diabetes
      • Osteoporosis
      • Hormonal status
      • Parkinson’s disease
      • Dementia
      • Urinary incontinence (fall-related)
      • Arthritis
    • Nutrition (muscle weakness, weight loss)
    • Psychological issues and lifestyle
functional mobility a case study
Functional Mobility: A Case Study
  • Annie is a 68-year-old woman with relapsed myeloma receiving bortezomib and dexamethasone.
  • After 6 cycles she is in a near complete remission but developed painful neuropathy in her feet.
    • Reported numbness, burning, shooting pain
  • Doesn’t feel like participating in usual activities due to pain, sits all day.
  • Husband is afraid she is “giving up;” she has lost her balance twice this week.
functional mobility a case study65
Functional Mobility: A Case Study

What are we most concerned about with Annie?

  • Risk of falls due to pain and decreased sensation in her feet can lead to bleeding with low platelets.
  • Risk of pneumonia due to inactivity.
  • Depression.
  • Neuropathy may limit the amount of treatment she is able to receive.
  • All of the above.
bone health and bone disease
Bone Health and Bone Disease
  • Bone disease is a hallmark of multiple myeloma
  • Caused by defects in the balance between bone formation and resorption
    • Skeletal events may progress despite an efficacious treatment.
  • Main manifestations of bone disease (at diagnosis):
    • Diffuse osteopenia and/or focal lytic lesions (70-80%)
    • Pathological fractures
      • Most common site is spine (55-70%)
    • Hypercalcemia (30%)
    • Bony pain (60%)
bone health and bone disease a case study
Bone Health and Bone Disease: A Case Study
  • JJ is a 76-year-old man diagnosed in 2001 with IgG Kappa Myeloma.
  • Prior therapies (3): thalidomide, bortezomib, lenalidomide
  • Bisphosphonates every 3 months (pamidronate)
  • While moving furniture he experiences 10/10 pain in his back.
  • Dx: L2 compression fracture
  • Balloon kyphoplasty is recommended; patient declines.
  • He receives a prescription for pain medication.
bone health and bone disease a case study68
Bone Health and Bone Disease: A Case Study

What would be the most important consideration for this elderly patient with a compression fracture?

  • Increased risk for DVT while on lenalidomide.
  • Increased risk for pneumonia due to altered skeleton (kyphosis).
  • Pain will decrease his ability to perform ADLs.
  • All of the above.
renal complications
Renal Complications

One of the common clinical features of symptomatic myeloma.

  • 20 to 60% of patients present with renal complications.
    • Elevated serum creatinine level
    • Anemia, fatigue
    • Fluid and electrolyte imbalances
    • Light-chain proteinurea
  • Proteinurea may lead to end-stage renal disease (ESRD) and dialysis.
  • Reasons for kidney failure:
    • Monoclonal immunoglobulin deposition disease (MMID)
    • Amyloidosis
    • Light-chain deposition disease (LCCD)
    • Acute tubular necrosis (ATN)
renal complications a case study
Renal Complications: A Case Study
  • Jane is a 43-year-old woman diagnosed with kappa light chain MM in 1998
  • Received 2 stem cell transplants in late 2001 and early 2002; she has been in remission since.
  • Blood work every 3 months, stable
  • Called complaining of nausea, vomiting, and fevers in the last 48 hours
renal complications a case study71
Renal Complications: A Case Study
  • Labs:
    • WBC 3.9 k/uL
    • Hemoglobin 7.9 g/dL
    • Platelet count 158 K/uL
    • Creatinine 3.9 g/dL (1.9 last month)
    • Calcium 11.7 mg/dL
    • Albumin 3.2 g/dL
    • Beta-2 M 7.9
  • Skeletal survey shows progressive disease: scattered lesions calvarium, pelvis and bilateral femurs
renal complications a case study72
Renal Complications: A Case Study

She is admitted for IV hydration and a blood transfusion She receives a pulse of dexamethasone and pamidronate for hypercalcemia of malignancy (HCM) What would you anticipate next?

  • Lenalidomide and Dexamethasone
  • Bortezomib and Dexamethasone
  • Bortezomib and pegylated liposomal Doxorubicin
  • Enroll in a clinical trial with an experimental agent
sexuality sexual dysfunction
Sexuality & Sexual Dysfunction
  • Sexual dysfunction (SD) is characterized by those psychological and physiological changes that negatively impact sexuality.
  • Publications regarding SD in cancer patients are limited
  • SD is not part of the normal aging process!! It is a result of physical illness and/or psychological factors
  • Types of SD (according to the DSM IV):
    • Sexual desire disorder (decreased libido)
    • Sexual arousal disorder
    • Orgasm disorder
    • Sexual pain disorder
the impact of myeloma treatment on sexuality
The Impact of Myeloma Treatment on Sexuality
  • Thalidomide
    • Reported to induce impotence in male patients
  • Bortezomib and lenalidomide
    • Unpublished reports of erectile dysfunction and decreased libido
      • Sildenafil has positive results in restoring proper functioning
  • Our knowledge of the effects of novel myeloma treatment on sexuality is very limited
    • Patients are reluctant to discuss the issue
    • Sexuality assessments are not performed

Murphy and O’Donnell, Haematologica, 92 (10), 2007

sexual dysfunction communication is critical
Sexual Dysfunction: Communication is Critical
  • There is an urgent need for open communication between physicians, nurses, and their patients
    • Multiple well-established treatments for ED are available for male and female patients
  • Stressors can lead to depression in men and women
  • Patients may be unable or unwilling to verbalize this as a side effect
  • This is often placed on the back burner, as treatment is most important
  • Ask your patients!!
sexuality and sexual dysfunction a case study
Sexuality and Sexual Dysfunction: A Case Study
  • Mrs. D is a 53-year-old woman diagnosed 3 years ago with MM. After a long remission, she relapsed and is now 2 months post stem cell transplant
  • Mr. D uncomfortably asks you if he and his wife “will ever be able to have sex again.”
  • Mrs. D says that she feels no desire and that when they tried to have sex 3 weeks ago, she did not feel stimulated and found it to be painful. Becomes teary eyed; their sexual relationship has been strained since her diagnosis 3 years ago. Mr. D told her that he “can’t take it anymore.”
sexuality and sexual dysfunction a case study77
Sexuality and Sexual Dysfunction: A Case Study

How would you approach this?

  • Think of Mr. D as being selfish after all his wife has been through
  • Avoid the question because Mrs. D starts crying. It’s a hard topic for her
  • Refer the couple to a social worker, who knows more than you
  • Pull up a chair and ask Mrs. D, “How do you feel?”
understanding and optimizing survivorship care

Understanding and Optimizing Survivorship Care

Tiffany Richards: MS, ANP, AOCNP

MD Anderson Cancer Center

Houston, TX

definition of cancer survivor
Definition of Cancer Survivor

“An individual is considered a cancer survivor from the time of diagnosis through the balance of his or her life. Family members, friends, and caregivers impacted by the survivorship experience are included.”

(NCI, 2004)

3 seasons of survival mullan
3 “Seasons of Survival” (Mullan)
  • Acute survival: Diagnosis treatment
    • Fear and anxiety
    • Confrontation of mortality
    • Family needs
  • Extended survival: watchful waiting, consolidation, or intermittent therapy
    • Fear of recurrence
    • Physical limitations adaptation to work and home
    • Experiences variable
  • Permanent survival: “cure”
    • Insurance and employment problems
    • Long-term effects of therapy

Mullan, NEJM 1985

comparisons of patient and physician expectations for cancer survivorship care
Comparisons of Patient and Physician Expectations for Cancer Survivorship Care

Investigators from the Harvard School of Public Health, Dana-Farber Cancer Institute, and the Institute of Clinical Evaluative Sciences (Toronto) conducted a study to compare expectations regarding survivorship care among PCPs, oncologists, and patients

  • The results demonstrated a lack of agreement among these constituents with respect to their roles in ongoing survivor care.
  • The discordance was particularly high between patients and their oncologists. The underlying causes for the discrepancies were unclear.
cancer survivorship from individual to experience
Cancer Survivorship: From Individual to Experience
  • Defined as:
    • A time frame
    • A stage or phase
    • An outcome
  • Must take into account:
    • Maintenance therapy
    • Incurable but treatable cancers
    • Regimen changes
    • Recurrences
    • Secondary tumors
    • Late effects of treatments
institute of medicine iom findings survivorship care
Survivorship care is neglected.

Cancer recurrence, second cancers, and late effects of treatment.

Few guidelines.

Providers lack education.

Institute of Medicine (IOM) Findings: Survivorship Care

Shulman & Ganz ASCO Survivorship Models 2008

iom findings survivorship care cont d
Survivors:

Unaware of risk

No plan for follow-up

Missed opportunities

Lack of care coordination

IOM Findings: Survivorship Care (cont’d)

Shulman & Ganz ASCO Survivorship Models 2008

iom findings survivorship care cont d85
Chronic care model

Essential care components:

Prevention

Surveillance

Intervention

Coordination

IOM Findings: Survivorship Care (cont’d)

Shulman & Ganz ASCO Survivorship Models 2008

iom findings survivorship care cont d86
IOM Recommendation:

“All patients completing Rx should receive a comprehensive treatment summary & care plan.”

IOM Findings: Survivorship Care (cont’d)

Shulman & Ganz ASCO Survivorship Models 2008

reasons for a survivorship care plan
Reasons for a Survivorship Care Plan
  • Summarize treatment
  • Communicate late effects of treatment
  • Promote continuous communication between patients and healthcare providers
  • Promote a healthy lifestyle
    • Prevent recurrence
    • Reduce risk of co-morbid conditions

Shulman & Ganz ASCO Survivorship Models 2008

key elements for an effective survivorship care plan
Key Elements for an Effective Survivorship Care Plan
  • Diagnosis and stage
  • Treatment plan and dates
  • Expected short- and long-term effects
  • Late toxicity monitoring
  • Surveillance for recurrence or second cancer
  • Responsibility for survivorship care
  • Psychosocial and vocational needs
  • Recommended preventive behaviors and recommendations

Shulman & Ganz ASCO Survivorship Models 2008

iom recommendations for quality healthcare in america
IOM Recommendations for Quality Healthcare in America
  • Care based on continuous healing relationships
  • Customized care
  • Patient as source of control
  • Shared knowledge and information
  • Evidence-based decision making
  • Safety as a system property
  • Transparency
  • Anticipation of needs
  • Continuous decrease in waste
  • Cooperation
quality healthcare optimal survivorship care
Quality Healthcare = Optimal Survivorship Care
  • Receipt of optimal survivorship care depends on a patient-centered approach (Berry et al., 2003).
  • Call for such an approach has been made by physician-researchers William Tierney and Elizabeth McKinley in their description of their cancer experience from the patient’s perspective (Tierney and McKinley, 2002).
essentials of survivorship care
Essentials of Survivorship Care
  • Prevention and detection of new cancers and recurrence
  • Intervention for consequences of cancer and its treatment (eg, osteoporosis)
  • Coordination between specialists and primary care providers
barriers to cancer survivor care
Barriers to Cancer Survivor Care
  • For the Cancer Survivor:
    • Fragmented delivery system
    • Lack of awareness
    • Barriers to communication
  • For the Provider:
    • Fragmented delivery system
    • Lack of education/training
    • Lack of survivorship standards of care
    • Capacity to deliver survivorship care
challenges to survivorship care
Challenges to Survivorship Care
  • As lives are extended, so too are the risks of developing late or delayed effects.
  • Major questions - who will be responsible for:
    • Monitoring patient’s health
    • Assisting in recovery
    • Making referrals
    • Paying for continued care

Leigh, Cancer Survivorship: A Nursing Perspective, in Cancer Survivorship Today and Tomorrow, 2007

why survivorship care for multiple myeloma
Why Survivorship Care for Multiple Myeloma?
  • 2008 expectations for MM patients:
    • >90% response upfront
    • CR + VGPR ≥60%
    • 3-year survival 80 to 90%
    • 6-year survival 60 to 70%
    • >10-year survival 30 to 40%

Increased survival leads to the need for new approaches to quality survivorship care

survivorship care continuum
Survivorship Care Continuum

Individuals with chronic or intermittent disease may receive ongoing treatment for their disease, but benefit from survivorship care as they live with their disease

Initial

treatment

Continuing

care

Palliative

care

Prevention

Follow-up

Diagnosis

Maintenance

Recurrence

Progressive

disease

Survivorship isn’t a stage!!!!

It is a continuum from diagnosis to the end of life

asco tools for survivorship care
ASCO Tools for Survivorship Care

An important component of survivorship care is a patient’s treatment summary

www.asco.org/treatmentsummary

focus on the future

Focus on the Future

Sandra Rome, RN, MN, AOCN

Cedars-Sinai Medical Center

Los Angeles, CA

new drugs new perspective for multiple myeloma
New Drugs – New Perspective for Multiple Myeloma
  • Thalidomide
  • Bortezomib
  • Lenalidomide

A Cure??

Chronic?

OR

Longer follow-up required!!

the future for transplant eligible patients
The Future for Transplant-Eligible Patients

VAD

Thalidomide

Dexamethasone

New combinations

Oldstandard

Lenalidomide/low Dexamethasone

Bortezomib + Dexamethasone

VTD…

New

standard

Transplant

Harvest

NCCN Clinical Practice Guidelines in Oncology, v2 2009

the future for transplant ineligible patients
The Future for Transplant-Ineligible Patients

MP

MPT

VMP

MPR

Lenalidomide/low Dexamethasone

Old

standard

New

standard

New

options

NCCN Clinical Practice Guidelines in Oncology, v2 2009

impact of novel therapies on survivorship care
Impact of Novel Therapies on Survivorship Care
  • Unexpected new long-term complications
  • Second cancers
  • Long-term maintenance for survivors: quality of life
  • Family/social problems
  • Financial/insurance concerns
  • Other
optimizing survival importance of health maintenance
Optimizing Survival: Importance of Health Maintenance
  • MM patients are expected to live longer
  • Proper health maintenance contributes toward longer survival and quality of life
risk factors affecting health maintenance
Risk Factors Affecting Health Maintenance
  • Lifestyle choices
  • Mental risk factors
    • Substance abuse
    • Depression
  • Fatigue
    • Depression, pain, and anemia
  • Cognitive changes
    • “Chemo brain” effect
  • Dermatological issues
    • Immune system weakened by therapy
      • Transplants
      • Radiation
    • Increased risk for skin cancer
shifting paradigm for survivorship care nurse role
Shifting Paradigm for Survivorship Care: Nurse Role

Old Model

Survivorship as a stage:

  • Decreasing contact
  • Brief check-ups
  • May not recognize survivorship
  • Busy clinics
    • Time constraints
    • Focus on acutely ill
  • Emerging Model
  • Survivorship as a process:
    • Contact along the extended continuum of care
    • Survival plan will be developed shortly after diagnosis
    • Survivors and families will be supported medically, emotionally, financially.
    • It is not just about IF and HOW LONG, but HOW WELL??

Leigh, Cancer Survivorship: A Nursing Perspective, Cancer Survivorship Today and Tomorrow, 2007

nurse centric model of survivorship care

Patient Monitoring

Patient Management

Patient Counseling

Patient Research

Nursing Roles Emerge as Central to Survivorship Care

Patient Advocacy

Patient Education

Nurse-Centric Model of Survivorship Care*

Nurses are Central to

Patient Management and

Healthcare Resource

Coordination

* Developed by ScienceFirst, LLC; All Rights Reserved (www.science-first.com)

nurse led survivorship care
Nurse-Led Survivorship Care

Nurses:

  • Expert knowledge
  • Close relationships with patients and families
  • Understand psychosocial issues
  • Recommend referral
  • Work within a model of wellness promotion rather than disease management

Leigh, Cancer Survivorship: A Nursing Perspective, Cancer Survivorship Today and Tomorrow, 2007

nurse led survivorship care cont d
Nurse-Led Survivorship Care (cont’d)

Barriers:

  • Shortage of trained oncology nurses, especially in outpatient settings
  • Lack of coordinated care and communication among healthcare providers
  • Insurance and reimbursement issues

Leigh, Cancer Survivorship: A Nursing Perspective, Cancer Survivorship Today and Tomorrow, 2007

national coalition for cancer survivors nccs imperatives
National Coalition for Cancer Survivors (NCCS) “Imperatives”

NCCS’s “Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability”:

  • Nurses are major players
  • Health promotion and wellness are critical in survivor clinics
  • Continued need for supportive care
  • Critical value of education and rehabilitation for symptoms:
    • Fatigue, chronic pain, weight changes, decreased stamina

NCCS. Imperatives for Quality Cancer Care: Access, Advocacy, Action, and Accountability, 1996

nursing sensitive patient outcomes nspo
Nursing-Sensitive Patient Outcomes (NSPO)
  • ONS defined nursing-specific outcomes for cancer patients:
    • changes in symptom management, functional status, safety, psychological status, costs
  • NSPO describes “continuum of care:”

Initial

treatment

Continuing

care

Palliative

care

Prevention

Follow-up

Diagnosis

Maintenance

Recurrence

Progressive

disease

Survivorship isn’t a stage!!!!

It is a continuum from diagnosis to the end of life

Given and Sherwood, 2005; Rutledge, 2005

what is a survivorship care plan
What is a Survivorship Care Plan?
  • A document:
    • Summarizes what transpired during cancer treatment
    • Gives recommendations for follow-up care
  • It needs to:
    • Be prospective
    • Identify known and potential long-term effects
  • It aims to:
    • Promote a healthy lifestyle
    • Prevent recurrence of cancer
    • Reduce risk of co-morbid conditions
    • Ensure adherence to follow-up recommendations

Implementing Cancer Survivorship Care Planning http://www.nap.edu/catalog/11739.html

meeting the unmet need
Meeting the Unmet Need

Opportunity to leverage the NLB’s experience by identifying relevant long-term side-effects and developing a Survivorship Care Plan for Multiple Myeloma

nlb developed consensus guidelines for management of acute side effects
NLB Developed Consensus Guidelines for Management of Acute Side-Effects

NLB determined the 5 most common emergent side effects requiring clinical “Consensus Statement” development

  • Peripheral neuropathy
  • DVT and PE
  • Myelosuppression
  • GI effects
  • Steroid effects

IMF-NLB ‘Consensus Statements’ supplemCJON June 2008

a new horizon in patient care
A New Horizon in Patient Care
  • Survivorship Care Plan offers the opportunity to enhance treatment outcome and patient quality of life
  • Survivorship Care Plan will need to be updated as new therapies emerge
goals of nlb survivorship care plan
Goals of NLB Survivorship Care Plan

How myeloma, treatments, and patient-specific characteristics affect:

  • Renal disease
  • Sexuality and sexual dysfunction
  • Bone metabolism
  • Safety and functional mobility
  • Health maintenance
goals of nlb survivorship care plan cont d
Goals of NLB Survivorship Care Plan (cont’d)

Develop recommendations for schedules of evaluations and evidenced-based interventions:

  • Prevention, screening through treatment of sequelae
  • Enable clinicians and patients to optimize therapy by preventing or adequately treating co-morbid conditions.
goals of nlb survivorship care plan cont d117
Goals of NLB Survivorship Care Plan (cont’d)

NLB will disseminate this information to those within in the community who can effect the most change:

  • Patients
  • Caregivers
  • Healthcare providers
creation of a mm survivorship care plan
Creation of a MM Survivorship Care Plan
  • Co-morbid conditions affect:
    • Treatment options
    • Survival
    • Late side effects
  • The plan will:
    • Prevent and control
      • Other cancer diagnosis
      • Treatment-related outcomes
        • Late effects of treatment
        • Second cancers
        • Suboptimal quality of life
    • Provide a knowledge base for follow-up care and surveillance
    • Optimize health after cancer treatment
multiple myeloma survivorship care plan
Multiple Myeloma Survivorship Care Plan
  • IMF Web site is a source for support and education in all aspects of MM
  • Resources for survivorship care will be posted on the site

http://myeloma.org

closing remarks

Closing Remarks

Beth Faiman, MSN, APRN-BC, AOCN

Cleveland Clinic Taussig Cancer Institute Cleveland, OH

slide121

NLB Accomplishments

PUBLISHED:

Managing the Side Effects of Novel Agents for Multiple Myeloma: Guidelines and Patient Education Sheets

  • Clinical Journal Oncology Nursing (CJON), Supplement 12(3), June 2008
  • Patient Education Insert Tear-Out Tools for 5 Side Effects
    • Myelosupression
    • Thromboembolic events
    • Peripheral neuropathy
    • Gastrointestinal side effects
    • Steroid-associated side effects
patient education tear out tools
Patient Education Tear-Out Tools
  • General format and clinical utility:
    • Side effect description
    • Novel therapies that may be associated with the side effect
    • Signs and symptoms
    • Risk factors
    • Healthcare provider recommendations

NLB Consensus Statements, CJON June 2008

future goals of nlb
Future Goals of NLB

Expand initiative to collaborate with nurses worldwide

  • Frame the importance of nursing.
  • Management of long-term side effects associated with MM therapies

Develop Survivorship Care Plan

slide124

Focus of NLB Commitment

Nurse-Centric Survivorship Care Plan

  • Five major long-term health risks identified
  • Five NLB focus groups are created to investigate the five risk categories and develop recommendation manuscripts
  • Health maintenance
  • Functional mobility
  • Bone health
  • Renal complications
  • Sexual dysfunctions
focus of nlb commitment cont d
Focus of NLB Commitment (cont’d)
  • Publication of the Survivorship Care Plan
  • will be immeasurably valuable to the general nursing community involved in multiple myeloma patient care
  • Communication and dissemination of the Survivorship Care Plan are important next steps.
  • Develop new educational materials/tools:
  • - Patient related
  • - Nurse related
communication and dissemination
Communication and Dissemination
  • Patient and nurse educational slide set development
  • NLB Speaker’s Bureau
  • Oncology conference presentations
  • ONS Web site:

- www.ons.org

  • IMF Web site:

- www.myeloma.org

educational resources
Educational Resources
  • American Cancer Society
  • National Cancer Institute
  • International Myeloma Foundation
    • - IMF Myeloma Today Newsletter
    • - (800) 452 CURE
    • - IMF Web site
      • www.myeloma.org
accreditation
Accreditation
  • Symposium Accreditation ProcessPlease complete the CE Certificate Registration and Program Evaluation Form found in the guidebook and return this completed form to the registration desk to receive 2.0 CEU credits2. CJON Supplement Accreditation OpportunityPlease visit www.cjon.org and complete the online tests for a maximum of 3.8 additional CEU credits
acknowledgements
Acknowledgements
  • Tiffany Richards
  • Sandra Rome
  • Joseph Tariman
  • International Myeloma Foundation
  • MER