Changing Patient Care in Multiple Myeloma:
The IMF Nurse Leadership Board's
Long-Term Survivorship Care Plan
May 13, 2010
San Diego
Diego
Accredited by Medical Education Resources
Supported by
by The International Myeloma
Myeloma Foundation
Grant Funding Provided by Celgene Corporation and
Millennium The Takeda Oncology Company
1
Welcome and Introductions
Elizabeth Bilotti, RN, MSN, APRN, BC
The John Theurer Cancer Center
at Hackensack University Medical Center
Hackensack, NJ
2
ONS Disclaimer
Meeting space
space has been assigned to
to provide
provide a satellite
satellite
symposium supported by the International Myeloma
Foundation via an unrestricted educational grant during
gg
the Oncology Nursing Society's (ONS) 35th Annual
Congress, May 13 - May 16, 2010, in San Diego, CA.
The Oncology Nursing Society's assignment of meeting
space does not imply product endorsement, nor does
the O
l
nco ogy Nursing Soci t
e y assume any responsibilit
ibility
for the educational content of the symposium.
3
Symposium Accreditation
Accreditation
· This continuing education activity provides 1.5 contact hours.
· Medical Education Resources is an approved provider of
continuing nursing education by the Colorado Nurses
Ai
Associ t
a ition, an
d
accre it
dit d
e approver by th
the A
i
mer can Nurses
Credentialing Center's Commission on Accreditation.
· Please complete
complete the
the CE Certificate Registration
Registration and Program
Evaluation Form found in your guidebook and return it to the
registration desk at the conclusion of this meeting.
4
Faculty
Chair:
Elizabeth Bilotti, RN, MSN, APRN, BC
John Theurer Cancer Center at Hackensack University Medical Center
Hackensack, NJ
Faculty:
Beth Faiman, MSN, APRN-BC,
Tiffany Richards, MS, ANP,
AOCN®
AOCNP®
Cleveland Clinic Taussig
MD Anderson Cancer Center
Cancer Institute
Houston, TX
TX
Cleveland, OH
Teresa Miceli, RN, BSN, OCN®
Joseph D. Tariman, PhC, MN,
Mayo Clinic - Rochester
APRN, BC
Rochester, MN
University of Washington
Seattle, WA
5
Agenda
Time
Discussion Topic
Presenter
We
W lcome/Introductions
e
and
12:00 - 12:10 PM
Elizabeth Bilotti
Multiple Myeloma Overview
Update on Current Therapies for the Treatment
12:10 - 12:30 PM
Beth Faiman
of Multiple Myeloma
12:30 - 12:45 PM
The NLB's Long-Term Survivorship Care Plan
Joseph Tariman
Impact of Myeloma Disease, Treatments, Long-Term Effects,
12:45 - 1:30 PM
and Patient-Specific Characteristics on:
Bone Disease and Bone Health
12:45 - 1:00 PM
Teresa Miceli
Functional Mobility and Safety
Renal Complications
Tiffany
1:00 - 1:15 PM
Sexuality and
and Sexual Dysfunctions
Dy
Richards
1:15 - 1:30 PM
Health Maintenance
Elizabeth Bilotti
1:30 PM
Closing Remarks and Panel Discussion
Elizabeth Bilotti
6
Learning Objectives
· Update on current therapies used in the management
of patients with multiple
multiple myeloma
myeloma (MM)
· Provide new data on emergent therapies in MM
· Understand how longer survival
survival may
may lead to a new
care paradigm for MM patients
· Understand the rationale and value of a Long-Term
g
Survivorship Care Plan
· Outline the role that nurses play in the implementation
of a Survivorship Care Plan
· Discuss medical implications of major long-term side
effects associated with novel therapies in MM
7
Multiple Myeloma: Epidemiology
Epidemiology
· ~1.4% of all cancers
Incidence and · US incidence: 20
20 580
,
new cases per ear
y
Rates
· US prevalence: ~60,000 patients
· US deaths: ~10 580
,
per year
· 62 years for males (75% older than
70 years)
Mean Age
· 61 years for females (79% older than
70 years)
Gender
· Affects more men than women (1.3:1)
Differences
8
NCCN Multiple Myeloma Guidelines, v.3.2010; Cancer Facts and Figures, 2009; SEER Stat Fact Sheets, Myeloma
(http://seer.cancer.gov/csr/1975_2006/results_merged/sect_18_myeloma.pdf)
Multiple Myeloma: Disease
Disease State
· Cancer of plasma cells
· Healthy plasma cells prod ce
u
antibodies or
immunoglobulins
Part of our humoral immunity, they are released
released in
response to foreign body invasion
9
San Miguel JF, et al. Pathogenesis of Multiple Myeloma: Rationale for New and Novel Therapies. Clinical Care Options:
http://clinicaloptions.com/Oncology/Treatment%20Updates/Myeloma/Modules/Pathophysiology/Pages/Page%203.aspx.
Multiple Myeloma:
Abnormal Plasma
Plasma Cells
Cells
Large nuclei (often
eccentric) are present in
multiple myeloma cells.
Multiple Myeloma
(bone marrow aspirate)
10
http://www.healthsystem.virginia.edu/internet/hematology/HessEDD/MalignantHematologicDisorders/MultipleMyelomas/Multiple-
myeloma.cfm
Multiple Myeloma Cells Overproduce Monoclonal
Protein and
and Abnormal Immunoglobulin
Immunoglobulin
· Ineffective immune function
· Decreased normal bone marrow function
· Impaired renal function
11
Kyle and Rajkumar, N Engl J Med 2004;351:1860-1873
Clinical Manifestations
of Multiple Myeloma
Overproliferation of plasma cells can cause:
Osteolytic
Bone marrow
bone
suppression
Renal
If
Inf
i
ect on
lesions
Hl
Hypercalcemia
(i
(pancytopenia)
compli
i
cat ons
12
http://myeloma.org/pdfs/ph07-eng_f2.pdf
Major Symptoms
Symptoms at
at Diagnosis
Diagnosis
Percent
Symptom
Presenting
Bone Pain
58%
Fatigue
32%
Weight Loss
24%
Paresthesias
5%
Asymptomatic
11%
11
13
Kyle RA. Mayo Clin Proc 2003;78:21
Common Sites
for Bone
Bone Involvement
· Skull
· Spine
Thoracic
Lumbar
Vertebrae
·Pelvis
· Long bones
14
http://www.emedicine.com/Radio/topic460.htm#section~Introduction
Diagnosing Multiple
Multiple Myeloma
Myeloma
Three Diagnostic Criteria Required
for a Positive Diagnosis of Multiple Myeloma
· Monoclonal plasma cells present in the bone
1
marrow 10%
· Presence of a documented plasmacytoma
2 · Presence of M component
p
in serum and/or urine*
· One or more of the following (CRAB criteria):
Calcium elevation (serum calcium >11.5 mg/dL)
3
Renal insufficiency (serum creatinine >2 mg/dL)
Anemia (hemoglobin <10 g/dL or 2 g/dL <normal)
Bone disease (lytic lesions or osteopenia)
*Monoclonal M spike on electrophoresis IgG >3.5 g/dL, IgA >2 g/dL, light chain >1 g/dL in 24-hour urine sample.
15
Durie et al for the International Myeloma Working Group. Leukemia. 2006:1-7.
Diagnostic Evaluation
of Multiple Myeloma
Test
Finding(s) With Myeloma
CBC with differential counts
Hgb, WBC, platelets
Electrolytes
Creat, Ca+, Uric acid, Alb
Serum electrophoresis with quantitative
M protein in serum, may have levels of normal
immunoglobulins
g
antibodies
Immunofixation
Identifies light/heavy chain types M protein
2-microglobulin
Levels (measure of tumor burden)
C-reactive protein
Levels (marker for myeloma growth factor)
24-hour urine protein electrophoresis
Monoclonal protein (Bence Jones)
Bone marrow biopsy
10% plasma cells
Skeletal imaging
Osteolytic lesions, osteoporosis
Serum free light chain
Free light chains
MRI
Evaluation of involvement of disease
Alb = albumin; CBC = complete blood count; Creat = creatinine; Hgb = hemoglobin;
MRI = magnetic resonance
resonance imaging;
imaging; WBC = wh
white
ite blood
blood cell
16
Abella. Oncology News International. 2007;16:27; Barlogie et al. In: Williams Hematology. 7th ed. 2006:1501; Durie et al. Hematol J. 2003;4:379;
MMRF. Multiple Myeloma: Disease Overview. 2006. www.multiplemyeloma.org; Rajkumar et al. Blood. 2005;106(3):812.
Durie-Salmon Staging System
for Multiple
Multiple Myeloma
Myeloma
Stage
Criteria
Myeloma Cell Mass
(x1012 cells/m2)
All of the following:
Hemoglobin >10 g/dL
Serum calcium level 12 mg/dL (normal)
I
Normal bone or solitary plasmacytoma on x-ray
<0.6 (low)
Low M component
component production rate:
IgG <5 g/dL
IgA <3 g/dL
Bence Jones protein <4 g/24 hr
II
Not fitting stage I or III
II
0.6 - 1.2 (intermediate)
()
One or more of the following:
Hemoglobin <8.5 g/dL
Serum calcium level >12 mg/dL
III
Multiple lytic bone lesions on x-ray
III
>1 2
. (high)
(high)
High M-componentd
t productition rate:
IgG >7 g/dL
IgA >5 g/dL
Bence Jones protein >12 g/24 hr
Subclassification criteria
criteria:
A
Normal renal function (serum creatinine level <2.0 mg/dL)
B
Abnormal renal function (serum creatinine level 2.0 mg/dL)
17
Durie and Salmon, Cancer 1975;36(9):842-854
Multiple Myeloma Staging: International
Staging System
System for Symptomatic
Symptomatic MM
Stage
Values
ß
Stage 1
2M <3.5 mg/dL
ALB 3.5 g/dL
Stage 2
Nt
Not St
Stage 1 or 3
Stage 3
ß2M >5.5 mg/dL
2M=serum 2 microglobulin in mg/dL; ALB=serum albumin in g/dL
· ISS should only be used in patients who meet diagnostic criteria for
myeloma since other conditions (
y(renal dysfunction
y
from diabetes or
hypertension) may cause elevated B2M levels
· ISS is more of a prognostic index; it does not quantify tumor burden or
extent of involvement
· It is recommended that
that ISS
ISS staging be
be used
used along with the Durie
Durie-Salmon
Staging System
18
Greipp PR, et al. Blood 2005; 102: 190a
Challenges in
in MM
MM Management
Management
Currently incurable in most patients
yp
Long-term complete responses are rare
Median overall survival for newly diagnosed patients is ~3.7 years
ASCT may prolong progression-free survival, but it's not curative
Newer drugs improved
gp
survival to up to ~2.6 years
y
from relapse
p
New treatment options are currently
in development with
with the
the goal to
to further
further improve outcomes
19
NCCN Practice Guidelines v.3.2010; Kumar et al, Blood 111(5), 2008
MM Treatment Options
Treatment Category
Interventions
Conventional
· Melphalan
· Doxorubicin
chemotherapy
· Vinc
n r
c ist
s ine
n
· Dexamethasone
Steroid therapy
· Prednisone
· Thalidomide
Novel therapies
· Lenalidomide
· Bortezomib
Stem cell
· Autologous
transplantation
· Allogeneic
Radiation therapy
· Localized
20