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

A multidisciplinary group-based survivorship intervention for those living with multiple myeloma: a feasibility study

BACKGROUND

While multiple myeloma continues to be an incurable cancer, advances in its understanding and management have led to significantly improved survival rates. Survivorship interventions for those living with multiple myeloma remain scarce, despite mounting evidence for multiple unmet support needs among multiple myeloma survivors. The current study aimed to evaluate the feasibility and preliminary effectiveness of a novel multidisciplinary group-based multiple myeloma survivorship intervention.

METHODS

A mixed-method, repeated measures feasibility study was conducted within a routine cancer support service. Seven participants, aged over 18, who had a multiple myeloma diagnosis and were clinically assessed as suitable for the intervention by their haemato-oncologist, attended online for six weekly group sessions of physical exercise and self-management input, completing qualitative, physical and self-report measures at baseline, post-intervention and follow-up.

RESULTS

The intervention was deemed overall feasible, with relatively high uptake, participants describing it as largely acceptable and appropriate and providing recommendations for feasibility-enhancing intervention refinements. Findings regarding the preliminary effectiveness of the intervention were mixed. While qualitative analyses stressed the benefits of the intervention (e.g. peer support, connectedness, improved well-being) and large effect sizes were observed for most physical outcomes, no improvements in self-reported outcomes (i.e. quality of life, fatigue) were reported.

CONCLUSIONS

This study represents the first investigation of a promising novel survivorship intervention for those living with multiple myeloma, highlighting the importance of peer support in particular, on which future clinical trials, aiming to establish the intervention's effectiveness for routine care, will be able to build.

Effects of early palliative care integration on patients with newly diagnosed multiple myeloma

PURPOSE

While numerous studies underscore the benefits of early palliative care (EPC) for patients with solid tumors, its effects on patients with multiple myeloma (MM) are not as widely known. This study aims to determine the effects of EPC integration on patients with newly diagnosed symptomatic MM and the feasibility of this approach.

METHODS

This prospective cohort study enrolled patients within eight weeks of diagnosis. Participants met with a palliative care team monthly for 12 months. Functional Assessment of Cancer Therapy-General (FACT-G) plus Multiple Myeloma Subscale (FACT-MM), and Hospital Anxiety and Depression Scale (HADS) were administered upon enrollment and every three months. Proportion of completed visits and assessments determined the feasibility of EPC.

RESULTS

Of the twenty participants enrolled from January 2020 to November 2022, median age was 65 (range 40, 77), 15 (75%) were female, 15 (75%) were white, 65% completed assessments at six months, and 60% at 12 months. The following measures significantly improved at 12 months versus baseline: FACT-G scores increased by 15.1 points (adjusted 95% CI: 2.2-28.1, adjusted p = 0.02); Functional Well-Being scores increased by 6.0 points (adjusted 95% CI: 1.1-10.9, adjusted p = 0.01); and Pain Subscale scores increased by 3.4 points (adjusted 95% CI: 0.5-6.4, adjusted p = 0.02). Depression and anxiety scores did not significantly change over time.

CONCLUSION

Functional well-being, pain experience and overall QOL improved in a cohort of patients with newly diagnosed MM after 12 months of EPC involvement. Although monthly visits seemed feasible, the findings suggest that further research is needed to explore the optimal timing of palliative care interventions in the MM trajectory.

TRIAL REGISTRATION

ClinicalTrials.gov ID NCT04248244 (Registration Date: January 30, 2020).

Multiple myeloma incidence and mortality trends in the United States, 1999-2020

Multiple myeloma (MM) is a plasma cell disorder accounting for approximately 10% of hematologic malignancies. There is limited epidemiological evidence regarding the long-term trends and disparities in MM in the US. We conducted a multiple time point cross-sectional study using MM incidence rate data from the Surveillance, Epidemiology, and End Results (SEER) database and mortality data from the CDC Wide-Ranging Online Data for Epidemiologic Research (CDC WONDER) Underlying Cause of Death database between 1999 and 2020. During this period, MM incidence has steadily increased, while MM mortality has steadily decreased, with substantial racial and ethnic disparities. Non-Hispanic Black individuals exhibited the highest incidence rates, which consistently rose from 12.02 (95% CI 10.54, 13.64) in 1999 to 14.20 (95% CI 12.93, 15.55) per 100,000 population by 2020. Non-Hispanic American Indian/Native Alaskans and Asian/Pacific Islanders demonstrated the lowest incidence rates of 5.59 (95% CI 2.69, 10.04) and 3.56 (95% CI 2.94, 4.27) per 100,000 population in 1999 to 5.76 (95% CI 3.49, 8.90) and 3.92 (95% CI 3.46, 4.42) per 100,000 population, respectively, by 2020. Disparities by gender, age, US census region, and rurality were observed, underscoring the importance of targeted, equity-centered interventions and MM screening initiatives for at-risk populations.

Current management of cancer pain in Italy: Expert opinion paper

Introduction

Chronic pain and breakthrough cancer pain (BTcP) have a high prevalence in all cancer types and cancer stages, combined with a significant physical, psychological, and economic burden. Despite efforts to improve appropriate management of cancer pain, a poor assessment and guilty undertreatment are still reported in many countries. The purpose of this expert opinion paper is to contribute to reduce and clarify these issues with a multidisciplinary perspective in order to share virtuous paths of care.

Methods

Common questions about cancer pain assessment and treatment were submitted to a multidisciplinary pool of Italian clinicians and the results were subsequently discussed and compared with the findings of the published literature.

Conclusion

Despite a dedicated law in Italy and effective treatments available, a low percentage of specialists assess pain and BTcP, defining the intensity with validated tools. Moreover, in accordance with the findings of the literature in many countries, the undertreatment of cancer pain is still prevalent. A multidisciplinary approach, more training programs for clinicians, personalised therapy drug formulations, and virtuous care pathways will be essential to improve cancer pain management.

Using nominal group technique to compare patients’ and clinicians’ perspectives on symptoms in multiple myeloma to inform the development of a self management tool for patients with relapsed myeloma

Background: The nominal group technique (NGT) allows stakeholders to directly generate items for needs assessment. The objective was to demonstrate the use of NGT to inform the development of a healthcare app in patients with relapsed myeloma. Healthcare professionals with experience in the care of patients with relapsed/refractory myeloma were invited to participate. Methods: One NGT group was conducted. In the group, health care professionals working in haematology were asked to vote anonymously in order of highest priority, on symptoms previously highlighted by relapsed/refractory myeloma patients in four focus groups. Results: A total of 18 healthcare professionals working in the area of haematology participated in the NGT discussion; consultants (n=6), haematology registrars (n=2), specialist nurses [Advanced Nurse Practitioner/Clinical Nurse Specialist] (haematology) (n=3), staff nurse (n=1), and “other” health care professionals (n=6). Participants ranged in experience of working with myeloma patients from 2 years to over 27 years. The symptoms voted in highest priority were: Pain, Fatigue, Peripheral Neuropathy, Infection Risk and Steroid Induced Side Effects. Conclusions: The NGT was an efficient method for obtaining information to inform a healthcare app.

Symptom burden and health-related quality of life impacts of smoldering multiple myeloma: the patient perspective

Background

Smoldering multiple myeloma (SMM) is an early form of multiple myeloma (MM). SMM is typically considered asymptomatic, and research on how it affects health-related quality of life (HRQoL) is limited. This study assessed the symptoms and HRQoL of patients with SMM and those who progressed from SMM to MM and evaluated the content validity of two patient-reported outcome instruments (EORTC QLQ-C30 and nine items from the EORTC QLQ-MY20) for use in SMM clinical trials. To address these objectives, concept elicitation and cognitive interviews were conducted with SMM patients and recently diagnosed MM patients.

Results

Fifteen adult SMM and six adult MM participants with a prior SMM diagnosis were interviewed. On average, SMM study participants were 61 years old (46.0–78.0), 11 (73%) were female, and diagnosed 2.6 (±2.0) years ago. Each participant had experienced at least one symptom, most commonly tiredness/fatigue, weakness, and pain. The most common HRQoL impacts were emotional and physical. SMM study participants demonstrated good understanding of both the EORTC QLQ-C30 and EORTC QLQ-MY20 subscales and found them relevant to their SMM health state. The average age of MM participants was 53 years old (39.0–62.0); 5 (83%) were female and diagnosed 1.9 years ago (±2.1). MM participants most commonly reported tiredness, weakness, constipation, shortness of breath, and dry mouth as occurring when they progressed from SMM to MM.

Conclusions

Although previously described as asymptomatic, these SMM participants reported experiencing symptoms that affected their lives. Additionally, the EORTC subscales measured symptoms SMM patients experienced. The participants with MM reported that the symptom burden and HRQoL impacts increased when diagnosed with MM. These findings suggest the need for increased surveillance of symptoms within the SMM population and further suggest that the EORTC subscales can be used to assess symptoms and impacts in both the SMM and MM populations.

Pain Management in Patients with Multiple Myeloma: An Update

Most patients with multiple myeloma (MM) suffer from chronic pain at every stage of the natural disease process. This review focuses on the most common causes of chronic pain in MM patients: (1) pain from myeloma bone disease (MBD); (2) chemotherapy-induced peripheral neuropathy as a possible consequence of proteasome inhibitor therapy (i.e., bortezomib-induced); (3) post-herpetic neuralgia as a possible complication of varicella zoster virus reactivation because of post-transplantation immunodepression; and (4) pain in cancer survivors, with increasing numbers due to the success of antiblastic treatments, which have significantly improved overall survival and quality of life. In this review, non-pain specialists will find an overview including a detailed description of physiopathological mechanisms underlying central sensitization and pain chronification in bone pain, the rationale for the correct use of analgesics and invasive techniques in different pain syndromes, and the most recent recommendations published on these topics. The ultimate target of this review was to underlie that different types of pain can be observed in MM patients, and highlight that only after an accurate pain assessment, clinical examination, and pain classification, can pain be safely and effectively addressed by selecting the right analgesic option for the right patient.

Interdisciplinary Management of Acute Leukemia Across the Continuum of Care

OBJECTIVE

To describe the interdisciplinary management of acute leukemias across the continuum of care.

DATA SOURCE

Literature review and experiential knowledge.

CONCLUSION

Acute leukemia, including acute myelogenous leukemia, acute promyelocytic leukemia, and acute lymphoblastic leukemia, represent a heterogeneous group of hematologic malignancies with complex diagnostic requirements that drive risk-adapted treatment selection. Involvement of clinicians from a variety of specialties and disciplines is required to ensure safe and effective treatment, mitigate adverse events, and maintain or improve quality of life. Patient-centered communication, shared decision-making, and interdisciplinary communication are integral to patient outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Oncology clinicians play a primary role in coordinating the interdisciplinary team and navigating the patient and caregiver experience across the acute leukemia continuum.

Review of the patient-centered communication landscape in multiple myeloma and other hematologic malignancies

OBJECTIVES

To identify factors limiting and facilitating patient-centered communication (PCC) in the United States hematology-oncology setting, with a focus on multiple myeloma (MM), given the limited attention to PCC and rapid pace of change that has taken place in this setting.

METHODS

A literature search was performed from 2007 to 2017 to identify published articles and congress abstracts related to clinician-patient communication and treatment decision-making in oncology. Search results were evaluated by year of publication and disease area. A thematic assessment was performed to identify factors limiting and promoting PCC for patients with MM and other hematologic malignancies.

RESULTS

Of the 6673 publications initially retrieved, 18 exclusively reported findings in patients with hematologic malignancies and were included in this review. We identified three critical, but modifiable, barriers to PCC in the hematologic malignancy setting, including insufficient information exchange, treatment goal misalignment, and discordant role preferences in treatment decision-making. Factors that enhanced interaction quality included educational programs for clinicians and patients.

CONCLUSIONS

Patients with MM and other hematologic malignancies experience a distinct set of challenges that may affect PCC.

PRACTICE IMPLICATIONS

Clinicians have the opportunity to improve patient care by proactively addressing the identified barriers and implementing strategies demonstrated to improve PCC.

Pain Management in the Cancer Survivor

OBJECTIVES

To describe assessment and interdisciplinary management of pain in the cancer survivor over the continuum of cancer care.

DATA SOURCES

Review of the literature and treatment standards.

CONCLUSION

Pain remains a primary concern throughout the cancer trajectory across all age groups and diagnoses, emphasizing the need to integrate pain assessment and management across the continuum of cancer survivorship and across care settings. Types of pain, pain patterns, assessment of cancer pain in cancer survivors, current strategies and challenges for management, and effective communication and documentation of the process are described. Communication between and among health care clinicians in a way that effectively articulates the individual patient experience, including documentation in the electronic medical record, requires consistent workflows and terminology. The opioid crisis increases the urgency in effective strategies for interdisciplinary pain assessment and management.

IMPLICATIONS FOR NURSING PRACTICE

Oncology clinicians must be able to adequately assess pain, track pain over time, understand and implement a cadre of strategies to manage pain, and effectively pursue any suspicious pain patterns that may indicate recurrence or progression of cancer or other underlying etiologies. The oncology nurse is at the core of patient-clinician communication, critical to effectively describing pain as experienced by the individual patient and continues to play a key role in maintaining consistency of message that is necessary to manage pain over the continuum of cancer survivorship.

Using nominal group technique to inform the development of a self-management app for patients with relapsed myeloma

Background: The nominal group technique (NGT) allows stakeholders to directly generate items for needs assessment. The objective was to demonstrate the use of NGT to inform the development of a healthcare app in patients with relapsed myeloma. Healthcare professionals with experience in the care of patients with relapsed/refractory myeloma were invited to participate. Methods: One NGT group was conducted. In the group, health care professionals working in haematology were asked to vote anonymously in order of highest priority, on symptoms previously highlighted by relapsed/refractory myeloma patients in four focus groups. Results: A total of 18 healthcare professionals working in the area of haematology participated in the NGT discussion; consultants (n=6), haematology registrars (n=2), specialist nurses [Advanced Nurse Practitioner/Clinical Nurse Specialist] (haematology) (n=3), staff nurse (n=1), and “other” health care professionals (n=6). Participants ranged in experience of working with myeloma patients from 2 years to over 27 years. The symptoms voted in highest priority were: Pain, Fatigue, Peripheral Neuropathy, Infection Risk and Steroid Induced Side Effects. Conclusions: The NGT was an efficient method for obtaining information to inform a healthcare app.

Impact of psychiatric comorbidities on health care utilization and cost of care in multiple myeloma

Approximately one third of cancer patients suffer from comorbid mood disorders that are associated with increased cost and poorer outcomes. The majority of patients with multiple myeloma (MM) are treated with corticosteroids; as many as three fourths of those taking corticosteroids develop neuropsychiatric complications, likely increasing morbidity and cost of care. MM patients diagnosed between 1991 and 2010 and reported in the Surveillance Epidemiology, and End Results-Medicare database were characterized as MM-Only, MM+Psychiatric (any psychiatric condition, preexisting or post-MM), or MM+Depression (depression as the only psychiatric diagnosis, preexisting or post-MM). Differences in demographic characteristics, occurrence of clinical myeloma-defining events (MDEs), health care utilization (inpatient, outpatient, ambulatory claims), and cost of care during the first 6 months of MM diagnosis were analyzed. Psychiatric comorbidities were reported more frequently in females, and racial minorities had lower rates of psychiatric comorbidities. All clinical MDEs were more common in the MM+Psychiatric and MM+Depression groups; within them, the majority were more common in patients diagnosed with the psychiatric condition or depression after MM compared with it being a preexisting condition. Health care utilization in all treatment settings was higher in those with psychiatric comorbidities. Cost of care within the first 6 months after MM diagnosis was significantly higher in the MM+Psychiatric and MM+Depression groups. This increase in cost was more pronounced for patients from racial minorities diagnosed with a psychiatric condition, including depression. Psychiatric comorbidities significantly impact the clinical presentations, health care utilization, and cost among patients with MM. These findings need to be addressed for improved survivorship of MM patients.