Supportive care in multiple myeloma: Current practices and advances.

Supportive care in multiple myeloma (MM) can have a major impact on quality of life and the survival outcomes of MM patients. In this review, we will focus on disease and treatment related toxicities experienced by MM patients and what are the best approaches to date to help mitigate the effects. We will specifically focus on a practical approach to managing bone disease, thrombosis, infection risk, peripheral neuropathy, dermatologic complications, gastrointestinal and ocular toxicities, and fatigue in MM.

Increased fecal primary bile acids in multiple myeloma with engraftment syndrome diarrhea after stem cell transplant.

Autologous stem cell transplant (ASCT) for multiple myeloma (MM) is associated with diarrhea during the peri-transplant period. We aimed to appraise mechanisms of peri-ASCT diarrhea in a prospective, longitudinal study of patients with MM. We compared by repeated measures (RM)-ANOVA daily bowel movements (BMs) and consistency [7-point Bristol Stool Form Scale (BSFS)], fecal calprotectin (intestinal inflammation), 13C-mannitol excretion in urine 0-2 h (small intestinal permeability), fasting serum C4 (bile acid synthesis) and total and primary bile acid in stool samples during baseline, peri-transplant period (Days 5-7 after stem cell infusion), and after hematological recovery post-ASCT. The 12 (5F, 7M) patients' median age was 61 y (IQR 54.8-63.3). All participants reported increased BMs (increase of 2 and 1 per day with and without engraftment syndrome, respectively). There were no significant increases in serum C4, total fecal bile acids, or intestinal permeability. Relative to patients without engraftment syndrome, four participants with engraftment syndrome had looser stool consistency (mean 2.6 points higher BSFS compared to without engraftment syndrome), increased primary fecal bile acids relative to baseline (>33 µmol/L vs. 6 µmol/L without engraftment syndrome), and increased fecal calprotectin compared to baseline (313 µg/mL vs. 35.6 µg/mL without engraftment syndrome; p = 0.06). Engraftment syndrome post-ASCT is associated with increased fecal primary bile acids.

Bone Health, Pain, and Mobility: Evidence-Based Recommendations for Patients With Multiple Myeloma

BACKGROUND: About 85% of patients with multiple myeloma develop bone disease. In these patients, lytic bone lesions can cause fractures, poor circulation, blood clots, pain, poor mobility, and decreased quality of life.
. OBJECTIVES: This article presents consensus statements to guide nurses in the assessment and management of bone disease, pain, and mobility in patients with multiple myeloma at varying points in their disease trajectory.
. METHODS: Members of the International Myeloma Foundation Nurse Leadership Board reviewed previously provided recommendations, current recommendations based on literature review, and evidence-based grading.
. FINDINGS: Oncology nurses play a key role in maximizing bone health, minimizing skeletal injury, maximizing pain control, and improving quality of life in patients by enhancing patient mobility and safety. Clinician assessment accompanied by effective interventions reduces patient injury and optimizes functioning in patients with multiple myeloma.

Myelosuppression, Bone Disease, and Acute Renal Failure: Evidence-Based Recommendations for Oncologic Emergencies

BACKGROUND: Oncologic emergencies associated with multiple myeloma include myelosuppression (anemia, neutropenia, and thrombocytopenia), bone-related emergencies, and acute renal failure. 
. OBJECTIVES: This article reviews the pathophysiology of these multiple myeloma-associated oncology emergencies and provides a framework for assessment and effective intervention.
. METHODS: A comprehensive review of the levels of evidence, focusing on assessment, diagnosis, comorbidities, treatment, ongoing monitoring, and patient education, are presented to support the plan of care for at-risk patients.
. FINDINGS: Attention to signs and symptoms is the foundation for preventing these emergencies or managing additional escalation of symptoms.

Hematopoietic Stem Cell Transplantation for Multiple Myeloma.

OBJECTIVE: To provide an overview of the hematopoietic stem cell transplantation (HSCT) process specific to patients with multiple myeloma (MM) and their caregivers. DATA SOURCES: Research studies, book chapters, websites, expert knowledge, and journal articles. CONCLUSION: Although not curative, autologous HSCT is an important, manageable treatment modality, and continues to be a standard of care in MM for those patients who are eligible. IMPLICATIONS FOR NURSING PRACTICE: Although an area of specialty practice, an understanding of the HSCT process is important to broaden the knowledge of all nurses who care for patients with MM.

Autologous hematopoietic stem cell transplantation for patients with multiple myeloma: an overview for nurses in community practice.

Autologous hematopoietic stem cell transplantation (AHSCT) is approved for the treatment of select solid tumors, autoimmune disorders, and most hematologic malignancies. Multiple myeloma (MM) is the most common indication for AHSCT. Despite improvement in response and survival rates in the era of novel agents, AHSCT remains an important treatment option for patients with MM who are eligible. Clinical management of patients with MM requires a multidisciplinary approach that incorporates healthcare professionals in a number of clinical settings as well as caregivers and the patient. Patients about to undergo AHSCT are generally referred to tertiary care centers that specialize in ASCT. Pre- and post-transplantation treatments and long-term follow-up often are managed by a community-based referring oncologist in collaboration with the transplantation team. Oncology nurses play an integral role in the care of patients with MM in each clinical setting. This article aims to provide non-transplantation oncology nurses with guidelines for education, clinical management, and support of patients with MM undergoing AHSCT with a primary focus on the pre- and post-transplantation period.

Clinical updates in blood and marrow transplantation in multiple myeloma.

The process of hematopoietic stem cell transplantation (HSCT) is well defined, yet debate remains surrounding the role and timing of HSCT in patients with multiple myeloma (MM). Since the 1980s, survival advances have been made with the use of newer agents by recognizing the role of transplantation, identifying the anticipated side effects at each phase, and improving supportive care strategies. Data support transplantation as part of the treatment strategy, but the optimal induction regimen and timing of transplantation have yet to be defined. The general consensus is that eligible patients should undergo autologous HSCT at some point in the treatment spectrum, preferably earlier rather than later in the disease. Allogeneic transplantation is only recommended in the context of a clinical trial and in patients with high-risk disease. The transplantation process can be overwhelming for patients and caregivers. Nurses play a key role in improving outcomes by caring for patients and families throughout the transplantation experience and, therefore, need to be knowledgeable about the process. This article is intended to expand discussion on the role of nurses in assisting patients and families undergoing transplantation to include an overview of the acute care phase of the transplantation process.

Autologous hematopoietic stem cell transplantation for multiple myeloma: frequently asked questions.

When caring for patients with multiple myeloma, questions often arise about the role and timing of autologous hematopoietic stem cell transplantation. As a complement to the other articles in this supplement, as well as to ensure that readers are provided with the insight needed to feel comfortable speaking to patients and other practitioners about this topic, the authors address eight frequently asked questions about common decision points in the process of autologous hematopoietic stem cell transplantation as a treatment for patients with multiple myeloma.

Survey of experiences of an e-mentorship program: Part II.

Nurse educators (NEs) are responsible for providing continuing education to nurses, who are expected to remain knowledgeble in the diagnosis and management strategies of a range of cancers. Remaining abreast of up-to-date information can be a challenge. Part I of the e-mentorship program was developed in 2009 to provide NEs with the latest updates and educational materials to enhance multiple myeloma (MM) nursing knowledge. The second phase was completed in January 2011. Faculty developed four modules: overview of MM, peripheral neuropathy, bone health, and overview of transplantation. Seventeen MM nurses were identified to participate as mentors and partner with 34 mentees. Mentees were trained through monographs, journal articles, webcasts, and telephone communication, and then they presented the modules to their nurses. All mentees were asked to participate in voluntary pre- and post-test assessments to measure improved knowledge and clinical competence in the management of patients with MM. A significant improvement in post-test scores, as compared to pretest scores, was seen; therefore, nurses who participated in the e-mentorship program demonstrated improved knowledge. In the future, this type of educational program should be expanded to other cancer types.

Survivorship care guidelines for patients living with multiple myeloma: consensus statements of the International Myeloma Foundation Nurse Leadership Board.

Novel therapies approved over the past decade for the management of multiple myeloma have contributed to improved overall survival in patients with newly diagnosed and relapsed disease. Nurses play a key role in educating, advocating for, and supporting patients throughout the continuum of care. Identifying potential and actual comorbid conditions associated directly with multiple myeloma and its treatment is important, as is confirming those that are patient specific so that prompt intervention can take place; therefore, the International Myeloma Foundation Nurse Leadership Board identified the most significant needs of patients diagnosed with multiple myeloma as bone health, health maintenance, mobility and safety, sexual dysfunction, and renal health. The Nurse Leadership Board then developed a survivorship care plan to assist healthcare providers and patients with multiple myeloma, their partners, and their caregivers to identify these needs.

Maintaining bone health in patients with multiple myeloma: survivorship care plan of the International Myeloma Foundation Nurse Leadership Board.

About 90% of individuals with multiple myeloma will develop osteolytic bone lesions from increased osteoclastic and decreased osteoblastic activity. Severe morbidities from pathologic fractures and other skeletal events can lead to poor circulation, blood clots, muscle wasting, compromised performance status, and overall poor survival. Supportive care targeting bone disease is an essential adjunct to antimyeloma therapy. In addition, the maintenance of bone health in patients with multiple myeloma can significantly improve quality of life. Oncology nurses and other healthcare providers play a central role in the management of bone disease and maintenance throughout the course of treatment. Safe administration of bisphosphonates, promotion of exercise, maintenance of adequate nutrition, vitamin and mineral supplementation, scheduled radiographic examinations, and monitoring of bone complications are among the important functions that oncology nurses and healthcare providers perform in clinical practice.

Management of side effects of novel therapies for multiple myeloma: consensus statements developed by the International Myeloma Foundation's Nurse Leadership Board.

Nurses play an essential role in managing the care of patients with multiple myeloma, who require education and support to receive and adhere to optimal therapy. The International Myeloma Foundation created a Nurse Leadership Board comprised of oncology nurses from leading cancer centers and community practices. An assessment survey identified the need for specific recommendations for managing key side effects of novel antimyeloma agents. Myelosuppression, thromboembolic events, peripheral neuropathy, steroid toxicities, and gastrointestinal side effects were selected for the first consensus statements. The board developed recommendations for healthcare providers in any medical setting, including grading of side-effect toxicity and strategies for managing the side effects in general, with specific recommendations pertaining to the novel agents.

Myelosuppression associated with novel therapies in patients with multiple myeloma: consensus statement of the IMF Nurse Leadership Board.

Novel therapies for multiple myeloma include the immunomodulatory drugs lenalidomide and thalidomide and the proteasome inhibitor bortezomib, which have increased response rates and survival times. However, the agents can cause myelosuppression, which, if not managed effectively, can be life threatening and interfere with optimal therapy and quality of life. The International Myeloma Foundation's Nurse Leadership Board developed a consensus statement that includes toxicity grading, strategies for monitoring and managing myelosuppression associated with novel therapies, and educational recommendations for patients and their caregivers. Although anemia, neutropenia, and thrombocytopenia are expected side effects of novel therapies for multiple myeloma, they are manageable with appropriate interventions and education.