Welcome and Announcements Kelly Cox
Director Support Groups & Senior Director Regional Community Workshops 1
Thank you to our sponsors!
2
IMF REGIONAL COMMUNITY WORKSHOP Saturday April 2, 2022 - Agenda
10:00 AM - Welcome and Announcements Kelly Cox, Director Support Groups & Senior Director of Regional Community Workshops 10:05 AM - Myeloma 101 and Frontline Therapy Frits Van Rhee, MD, PhD, Winthrop P. Rockefeller Cancer Institute, Little Rock, AR 10:40 AM - Q & A with Panel 10:55 AM – Meditation and Stretch Break 11:05 AM - Relapsed Therapy and Clinical Trials Agne Paner, MD, Rush University Medical Center, Chicago, IL 11:45 AM - How to Manage Myeloma Symptoms and Side Effects Kevin Brigle, PhD, MD, VCU Massey Cancer Center, IMF Nurse Leadership Board 12:05 PM - Q&A with Panel
4
Myeloma 101 and Frontline Therapy
Frits Van Rhee, MD, PhD Winthrop P. Rockefeller Cancer Institute, Little Rock, AR 5
Myeloma-101
F r i t s v a n R h e e , M D, P h D, M R C P ( U K ) , F R C Pa t h C l i n i c a l D i re c to r, P ro fe s s o r o f M e d i c i n e
What is Multiple Myeloma?
Proportion Surviving
Plasma Cells
Myeloma Cells
Outline
Introduction Myeloma tests explained
Do I have high risk myeloma?
Should we treat smoldering myeloma?
Treatment of elderly patients
Treatment of transplant eligible patients
Diagnosis of Myeloma Bone marrow clonal plasmacytosis Monoclonal immunoglobulin Plasmacytomas on tissue biopsy and/or skeletal lesions
© 2009 OptumHealth Education
© 2009 OptumHealth Education
How does myeloma work?
Bone Pain Bone Destruction
Hypercalcemia
Release of Cytokines Anemia
Marrow Infiltration
MULTIPLE MYELOMA
Monoclonal Protein
Renal Failure
Hyperviscosity
Amyloidosis
Immune Deficiency
LCDD
Infection
Commonly Performed Tests
Blood Tests
Urine Tests
Bone Marrow Biopsy
Imaging
Diagnostic Tools: Free Light Chains and Clonal Plasma Cells Serum Protein Electrophoresis Normal
Serum Immunofixation or Immunoelectrophoresis
Used to detect an “M spike” in serum
Myeloma
Used to determine the subtype of M protein (Ig) present
M spike = large amount of monoclonal Ig proteins
Serum Free Light Chain Assays Heavy chain
Light chain
Tail region: IgG, IgA, IgM, IgD, IgE
FLC Ratio: Kappa/Lambda “Clonal” plasma cells all make the same (monoclonal) Ig protein and also produce extra light chains that do not have a heavy chain partner to which to bind, causing “free” light chains
Abnormal ratios of free kappa or lambda light chains indicate excess of one type of clonal plasma cells due to myeloma
What is the M-protein? An immunoglobulin has heavy chains (IgG, IgA, IgM, IgD and IgE) and two light chains )kappa or lambda) Light chains are excreted in the urine.
This is referred to as Bence Jones Proteinuria and is further defined as being either free kappa or lambda.
The amount of proteinuria is quantified using a 24 hour urine collection
Urine “M” (myeloma or monoclonal) protein.
What are free light chains? exposed surface
Kappa
exposed surface
hidden surface
Previously hidden surface
heavy chain
Lambda light chain
Both Kappa and Lambda abnormal
MGUS, SMM, Myeloma (κ/λ ratio very frequently abnormal Renal impairment (κ/λ ratio normal) Activation or suppression of the immune system (κ/λ ratio normal)
Examples of Serum and Urine Electrophoresis
24 hour urine collection Total protein in 24 hour = albumin + light chains e.g. 10gm/day Amount of light chains e.g. 9 gm/day
• To track loss of protein and response to therapy • To determine type of kidney disease caused by myeloma
Imaging in Multiple Myeloma CT-scan
• Mandatory in the diagnostically workup for MM • Gold standard for detection of osteolytic bone disease
Conventional MRI
• Gold standard for suspected cord compression • Recommended for work up of SMM
FDG-PET/CT
• Wide use in the FU of extramedullary disease, and nonsecretory MM, Assessment of response
DWIBS
• Investigational • Advantage: higher sensitivity than PET, pick up diffuse disease, can be used for response assessment
Do I have high risk disease? (R)-ISS Staging
Metaphase Cytogenetics
FISH
1
6
7
13
19
Gene Expression Profiling
2
3
8
4
9
14
15
20
21
5
10
11
16
17
22
X
12
18
Y
Imaging
NSG
5-Year Deaths / N Estimate A: MRI-FL normal 45 / 191 73% (65,80) B: MRI-FL between 1-7 62 / 218 67% (59,74) C: MRI-FL >7 85 / 202 54% (46,62) P-val: Overall<0.001, A vs. B=0.42, A vs. C<0.001, B vs. C=0.001
100% 80% 60% 40% 20% 0%
0
2
4
6
8
Revised ISS Staging System ISS Definition
II
Not stage I or III
III
β2-M ≥ 5.5 mg/L
R-ISS Definition I
ISS stage I AND Normal LDH No t(4;14), t(14;16), or del(17p)
II
Not stage I or III
III
ISS stage III AND Serum LDH > ULN OR With t(4;14), t(14;16), or del(17p)
Palumbo. J Clin Oncol. 2015;33:2863.
80
OS (%)
I
Serum albumin ≥ 3.5 g/dL AND β2-M < 3.5 mg/L
100
60 40 Median OS, Mos R-ISS I NR R-ISS II 83 R-ISS III 43
20 0
0
12
24
36 48 Mos
60
72
Slide credit: clinicaloptions.com
FISH ‘High-risk’ • t(4;14) • t(14;16) • del(17p) • Amplification 1q FISH can be done on resting cells and will yield information in all cases You will only find what you look for
Example of metaphase cytogenetics
1
6
13
19
2
7
3
8
4
9
14
15
20
21
5
10
16
22
11
17
X
12
18
Y
CT-PET scanning in Multiple Myeloma • Measures metabolic activity • Identifies macrofocal disease • Detects extramedullary disease • CT-portion very sensitive in detecting osteolytic lesions • CT-PET has prognostic implications Normal FDG PET
Myeloma FDG PET
• Medicare approved
University of Arkansas for Medical Sciences
Prognostic significance of PET scan at diagnosis
Bartel et al. Blood 2009
Three or more large Lesions on DWIBS-MRI are associated with worse outcome Progression Free survival
Overall Survival
Rasche et al. Blood 2018;132:59-66
What are large FLs?
Do I have high risk disease? That depends………. It is not so easy. Many factors come into play and risk classifications are changing
Certainly not everyone with ‘bad’ FISH will behave like high risk
Early relapse on therapy is not good (‘functional high risk’)
Does the patient need therapy for smoldering myeloma? MGUS M protein < 3 g/dL Clonal plasma cells in BM < 10% No myeloma-defining events
Smoldering Myeloma M protein ≥ 3 g/dL (serum) or ≥ 500 mg/ 24 hrs (urine) Clonal plasma cells in BM ≥ 10% to 60% No myeloma-defining events
*S: Sixty percent clonal bone marrow plasma cells Li: Serum free Light chain ratio ≥ 100 (involved kappa) or ≤ .01 (involved lambda) M: MRI studies with > 1 focal lesion (> 5 mm in size) Rajkumar. Lancet Oncol. 2014;15:e538.
Active or Symptomatic Multiple Myeloma Underlying plasma cell proliferative disorder AND ≥ 1 SLiM-CRAB* feature
C: Calcium elevation (> 11 mg/dL or > 1 mg/dL higher than ULN R: Renal insufficiency (CrCl < 40 mL/min or serum creatinine > 2 mg/dL) A: Anemia (Hb < 10 g/dL or 2 g/dL < normal) B: Bone disease (≥ 1 lytic lesions on skeletal radiography, CT, or PET/CT)
Risk of Progression to Symptomatic Myeloma
Kyle. N Engl J Med. 2007;356:2582.
Risk Stratification of SMM: 20/2/20 Model Patients With Active MM
Median Time to Progression (Mos) High
1.0
RFs: PCs > 20% M spike > 2.0 g/dL FLCr >20
0.8 0.6
29.2
0.4
Intermediate 67.8 109.8 Low
0.2 0
P < .0001 0 12 24 36 48 60 72 84 96 108 120
Months
Risk, %
2 Yrs
5 Yrs
10 Yrs
High (≥ 2 RFs)
47.4
81.5
96.5
Intermediate (1 RF)
26.3
46.7
65.3
Low (0 RFs)
9.7
22.5
52.7 Slide credit: clinicaloptions.com
Smoldering Myeloma To Treat or Not To Treat? • How good are our predictions in terms of predicting risk of progression? • Who needs treatment? • What is the goal of therapy: delay progression or ‘cure’? • Early treatment may prevent serious complications and have lower mutational burden with potential for better outcome • Some patients may get unnecessary therapy with risk of side-effects and even death
Options for treatment of high risk smoldering myeloma Lenalidomide Lenalidomide/ dexamethasone Daratumumab Transplant ? Bispecific Antibodies
1. Kyle. NEJM. 2007;356:2582. 2. Pérez-Persona. Blood. 2007;110:2586. 3. San Miguel. ASCO 2019. Abstr 8000. 4. Mateos. NEJM. 2013;369:438. 5. Mateo. Lancet Oncol. 2016;17:1127. 6. Mateos. ASH 2019. Abstr 781.
Benefit of lenalidomide confined to patients deemed high risk by 20/2/20 Model Progression to MM (%)
High Risk
Low Risk
Intermediate Risk
100
100
100
80
80
80
60
60
60
40
40
40
20
20
20
0
0
0
0
6
12 18 24 30 Months
36
40
0
6
12 18 24 30 Months
36
40
Lenalidomide Observation
0
6
12 18 24 30 Months
36
40
Lenalidomide reduced the risk of clinical progression in high-risk SMM by 91% Lonial. J Clin Oncol. 2020;38:1126.
Slide credit: clinicaloptions.com
Curative Strategy for High-Risk Smoldering Myeloma Induction
Consolidation
6 x 28-day cycles Carfilzomib Lenalidomide Dexamethasone
Mateos. ASH 2019. Abstr 781.
High-dose melphalan 200 mg/m2 followed by ASCT
Maintenance
2 x 28-day cycles
24 x 28-day cycles
Carfilzomib
Lenalidomide
Lenalidomide
Dexamethasone
Dexamethasone
Curative Stretegy for High-Risk Smoldering Myeloma 100
100
PFS
35-Mo PFS: 92%
60 40 20 0
OS
80
Patients (%)
Patients (%)
80
35-Mo OS: 96%
60 40 20
Median follow-up: 35.2 (5.4-53.2) 0
10
20
Mos
0 30
40
50
6 patients progressed (biological PD, n = 5) ‒ 4 patients with PD were at ultrahigh risk Mateos. ASH 2019. Abstr 781.
Median follow-up: 35.2 (5.4-53.2) 0
10
20
30
Mos
40
50
60
3 patients died; only 1 was considered a treatment-related death
Observe evolution of disease before starting therapy The Spanish Experience[1]
Progression to MM (%)
100
After evolving While not evolving
Median TTP: 1.1 yrs
80 60 40 20 HR: 5.1 (95% CI: 3.4-7.6; P < .001)
0 0
5
10
15
25 20 Years
1. Fernandez de Larea. Leukemia. 2018;32:1427. 2. Ravi. Blood Cancer J. 2016;6:e454.
30
35
40
Slide credit: clinicaloptions.com
What do I do in clinical practice for smoldering myeloma? Confirm SMM diagnosis : MRI/CT-PET
Multiple HR features
Younger and Fit Treat as myeloma
High risk SMM
Observe for evolution
Standard risk SMM
Follow up every 3 months
Evolving SMM
Intervene
Myeloma Drugs Approved Since 2000
Bortezomib
Daratumumab Melflufen Ixazomib Ide-cel Selinexor Pomalidomide Elotuzumab Isatuximab Belantamab Carfilzomib Panobinostat
Liposomal doxorubicin Thalidomide Lenalidomide
2000
2005
2010
2015
2019
2020
2021
Cilta-cel
2022
To transplant or not: that is the question Physiologic Age ‒ Elderly patients my be transplant ineligible ‒ Older patients more sensitive to toxicity; less physical reserve
Performance status
Other medical factors ‒ kidney impairment ‒ Cardiovascular disease ‒ Lung disease ‒ Liver disease (eg, chronic hepatitis or cirrhosis)
Therapeutic Approach to Elderly Patients “Staging the Aging” helps to establish what level of treatment intensity the patient is able to tolerate Avoid early treatment discontinuation Minimize treatment toxicities Optimize treatment efficacy and preserve quality of life
Accumulative Lines of Therapy Received by Age at Diagnosis : Best Therapy Should Be Used Upfront in Elderly Patients 100
93
<70 years, n = 165
89
90
70+ years, n = 174
80
Percent
70 59
60 50 40
35
35
30 20 10 0
17
11
6 0
18 7
1
2
3
Accumulative Lines of Therapy
4
4
2 5
Your first shot is your best, and maybe your only one…..
Courtesy of A Spencer
Myeloma in the Elderly: Other Considerations What are the goals of therapy? ‒ Palliate ‒ 4-drug vs 3-drug vs 2-drugs with maintenance to control the disease ‒ Can or even should we keep patients on continuous therapy?
How do we deliver therapy: Is the patient able to get sc or iv therapy by oncologist or is all oral regimen desired? What about heart disease, diabetes, kidney disease etc.? Palumbo. Blood. 2015;125:2068.
What to do with the elderly patient? Frail RD IRD
Intermediate Fitness DaraRD IRD VRD-lite
Fit Dara-VRD
VRD
KRD ASCT
Three drugs (VRD) are better than two: SWOG 0777 100
VRd (n = 242) Rd (n = 229)
60 40
80
VRd (n = 242)
Median OS, Mos 75
Rd (n = 229)
64
60 40 20
20 0
100
OS (%)
PFS (%)
80
Median PFS, Mos 43 30
0
24 48 72 Mos Since Registration
Durie. Lancet. 2017;389:519.
0
0
24 48 Mos Since Registration
72
Phase III MAIA Trial: Survival With DaraRd vs Rd in Older Transplant-Ineligible Patients
PFS (%)
100
30 mos
80
71%
60
56%
D-Rd Median: not reached
Rd Median: 31.9 mos
40 20 0
0
Pts Risk, n Rd 369 DaraRd 368
3 332 347
6
9
12
307 280 254 335 320 309
Facon. ASH 2018. Abstr LBA-2.
15
18
21 Mos
236 219 200 300 290 271
27
30
33
36
39
42
149 94 203 146
50 86
18 35
3 11
2 1
0 0
24
RD-Dara new standard of care for the elderly? ?
55 50 45 40
36.4
35.1
35 29.7
mPFS
30 25 20
31.9
18.3
25.3
26
Rd (ECOG)
Rd (FIRST)
25.3
26
34
19.1
15 10 5 0 mPFS
VMP (VISTA) 18.3
VMP VMP-D (ALCYONE) (ALCYONE) 19.1 35
IMiD-free
Rd (SWOG 0777) 29.7
Rd (MAIA) 31.9
RVd Lite RVd (SWOG RdD (MAIA) (O'Donnell) 0777) 35.1 34 55
IMiD-foundation
Randomized Phase 2 GRIFFIN Study: RVd + Daratumumab in Transplant-Eligible Patients
1:1 Randomization
Induction: Cycles 1-4
Consolidation: Cycles 5-6
T R A N S P L A N T
Dara-RVd
RVd
21-day cycles Stem cell Collection Kaufman Abstract 549.
Dara-RVd
RVd
21-day cycles
Maintenance: Cycles 7-32
+
Dara-R
R
28-day cycles
Progression free survival
Durable MRD negativity better in daratumumab arm
Unmet need in high risk Myeloma
New immunotherapies for Myeloma Antibody-Drug Conjugate Precisely Delivers Cytotoxic Drug to Myeloma Cells
Cytotoxic Drug
oys Myeloma Cell
Bispecific Antibody
Links Effector Cells to Myeloma Cells to Induce Tumor Lysis
CAR T-cells
Links Effector Cells to Myeloma Cells to Induce Tumor Lysis
Myeloma Cell
55
IMF REGIONAL COMMUNITY WORKSHOP – Tri-State Agenda After Break
11:05 AM - Relapsed Therapy and Clinical Trials Agne Paner, MD, Rush University Medical Center, Chicago, IL 11:45 AM - How to Manage Myeloma Symptoms and Side Effects Kevin Brigle, PhD, MD, VCU Massey Cancer Center, IMF Nurse Leadership Board 12:05 PM - Q&A with Panel
57
Relapsed Therapy and Clinical Trials Agne Paner, MD, Rush University Medical Center, Chicago, IL 58
Clinical trials and treatment of relapsed Multiple Myeloma
Agne Paner, MD Associate Professor of Medicine Director of Multiple Myeloma and Amyloidosis Program Rush University Cancer Center August 7th, 2021
All the treatments we have today are a result of clinical trials Preclinical research:
Laboratory research Animal models
Trials with humans: Phase I – is it safe? Phase II – how many will respond? Phase III –Is new treatment better than standard?
Road blocks in myeloma journey:
Natural history and treatment course of MM: ASCT transplant Maintenance
Newly diagnosed
Early relapse
Multiple relapses
Nature of trials by timeline: Phase III Is new treatment better than what is standard?
Phase I/II Is it safe, do patients respond?
Terminology in the clinical trials • What phase is the trial • What patient population participated in the trial • Randomized: computer decides which treatment patient will receive • Overall Response Rate: how many patients had at least 50% reduction in tumor • Progression free survival: how long patient remained in remission • Duration of response: how long patients who responded remained in remission • Overall survival: how long patients lived after starting this treatment • Adverse events: side effects during clinical trial
Unmet medical need: triple class refractory MM
IMIDs: 1. Lenalidomide (Revlimid) 2. Pomalidomide (Pomalyst)
Proteosome Inhibitors: 1. Bortezomib (Velcade) 2. Ixazomib (Ninlaro) 3. Carfilzomib (Kyprolis)
Anti-CD38 Monoclonal antibodies: 1. Daratumumab (Darzalex) 2. Isatuximab (Sarclisa)
Autologous stem cell transplant with Melphalan conditioning for those who are eligible
BCMA* – New target for treatment of MM BCMA-targeting modalities Antibody-drug conjugate
T-cell activating strategies CAR T-cell therapy
Bispecific antibody
BCMA, B-cell maturation antigen; CAR, chimeric antigen receptor. Cho SF et al. Front Immunol. 2018;9:1821. doi:10.3389/fimmu.2018.01821.
64
* BCMA - B cell Maturation Antigen
Anti-BCMA therapies Antibody-drug conjugate: 1. Belantamab mefadotin (Blenrep)
BCMA
Car T cells: 1. Ida-cell 2. Cilta-cell
* BCMA - B cell Maturation Antigen
BiTes:
1. Erlanatamab 2. Teclistamab et cet
How does it work: Belantamab mefadotin
Things to know: Belantamab mefadotin • In a phase 2 clinical trial 30% of patients triple class refractory MM responed to belantamab. • Among patient who did respond (DOR), remission lasted about a year. • Belantamab can cause:
• dry eyes, • impaired vision • changes in the lining of cornea, that may not cause symptoms, but can be seen on a slit lamp exam.
• Eye exam required every 3 weeks • Eyes recover when drug is held and patients can be treated again. • Holding drug is safe – vast majority of patient remain in remission while holding drug for eye side effects. Lancet Onocology 2020
Strengths and weaknesses: Belantamab Strengths
Weaknesses
Easy access, available in each office
Ongoing therapy
Convenient schedule: intravenous 30min infusion every 3 weeks
Side effect of dry eyes and impaired vision
Well tolerated except for side effects for eyes
Requires eye exam every 3 weeks by eye care professional
Can be given without steroids
How does it work: BiTes (Bispecific T cell engagers)
Things to know: BiTes • Currently in clinical trials only • Administered intravenously or Sq, weekly-every three weeks. • Response rates range from 60-70% • During initial cycles can cause cytokine release syndrome (CRS) • Can cause neurotoxicity
Phase ½ studies with BiTes presented in ASH meeting 2021
n ORR 6 months DOR CRS, grade 1/2 Neutropenia Infection ICANS
Elranatamab 58 70% 92% 83% 64% 20%
ORR- overall response rate DOR- duration of response CRS – cytokine release syndrome ICANS – Immune effector cell-associated neurotoxicity
Teclistumab 159 65% 90% 67% 53% 63% 2.5%
Strengths and weaknesses: BiTes Strengths
Weaknesses
Currently available only through clinical trials
Ongoing therapy
High response rates Too early to say how long remission will last
Risk of CRS with first cycles
Schedule varies from weekly to every three weeks. Administered IV or SQ
Risk of neurotoxicity (ICANS)
How does it work: CAR Tcells
Currently FDA approved CAR Tcells for RRMM n ORR PFS CRS ICANS Neutropenia Infection
Ide-Cel 140 73% mPFS 8.8m 84% (5% grade ¾) 18% 91% 69%
Cilta-Cel 113 98% (83% in CR) 2y PFS 67% 95% (4% grade 3/4) 21% 95% 58%
Strengths and weaknesses: Car T cells Strengths
Weaknesses
One and done treatment
Requires hospital admission
High response rates and duration of response
Logistics can be difficult: Need to travel to specialized center Delays due to manufacturing shortage Risk of CRS
Risk of neurotoxicity (ICANS)
What other Bites can we expect coming soon: • Cevostamab –targets FcRH5 (ORR 56%, DOR 11.5 months) • Talquetamab – targets GPRC5D (66-70%, DOR not reached at 10months)
* BCMA - B cell Maturation Antigen
Thank you agne_paner@rush.edu
How to Manage Myeloma Symptoms and Side Effects Kevin Brigle, PhD, NP, VCU Massey Cancer Center, IMF Nurse Leadership Board 78
April 2, 2022
LIFE IS A CANVAS, YOU ARE THE ARTIST Kevin Brigle, PhD, NP Virginia Commonwealth University Massey Cancer Center
Patient Education Slides 2021
FRAMING YOUR CARE Know your care team, Shared Decision Making & Reliable Resources
You are central to the care team
Pharmacist
CARE TEAM COLLAGE General Hem/Onc Myeloma Specialist
Communicate with your team • Myeloma is a chronic disease • Understand the roles of each
team member and who to contact for your needs • Participate in support network
Be empowered • Ask questions, learn more • Participate in decisions • Know your history –
Myeloma ManagerTM Personal Care AssistantTM
Primary Care Provider (PCP)
You and Your Caregiver(s) Support Network
Subspecialists Allied Health Staff
81
SHARED DECISION-MAKING Be empowered to be part of the treatment decision-making • Ask for time to consider options (if needed/appropriate) • Understand options; consider priorities • Use reliable sources of information • Use caution considering stories of personal
experiences • Consider your goals/values/preferences • Get a 2nd opinion, Meet with a Myeloma expert
• Express your goals/values/preferences; create a
dialog
• My top priority is [goal/value]; additional [preferences] are also important. • I think [treatment] may be a good choice given my priorities… What do you think?
• Arrive at a treatment decision together
Data From Research
HCP Clinical Experience TREATMENT DECISION
Your Preference Philippe Moreau. ASH 2015.
82
COLOR WHEEL OF TREATMENT
Treatment options, side effects, symptom management, & supportive care
MANAGING MYELOMA: THE BIG PICTURE Transplant Eligible Patients
Transplant Ineligible patients
Everyone
Transplant Consolidation
Maintenance
Initial Therapy
Treatment of Relapsed disease Consolidation/ Maintenance/ Continued therapy
Supportive Care
84
SHADES OF “AUTO” STEM CELL TRANSPLANT (ASCT) • There are no black and white answers to deciding to undergo a transplant • Undergoing transplant is a commitment for both you and your care partner • Understanding the process will help decide if/when to undergo transplant
Clinical Experience
Data from Research DECISION
Patient Preference
Adapted from Philippe Moreau, ASH 2015
(WHEN) IS TRANSPLANT RIGHT FOR ME? Current studies continue to support early autologous transplant Commitment: Quality of life must be considered when deciding timing Allogeneic transplant not recommended as initial therapy
Upfront autologous transplant remains the standard of care for transplant-eligible patients. Phase 1: Eligibility
Phase 2: Transplantation
Phase 3: Post-Transplantation
Miceli T, et al. Clin J Oncol Nurs. 2013;17(6)suppl:13-24. Kaufman GP, et al. Leukemia (2016) 30, 633-639.
TRANSPLANT BY NUMBER
• Duration: Approximately 2 weeks • Location: Transplant Center
• High Dose Chemotherapy, stem cell infusion • Supportive Care • Engraftment
• Duration: Approximately 3-4 weeks • Location: Transplant Center
POST-TRANSPLANT
PHASE 3
•Measuring treatment response •Determining Transplant Eligibility •Insurance authorization •Collecting stem cells
TRANSPLANT
PHASE 2
PHASE 1
ELIGIBILITY
• Restrengthening • Appetite recovery • “Day 100” assessment • Begin maintenance therapy • Duration: Approximately 10-12 weeks • Location: HOME!
CARE PARTNER SUPPORT Care partner support is essential for the entire transplant process. Phase 1: Sedated procedures; Education sessions Phase 2: Some transplant centers allow for outpatient transplant management Phase 3: Continued support and assistance is often Care partner can be one person or a rotation of many people.
PATIENT-REPORTED SYMPTOMS Symptoms resulted from both myeloma disease and treatment and can impact quality of life at all stages of disease. They fall into 3 categories:
Physical
Psychological
• Fatigue
• Depression
• Constipation
• Anxiety
• Pain
• Sleep Disturbance
• Neuropathy
• Decreased Cognitive Function
• Impaired Physical Functioning • Sexual Dysfunction
Ramsenthaler, et al. 2016. https://doi.org/10.1111/ejh.12790.
Financial • Financial burden • Financial toxicity
• Decreased Role & Social Function
89
GI SYMPTOMS: PREVENTION & MANAGEMENT Diarrhea may be caused by medications and supplements • • • •
Laxatives, antacids with magnesium Antibiotics, antidepressants, others Milk thistle, aloe, cayenne, saw palmetto, ginseng Sugar substitutes in sugar free gum
Avoid caffeinated, carbonated, or heavily sugared beverages Take anti-diarrheal medication • Imodium®, Lomotil®, or Colestid if recommended • Fiber binding agents – Metamucil®, Citrucel®, Benefiber® • Welchol® if recommended
Physical
Constipation may be caused by • Opioid pain relievers, antidepressants, heart or blood pressure medications, others • Supplements: Calcium, Iron, vitamin D (rarely), vitamin B-12 deficiency
Increase fiber • Fruits, vegetables, high fiber whole grain foods • Fiber binding agents – Metamucil®, Citrucel®, Benefiber®
Fluid intake can help with both diarrhea and constipation, and good for kidneys. Discuss GI issues with health care providers to identify causes and make adjustments to medications and supplements.
Smith LC, et al. CJON.2008;12(3)suppl:37-52. Faiman B. CJON. 2016;20(4):E100-E105. Miceli, T. et al. (2021). Cancer Treatment and Res Com, 100476.
90
PAIN: PREVENTION AND MANAGEMENT
Physical
Pain can significantly compromise quality of life Sources of pain include bone disease, neuropathy and medical procedures Management • Prevent pain when possible • Bone strengtheners to decrease fracture risk; anti viral to prevent shingles; sedation before procedures
• Interventions depends on source of pain • May include medications, physical therapy, surgical intervention, radiation therapy, etc
• Complementary therapies • Mind-body, meditation, yoga, supplements, acupuncture, activity, etc
Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Miceli, T. et al. (2021). Cancer Treatment and Res Com, 100476.
Tell your health care provider about any new bone pain or chronic pain that is not adequately controlled
91
PERIPHERAL NEUROPATHY MANAGEMENT Peripheral neuropathy: damage to nerves in extremities (hands, feet, or limbs) • • • • • •
Numbness Tingling Prickling sensations Sensitivity to touch Burning and/or cold sensation Muscle weakness
Physical
Prevention / Management: • Bortezomib once-weekly or subcutaneous administration • Massage area with cocoa butter regularly • Supplements:
• B-complex vitamins (B1, B6, B12) • Folic acid, and/or amino acids but do not take on day of Velcade® (bortezomib) infusion
• Safe environment: rugs, furnishings, shoes
If PN worsens, your HCP may: Report symptoms of peripheral neuropathy early to your health care provider; nerve damage from PN can be permanent if unaddressed
• Change your treatment • Prescribe oral or topical pain medication • Suggest physical therapy
Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Tariman, et al. CJON.2008;12(3)suppl:29-36. Miceli, T. et al. (2021). Cancer Treatment and Res Com, 100476.
92
Physical symptoms impact mental well being. All can affect quality of life and relationships.
FATIGUE, ANXIETY & DEPRESSION
• Fatigue is the most common reported symptom (98.8%) Sources include anemia, pain, reduced activity, insomnia, treatment toxicity, bone marrow suppression
Physical Psychological
• Anxiety reported in >35% • Depression nearly 25% Financial concerns, disease progression, end-of-life, and change in social and sexual function were highlighted sources
Often, people do not share these symptoms with their provider. Talk to your provider about symptoms that are not well controlled or thoughts of self harm. Help is available. Ramsenthaler, et al. 2016. https://doi.org/10.1111/ejh.12790. Catamero D et al. CJON. 2017; 21(5)suppl:7-18.
93
REST AND RELAXATION CONTRIBUTE TO GOOD HEALTH 🐑🐑 Adequate rest and sleep are
essential to a healthful lifestyle
Short and disturbed sleep increase risk of • Heart related death • Increase anxiety • Weaken immune system • Worsened pain • Falls and personal injury
🐑🐑 Things that can interfere with sleep • Medications : steroids, stimulants, herbal
supplements, alcohol • Psychologic: fear, anxiety, stress • Physiologic: sleep apnea, nocturia, pain, inactivity, heart issues Rod NH et al 2014. PloS one. 9(4):e91965; Coleman et al. 2011. Cancer Nurs. 34(3):219-227. National Sleep Foundation. At: http://sleepfoundation.org/ask-the-expert/sleep-hygiene
Psychological
🐑🐑 Sleep hygiene is necessary for
quality nighttime sleep, daytime alertness
• Engage in exercise but not too near • • • • • •
bedtime Increase daytime natural light exposure Avoid Daytime napping Establish a bedtime routine - warm bath, cup of warm milk or tea Associate your bed ONLY with sleep Sleep aid may be needed Avoid before bedtime: • Caffeine, nicotine , alcohol and sugar • Large meals and especially spicy, greasy foods • Computer screen time
Mustian et al. Journal of clinical Oncology. Sep 10 2013;31(26):3233-3241. Stan DL, et al. Clin J Oncol Nurs. Apr 2012;16(2):131-141. Zeng Y et al., Complementary therapies in medicine. Feb 2014;22(1):173-186.
94
Manage stress
HEALTHFUL LIVING STRATEGIES: PREVENTION
• Rest, relaxation, sleep hygiene • Mental health / social engagement • Complementary therapy
Maintain a healthy weight • Nutrition • Activity / exercise
Preventative health care • Health screenings, vaccinations • Prevent falls, injury, infection • Stop smoking
Physical Psychological
Maintain renal health • Myeloma management • Hydration • Avoid renally-toxic medications – Dose adjust to renal function • Diabetes management
Protect your bones • Nutrition, Calcium + D supplement • Weight-bearing activity / walking • Bone strengthening agents
• Dental care
“An ounce of prevention is worth a pound of cure.” Benjamin Franklin Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Dimopoulous M, et al. Leukemia. 2009;23(9):1545-56. Miceli, T. et al. (2021). Cancer Treatment and Res Com, 100476. Brigle K, et al. CJON. 2017;21(5)suppl:60-76. Faiman B, et al. CJON. 2017;21(5)suppl:19-36. Faiman B, et al. CJON. 2011;15suppl:66-76. Miceli TS, et al. CJON. 2011;15(4)suppl:9-23.
95
Financial
FINANCIAL BURDEN Financial burden comes from • Medical costs • • • •
Premiums Co-payments Travel expenses Medical supplies
• Prescription costs • Loss of income
• Time off work or loss of employment • Caregiver time off work
Contact the Social Services department at your hospital or clinic to talk to a social worker for assistance.
Funding and assistance may be available • • • •
Federal programs Pharmaceutical support Non-profit organizations Websites: • • • • • • •
Medicare.gov SSA.gov LLS.org Rxassist.org NeedyMeds.com HealthWellFoundation.org Company-specific website
96
YOU ARE NOT ALONE
Thank you to our sponsors!
100
101