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Announcer:
Welcome to Project Oncology on ReachMD. Here’s your host, Dr. Charles Turck.

Dr. Turck:
This is Project Oncology on ReachMD. I'm Dr. Charles Turck, and joining me to share their perspectives on treating patients with relapsed or refractory multiple myeloma, otherwise referred to as RRMM, are Drs. Morie Gertz and Ravi Vij. Dr. Gertz is a Hematology Specialist at the Mayo Clinic Comprehensive Cancer Center in Rochester, Minnesota. Dr. Gertz, welcome to the program.

Dr. Gertz:
Thank you.

Dr. Turck:
And Dr. Vij is a Professor of Medicine in the Oncology Division and Section of Bone Marrow Transplantation at the Washington University School of Medicine in St. Louis, Missouri. Dr. Vij, it’s great to have you with us as well.

Dr. Vij:
Thank you for the invitation.

Dr. Turck:
So let's dive right in starting with you, Dr. Gertz, which of our patients with multiple myeloma are at risk of relapsed or refractory disease?

Dr. Gertz:
I think we have to assume that every patient we see will ultimately relapse. Although all of us have a small proportion of patients who are long-term survivors unmaintained, it's pretty clear that the overwhelming majority of patients, including those who achieved the holy grail of MRD negativity of 10 to the minus six where there's no plateau in the progression-free survival curve, will relapse. And we always have to have in mind, quite frankly, with every visit, what will I plan to do next for this patient?

Dr. Turck:
Turning to you now, Dr. Vij, what are some common challenges care teams encounter when managing these patients?

Dr. Vij:
The challenges in the care of patients with multiple myeloma are many-fold. I think coordination of care is one of the major things that we have to be careful about arranging. We have to have a team approach with nurses, with physicians, nurses in the infusion suite, nurses in the treatment area, but also nurses in the clinic. We also have to have pharmacists involved. We need to make sure that the doses of the drugs delivered are appropriate, adjusted for any interactions with other medicines. And at times, social workers and dietitians are also key in the management of these patients.

We also, in several cases, have to make sure that we can get patients co-pay support if they have substantial out-of-pocket costs for these patients.

Managing the toxicities of these drugs is also another area that can be challenging. Trying to be proactive to pick up the side effects before they get worse is important, including neuropathy, cytopenias, and other side effects that these patients can have with steroids, which include muscle weakness, problems with their blood sugars, problems with their ability to sometimes function appropriately, mood swings, and the like.

Dr. Turck:
For those just tuning in, you're listening to Project Oncology on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Drs. Morie Gertz and Ravi Vij about the management of relapsed or refractory multiple myeloma, or RRMM for short.

So now that we have a better understanding of the challenges associated with RRMM, let's focus on how we might better manage these patients. Dr. Vij, would you share some strategies that could help improve our patient's care?

Dr. Vij:
I think to improve our patient's care, we need a team strategy. We need to have the nurses, the pharmacists, the physicians, and the ancillary support staff all work in cohesion. We need to make sure that we are able to detect any toxicity that patients are experiencing in a timely manner so that we can intervene. We also need to make sure that we tailor the treatments to the patient's demographic, to their comorbidities, and have a sound understanding of the efficacy and toxicity of these treatments.

Dr. Turck:
And from your perspective as a Hematologist, Dr. Gertz, how might we enhance our approach to treating patients with relapsed or refractory disease?

Dr. Gertz:
Well, multiple myeloma is truly a disease where individualized therapy applies. Unfortunately, you just can't look at a recommendation from the National Comprehensive Cancer Center Network and plan therapy. There's a good deal of care coordination, 15 percent of patients will have renal insufficiency, which is going to affect the pharmacology of the treatments that we're going to give them. Relapsed patients often carry with them toxicities associated with their prior therapy, such as permanent painful neuropathy, which will affect decisions on second- and third-line therapy.

But supportive care becomes such an important aspect of the management of these patients. Because with newer therapies, these patients have high risks of bacteremia, fungal infections, pneumocystis, and disseminated herpes zoster. These patients also need significant supportive care to prevent skeletal events from occurring. And that can be pharmacologic or involvement of a specialist in kyphoplasty.

And so a pharmacy consultation can be really quite helpful in these patients because although they may be on four chemotherapy or anti myeloma treatments, the supportive care can be a half a dozen additional medications. And when you're starting with a patient who's median age is 70, there's a lot of possibilities for medication error to occur because the medications are not given every day, they're given in pulses once a week, and that can lead to serious medication errors.

Dr. Turck:
Now before we close, I'd like to hear some final thoughts from each of you. Starting with you, Dr. Gertz. What takeaways would you like to leave with our audience?

Dr. Gertz:
I think that we need to systematize the care of our patients with multiple myeloma. I think it's useful to develop actual checklists for the office patients so we can run through when we see the patient and we decide on second-line therapy, which will be determined based on what's previously failed, as well as what toxicities may preclude some other agents. But venous thromboembolism prophylaxis, antibacterial prophylaxis, prevention of steroid ulceration, vaccinations to prevent disseminated herpes zoster, and pneumococcal infections–having a checklist should the patient see a radiation oncologist or an orthopedic oncologist or a nephrologist can really be valuable in creating a workflow so that these patients get optimized care.

Dr. Turck:
Thank you, Dr. Gertz. And Dr. Vij, I'll give you the final word.

Dr. Vij:
I totally agree with what Dr. Gertz just said, I think we do need to improve our practices. But I also think that we have made tremendous progress in the treatment of this disease in the last 20 years. And the new advances in CAR T-cells, bispecifics, and other immune-based therapies that are now coming about tell us that the best may yet to come.

Dr. Turck:
Thank you both for sharing those key takeaways. And as that brings us to the end of today's program, I want to thank my guests, Drs. Morie Gertz and Ravi Vij, for joining me to discuss best practices for the care of patients with relapsed or refractory multiple myeloma. Dr. Gertz, Dr. Vij, it was a pleasure speaking with you both today.

Dr. Gertz:
Thank you for having me.

Dr. Vij:
Likewise.

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