Advanced Practice Nursing and CAR-T Cell Therapy: Opportunities, Challenges and Future Directions.

OBJECTIVES: Chimeric antigen receptor (CAR)-T cell therapy is a new treatment for patients with myeloma and other B cell malignancies where advanced practice nurses (APN) can make a great contribution. The aim of this review is to identify key aspects of current literature relevant to APNs working with this population. METHODS: Discussion of selected peer-reviewed literature and best practice guidelines found through electronic database searches (CINAHL, MEDLINE). RESULTS: Although few APN roles in CAR-T cell therapy have been published to date, recent research suggests that the APN is central to the care of these patients. They are essential for continuity of care and navigation through the treatment process, providing an important and consistent point of contact for patients' and carers' anxieties and uncertainties. APNs play a central role in symptom management, as they constantly incorporate new experience and scientific findings into the refinement of existing protocols. The continuum of care extends far beyond the inpatient stay and addresses symptoms that may persist long after cytokine release syndrome and neurotoxicity have resolved. The APN may therefore make a relevant contribution to patients' health-related quality of life, given its likely correlation with the dynamics and intensity of treatment-related symptoms. The APN also takes on a leadership role in the treatment team. CONCLUSIONS: APNs use all core competencies to sustainably support and empower patients and caregivers. This is achieved through counseling and education, in addition to identifying, developing, and implementing evidence-based symptom management. They play pivotal roles in introducing new CAR-T cell products, educating teams, and advancing their role through APN networks. Finally, APNs are integral members of multiprofessional teams, supporting colleagues in ethically challenging patient situations. IMPLICATIONS FOR NURSING PRACTICE: APNs in the field of CAR-T cell therapy make an important contribution to the continuous care of patients, caregivers, and treatment teams.

Nursing Considerations for Cytokine Release Syndrome in Relapsed/Refractory Multiple Myeloma: Experience with Teclistamab from the MajesTEC-1 Study.

OBJECTIVES: Cytokine release syndrome (CRS) is a systemic inflammatory response that is commonly observed as a class effect of T-cell-redirecting therapies. This article provides important practical guidance for nurses relating to the diagnosis, monitoring, and management of CRS in patients receiving teclistamab, based on experience from the MajesTEC-1 clinical trial and real-life nursing practice. METHODS: MajesTEC-1 is a phase 1/2 study of teclistamab in heavily pretreated patients with relapsed/refractory multiple myeloma. To mitigate the risk of high-grade CRS, patients were carefully monitored for early signs and symptoms of CRS (including fever, which must have fully resolved before teclistamab administration). RESULTS: A survey of nurses from several of the study sites provided additional real-life insights into nursing best practices for managing CRS from four academic institutions in three countries. CONCLUSIONS: In MajesTEC-1, 72% of patients treated with teclistamab experienced CRS, the majority of which was low grade. All cases resolved and none led to treatment discontinuation. Real-life supportive measures for CRS are generally aligned with those outlined in the study. IMPLICATIONS FOR NURSING PRACTICE: Because nurses are on the frontline of patient care, they play a crucial role in promptly recognizing the signs and symptoms of CRS and responding with timely and appropriate supportive treatment. This review provides important practical guidance for nurses on diagnosis, monitoring, and management of CRS in patients receiving teclistamab, based on experience from the MajesTEC-1 trial and real-life nursing practice.

Isatuximab: Nursing Considerations for Use in the Treatment of Multiple Myeloma.

BACKGROUND: Isatuximab is a CD38 monoclonal antibody approved for use in combination with pomalidomide plus dexamethasone to treat adults with relapsed/refractory multiple myeloma who have received at least two prior therapies. Because isatuximab is a relatively new treatment option, published guidelines for oncology nurses are limited. OBJECTIVES: This article provides nurses with guidance on all aspects of isatuximab administration and patient management to better support those receiving this treatment. METHODS: Data from the ICARIA-MM (NCT02990338) clinical trial and additional nursing resources were collected and condensed into concise treatment and management recommendations for the care of patients with multiple myeloma undergoing treatment with isatuximab. FINDINGS: Nursing care of patients prescribed isatuximab includes monitoring of clinical and laboratory parameters and requires knowledge and management of associated adverse events, including infusion reactions and neutropenia. This information could aid oncology nurses in providing optimal, treatment-specific education to patients and caregivers.

The experiences and needs of primary family caregivers of patients with multiple myeloma: A qualitative analysis.

BACKGROUND: Family caregivers play a key role in the lives of patients with multiple myeloma. However, very little is known about the impact that the disease (its diagnosis, course and prognosis) has on the main family caregiver. AIM: To achieve a deeper understanding of the lived experience of individuals who are the primary caregiver of a relative with multiple myeloma and to shed light on their needs. DESIGN: Interpretative phenomenological study. SETTING AND PARTICIPANTS: A total of 12 individuals who were the main family caregivers of a relative with multiple myeloma who was under outpatient follow-up at a cancer unit in Barcelona were recruited via purposive sampling until data saturation was reached. In semi-structured in-depth interviews, participants described their experiences of caring for their relative with multiple myeloma. Interviews were recorded, transcribed and analysed using ATLAS.ti v7.2. The seven steps proposed by Colaizzi were used for data analysis, and the relationships among emerging themes were examined. FINDINGS: Four main themes emerged: (a) a new life, adapting to the disease, (b) commitment to the patient, (c) the emotional sphere and (d) experiences in relation to the care and support received. The analysis also revealed a core overarching theme: uncertainty. CONCLUSION: Primary family caregivers experienced intense uncertainty, and they described a strong need to air their feelings. Specific practical initiatives, targeting both health-related and logistical aspects of care, need to be developed in order to support family caregivers of myeloma patients.

Multiple Myeloma: Detecting Genetic Changes Through Bone Marrow Biopsy and the Influence on Care.

Knowledge of genetic mutations and how these affect patient outcomes is rapidly expanding in the care of individuals diagnosed with multiple myeloma (MM). Genetic analysis of bone marrow biopsies now provides information about diagnosis,response to treatment, and prognosis. Oncology nurses need to understand the science and meaning of bone marrow biopsy reports, including the implications of genetic alterations and minimal residual disease. This will allow them to provide care, support, and education related to MM and its treatment to patients and their families.

Decision Aids: Assisting Patients With Multiple Myeloma and Caregivers With Treatment Decision Making

A consolidated evaluation of resources on treatment decision aids (DAs) for multiple myeloma (MM) is lacking in the literature. This review identified 29 published DAs. Further analysis of these DAs revealed that the personal values and preferences of patients with MM are not well integrated into the development of these DAs, indicating the need for a more explicit shared decision-making model of MM care delivery. The development and testing of a web-based and individualized treatment DA will likely promote a shared decision-making process in clinical practice, improve patient satisfaction with treatment decisions, and decrease decisional regrets in patients newly diagnosed with MM.
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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.

Disease and Symptom Care: A Focus on Specific Needs of Patients With Multiple Myeloma.

Patients with multiple myeloma (MM) often deal with short- and long-term side effects of the treatment and disease sequelae. Reasons for inadequately managed symptoms are multifactorial (e.g., the patient may fear treatment interruption, the clinician does not assess or address the symptoms) and can affect patients' ability to remain on the recommended treatment. This article provides background surrounding this supplement's development and describes the importance of symptom assessment and management.
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The Experience of Myeloma Caregivers During Home-Based Oral Chemotherapy Treatment: A Qualitative Study.

OBJECTIVE: The primary aim of this qualitative study was to explore myeloma carers/caregivers experience during outpatient-based oral treatment for patients with multiple myeloma (MM). DATA SOURCES: Literature review. In-depth, open-ended interviews of seven purposively selected caregivers of MM patients in the United Kingdom. CONCLUSION: Findings showed that carers were involved in practical and emotional caregiving activities, assisting the patient with managing complex oral combination treatments, and monitoring side effects. Care-giving activities continued after treatment, and experiences were described within the context of the MM journey and fear and uncertainty about the future. Caregivers also experienced a range of emotions, which they often kept hidden from the MM patients and other family members. Difficulties balancing caring responsibilities, particularly for those with jobs, were expressed. IMPLICATIONS FOR NURSING PRACTICE: Nurses need to understand the importance of considering carers' involvement when assessing patients, and the need to address caregivers' continuing support and information needs. Problems navigating health and social care processes should be anticipated, and nurses can direct the carers to appropriate resources to meet their needs.

Patient Reported Outcomes in Optimizing Myeloma Patients' Health-Related Quality of Life.

OBJECTIVE: To review the current state of evidence for the use of patient-reported outcomes (PROs) and health-related quality of life (HRQoL) in optimizing best supportive care for patients with multiple myeloma (MM). DATA SOURCES: Peer-reviewed journal articles, research reports, state of the science papers, and clinical guidelines. CONCLUSION: The diagnosis and treatment of MM negatively impacts an individual's HRQoL. Validated self-report tools that assess HRQoL and other PROs provide an insight into how the treatment or disease is impacting the individual, enabling early recognition of physical and emotional concerns. There is a growing body of evidence to support the use of PROs in assessing HRQoL in MM in clinical care. IMPLICATIONS FOR NURSING PRACTICE: There is a clear benefit for nurses to utilize PROs for patients with MM in order to obtain an understanding of how the treatment effects HRQoL. Thoughtful use of PRO measures can enable nurses to individualize supportive care interventions to meet the specific needs of the patient, and facilitate timely access to optimal symptom support.

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.

Evidence-Based Guidelines for Preventing and Managing Side Effects of Multiple Myeloma.

OBJECTIVE: To review disease-related symptoms and side effects of treatment in patients with multiple myeloma (MM). DATA SOURCES: Peer-reviewed articles, research studies, and clinical guidelines. CONCLUSION: New therapies provide patients with extended survival, but in many cases this benefit is counterbalanced by an increased incidence of side effects. Preservation of organ function, while managing side effects, is essential for the care of patients with MM. IMPLICATIONS FOR NURSING PRACTICE: Disease- and treatment-related adverse events are prevalent in patients with MM. Patient, family, and health care professional education is essential to monitor and manage these side effects.

Young Adults with Multiple Myeloma.

OBJECTIVE: To identify the salient issues of young adults (YAs) diagnosed with multiple myeloma (MM), a hematologic disease of older adults, that is rare in patients 19-40 years of age. DATA SOURCES: Peer-reviewed journal articles, case reports, single-institution series, and national guidelines. CONCLUSION: Compared to older adults with MM, YAs live longer and are at higher risk for survivorship-related issues, which include treatment adherence, infertility, reproductive concerns, risk of second primary cancers, treatment-related cardiotoxicity, and higher risk of non-cancer-related mortality. IMPLICATIONS FOR NURSING PRACTICE: In addition to understanding disease biology, the oncology nurse should have an understanding of the unique developmental, psychosocial, and medical and psychosocial needs of the young adult with MM. The oncology nurse will then be able to provide targeted education about the disease, its treatment trajectory, and supportive care issues, as well as advocate for therapies, and based on response, toxicities, while taking into consideration patient-centered needs.

Immunomodulatory Agents and Proteasome Inhibitors in the Treatment of Multiple Myeloma.

OBJECTIVE: To review the current evidence on the use of immunomodulatory agents (IMiDs) and proteasome inhibitors (PIs) in the treatment of multiple myeloma (MM). DATA SOURCES: Journal articles, research reports, state of the science papers, and clinical guidelines. CONCLUSION: There has been a tremendous increase of new agents to treat multiple myeloma in the last 15 years. The IMiDs and PIs remain essential components of many anti-myeloma regimens. IMPLICATIONS FOR NURSING PRACTICE: With these advances in the therapeutic landscape, knowledge of these drugs, side effects and nursing implications are essential to improve outcomes. Patient education is also of vital importance in achieving optimal responses to treatment.

Living with Multiple Myeloma: A Continuum-Based Approach to Cancer Survivorship.

OBJECTIVES: To describe a tailored approach to survivorship care for health care providers (HCPs) involved in the care of patients and caregivers living with multiple myeloma (MM) and identify key transition points within the continuum of care with recommended adaptation to the survivorship care plan (SCP). DATA SOURCES: Review of the literature, web-based resources. CONCLUSION: The health care needs of cancer survivors will vary throughout the continuum of care. Effective patient self-management requires several key elements: consistent and clear communication that allows the patient to make informed decisions, reinforcement of key messages at each visit, adjustment of visit frequency to the specific phase of survivorship and health care needs, integration of community programs and resources, and development of mutually determined goals. The goal is to focus on living, maintaining or improving quality of life (QOL) in the MM survivor with consideration of the needs of caregivers. IMPLICATIONS FOR NURSING PRACTICE: Implementation of a tailored survivorship care plan (SCP) based on individual disease- and treatment-related factors, personal preferences, and available resources, setting expectations, and continuing to communicate openly with the MM patients and their caregivers promotes health-self-management, reduces symptom burden, and improves QOL. Innovative strategies for survivorship care that promote communicative health literacy, engage the patient and their caregivers in health self-management, involve the survivor in developing the SCP, and clearly designate the roles of HCPs are needed.

Strategies for Selecting the Optimal Treatment in Newly Diagnosed Multiple Myeloma Patients.

OBJECTIVE: To review the current evidence on strategies for selecting the optimal treatment for newly diagnosed patients with multiple myeloma (MM). DATA SOURCES: Journal articles, research reports, state of the science papers, and clinical practice guidelines. CONCLUSION: Despite the plethora of drugs to effectively treat MM, the optimal induction regimen for patients with newly diagnosed MM is unknown. Rapid control of the disease, appropriate treatment selection and effective supportive care strategies remain integral to prevention and management of the disease. Strategies for selecting the optimal treatment include considering inherent patient characteristics, frailty, and existing clinical practice guidelines. IMPLICATIONS FOR NURSING PRACTICE: Nurses should provide patients with disease- and treatment-related education to enhance patient and caregiver understanding of the disease and treatment options, taking into consideration clinical data and overarching goals of treatment.

Patients with myeloma need more time to ask questions.

According to a report by charity Myeloma UK, many patients are unsure about the issues they should be discussing with their nurse and other healthcare professionals.

Patients' Experiences With Multiple Myeloma: A Meta-Aggregation of Qualitative Studies.

PROBLEM IDENTIFICATION: To systematically review qualitative evidence regarding patients' experiences of living with multiple myeloma. The main objective was to gain structured understanding of this experience, which is a prerequisite for advancing nursing care and ensuring it is effective.
. LITERATURE SEARCH: Qualitative research articles from January 2005 to March 2016 were located in CINAHL®, PubMed, and Scopus. Supplementary resources were found by scrutinizing reference lists and performing citation tracking. All included articles fulfilled predetermined criteria.
. DATA EVALUATION: Three reviewers independently assessed the risk of methodologic bias by using the Joanna Briggs Institute (JBI) Qualitative Assessment and Review Instrument. The JBI methodology of meta-aggregation was used to synthesize findings.
. SYNTHESIS: Eleven studies fulfilled the eligibility criteria. From these, 84 findings were extracted. Each finding was assigned a level of credibility. CONCLUSIONS: Patients with myeloma require a different form of follow-up compared to patients with many other cancers because of its chronic nature. Results demonstrate that widespread physical, emotional, and social challenges were experienced by patients throughout their illness trajectories, even in periods of remission. Nursing care should incorporate knowledge of patients' experiences.
. IMPLICATIONS FOR PRACTICE: The results provide directions for nurses to improve supportive strategies in the care of patients with multiple myeloma. The categories provide a useful framework for developing clinical assessment tools.

Multiple Myeloma Mentorship: Bridging Communication and Educational Gaps.

BACKGROUND: The 2014 Multiple Myeloma (MM) Mentorship Program provided a focused, interactive, peer-to-peer educational experience, including updates in MM, for 10 mentees that led to advanced clinical educator status. OBJECTIVES: The objective of the program was (a) to improve mentees' knowledge, competency, confidence, and level of performance in the management of MM and (b) to build speaking expertise. METHODS: From May 2014 to March 2015, 10 mentees were educated on MM with a structured serial learning curriculum. Mentees then presented slide decks, and modular activities were opened to a national audience of professionals. Pre- and post-test surveys were compiled, and a RealIndex® composite score was calculated. FINDINGS: Gains were measured across the curriculum in learning domains of knowledge, confidence, and practice strategy. Pre-/post-test scores show that the mentorship cohort's average scores on knowledge, confidence, and performance were higher compared to the national program.