Multiple Myeloma Care: Translating Evolving Practices to Oncology Nurses in Community Settings

Multiple Myeloma Care: Translating Evolving Practices to Oncology Nurses in Community Settings

The approval of new agents in multiple myeloma (MM) theoretically broadens treatment options; however, complex therapies, such as chimeric antigen receptor T-cell (CAR-T) therapy, which has limited manufacturing slots, currently requires a patient to be established with an academic center. Bispecific therapy, on the other hand, which was initially available only through academic and tertiary centers, is being made available in community cancer centers. Oncology nurses may find themselves directly, or indirectly, involved in the care of patients with MM who have come through several treatment lines and are now facing additional complications with newer therapies.

The wider adoption of novel agents that were initially integrated into practice at academic or tertiary centers in non-academic and community cancer care practices increases access, but creates new challenges, especially in the management of unique adverse events (AEs), including cytokine release syndrome (CRS), neurotoxicity, and long-term infection risk. Treatment and AE management protocols developed in tertiary care centers provide a framework for current best practices that community practitioners can adapt to their own settings. 

In order to respond effectively to AEs, nurses must be able to determine when symptoms are related to AEs, assess and grade the severity of AEs, and understand how to manage AEs based on type and grade.¹

The important AEs and related nursing considerations associated with different classes of MM medications are summarized in Table 1 below.

Table 1. Drug classes, key potential adverse events, and nursing considerations for therapies commonly used to treat patients with MM.

AE, adverse event; ARR, administration related reaction ; ASA, acetylsalicylic acid; BD, birth defects; C, cardiac; CBC, complete blood count; D, diarrhea; DOAC, direct oral anticoagulant; DVT, deep vein thrombosis; F, fatigue; GI, gastrointestinal toxicities; H, hyperglycemia; IR, infusion reaction; IV, intravenous; LMWH, low molecular weight heparin; M, myelosuppression; MM, multiple myeloma; MS, metabolic syndrome; N, nausea; PN, peripheral neuropathy; R, renal dose adjustment necessary; RD, response disruption; SQ, subcutaneous; T, thrombocytopenia

Cytokine release syndrome and neurotoxicities are unique and significant AEs associated with CAR-T and bispecific antibody treatment. Because of these risks, CAR-T and bispecific antibodies for MM are currently administered at a Risk Evaluation and Mitigation Strategy (REMS) certified center. Table 2 below summarizes key nursing considerations in patients with MM treated with CAR-T or bispecific therapies.

Table 2. Drug classes, key potential adverse events, and nursing considerations for CAR-T and bispecific antibody therapies used to treat MM.

C, cardiac; I, immune-related AEs; M, myelosuppression; N, neurotoxicity

CRS and ICANS

The most common symptoms of CRS are not unique to CRS, therefore, healthcare providers must exclude other causes of fever, hypotension, hemodynamic instability, and/or respiratory distress, for example, an overwhelming infection. Bacteremia and other infections have been reported concurrently with CRS and, in some cases, been mistaken for CRS. Symptoms must present within a reasonable timeframe relative to administration of the CAR-T or bispecific therapy. Immune effector cell-associated CRS may have a delayed onset; however, it rarely presents beyond 14 days after initiation of therapy. “Patients exhibiting symptoms consistent with CRS presenting outside this window should be carefully evaluated for other causes.”²

Patients who experience immune effector cell-associated neurotoxicity syndrome (ICANS) often exhibit a specific set of symptoms. The earliest manifestations of ICANS are tremor, dysgraphia, mild difficulty with expressive speech (especially in naming objects), impaired attention, apraxia, and mild lethargy. Headache frequently occurs during fever or after chemotherapy in patients without another neurologic dysfunction and alone is not a useful marker of ICANS. Expressive aphasia, on the other hand, appears to be a very specific symptom of ICANS.²

The American Society for Transplantation and Cellular Therapy (ASTCT) has developed grading systems for both CRS and neurotoxicity; the severity of the AE determines the management approach. Table 3 below summarizes clinical actions to address CRS and ICANS based upon the ASTCT grading systems.² The ASTCT and grading metrics for CRS and ICANS were included in the Resources section of the activity, “Multiple Myeloma Care: Translating Evolving Practices to Oncology Nurses in Community Settings.”

Table 3. Grades and associated strategies for managing cytokine release syndrome and immune-cell-associated neurotoxicity syndrome.

ICP, intracranial pressure; ICU, intensive care unit; IV, intravenous

Standardized management strategies for CRS and ICANS are evolving as more data and clinical experience accrue. While CRS and ICANS are often self-limiting, in some instances they can be life-threatening or fatal, so early identification and intervention are essential. Management of CRS and ICANS currently involves supportive care with or without corticosteroids and/or cytokine-directed therapies in selected patients. The Tables shown in this activity are included in the Resources section of the activity, “Multiple Myeloma Care: Translating Evolving Practices to Oncology Nurses in Community Settings.”

References

1. Goodrich A, Wagner-Johnston N, Delibovi D. Lymphoma therapy and adverse events: nursing strategies for thinking critically and acting decisively. Clin J Oncol Nurs. 2017;21(1 Suppl):2-12. doi: 10.1188/17.CJON.S1.2-12.
2. Lee DW, Santomasso BD, Locke FL, Ghobadi A, et al. ASTCT consensus grading for cytokine release syndrome and neurologic toxicity associated with immune effector cells. Biol Blood Marrow Transplant. 2018;(4):625-638. doi: 10.1016/j.bbmt.2018.12.758. Epub 2018 Dec 25.
3. Neelapu SS, Tummala S, Kebriaei P, et al. Chimeric antigen receptor T-cell therapy - assessment and management of toxicities. Nat Rev Clin Oncol. 2018;15(1):47-62. doi: 10.1038/nrclinonc.2017.148. Epub 2017 Sep 19.
4. Neelapu SS. Managing the toxicities of CAR T-cell therapy. Hematol Oncol. 2019;37 Suppl 1:48-52. doi: 10.1002/hon.2595.