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Axel Stuart Merseburger, MD, PhD, explained that with TKIs like axitinib, it is necessary for oncology nurses to spend time with each patient to provide the best care.

Becoming Familiar With Patients’ AEs is Essential, Says Expert

Avelumab in combination with axitinib was found effective and safe as frontline treatment for advanced RCC in real-world findings.

Real-World Data Back First-Line Avelumab and Axitinib in Advanced RCC

Patient-reported outcomes were consistent between patients with RCC using tivozanib/nivolumab and tivozanib monotherapy according to study findings.

Person acute kidney injury Comprehensive image overview of kidneys showing sudden loss of function | Image Credit: © Premium Graphics - stock.adobe.com.

Tivozanib Combo Yields Similar PROs to Monotherapy in Advanced Clear Cell RCC

Katy Beckermann, MD, PhD, explained that oncology nurses and APPs should be ready to administer and explain dose modifications for patients with RCC.

Dose Reductions Possible for Tivozanib With and Without Nivolumab for RCC

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The FDA has approved neoadjuvant durvalumab plus chemotherapy followed by adjuvant durvalumab after radical cystectomy in MIBC.

FDA Approves Perioperative Durvalumab Plus Chemotherapy for MIBC

Debriefing after patient loss, supporting patients at the end of life, and finding outlets outside of work can help oncology nurses avoid burnout.

Managing Oncology Nurse Burnout Through Peer Support, Emotional Intelligence

Indications for 177Lu-PSMA-617 now include taxane-based chemotherapy naive adults with PSMA+ mCRPC.

177Lu-PSMA-617 Approved for PSMA+ mCRPC

Seth Eisenberg, ASN, RN, OCN, BMTCN discussed the results of a real-world trial of Splashblocker, a toilet seat cover designed to mitigate exposure to toxins.

Q&A: Real-World Data on Protecting Oncology Nurses From Toilet Plumes

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Rapid changes occurring nationally and worldwide&mdash;including shifts in demographics, languages, epidemiological patterns, and social systems&mdash; have direct implications for patient care. These trends are projected to continue, and nurses need to be prepared to care for increasingly diverse patient populations.
 

Nurses Must Adapt to Meet the Needs of a Diverse Patient Population

New data from a real-world, multicenter study published in the 

Journal of Occupational Environmental Hygiene

 show that the Splashblocker portable toilet  cover is effective in reducing the number of particles released in toilet plume aerosols (TPA) in hospitals.

Across 145 toilets in 15 hospitals, the median reduction in particle concentration after implementation of Splashblocker was approximately 100%, with a mean of 101±11% (

 = .0002). Of note, this was regardless of HEPA filter usage. Without a cover, mean particle concentration was 3951#/L±8606 #/L, and the median was 1916 #/L (range: 136-71,959).

As noted in the study, the release of toxins from patient urine has been identified as a significant risk for oncology nurses, and it is recommended by the Oncology Nursing Society that oncology nurses cover toilets with a plastic-backed pad when flushing waste from patients.

“We need to be thinking about all the different avenues of exposure. We’ve gotten pretty good—not perfect—on wearing PPE for administering chemo and disconnecting chemo… But this is an area that, really, we haven’t really done much about,” said Seth Eisenberg, RN, ON, BMTCN, in an interview with Oncology Nursing News. “People have to realize that you need to step up and do things for protection. So that's an obligation for the profession.”

Of note, 94 (85%) toilets demonstrated a particle count reduction of at least 90% when covered with Splashblocker, 107 (97%) showed reduction by at least 80%, and 3 (less than 3%) toilets had a reduction of less than 80%. Investigators found that these toilets had uneven surfaces that cause several gaps of 2-3 mm each between the porcelain and the cover.

“Given the observed variability in effectiveness, future studies might also consider a more nuanced examination of design and environmental factors to optimize particle reduction strategies in healthcare settings,” Eisenberg and Changjie Cai, PhD, noted in the publication of the results.

Floors with HEPA filters were associated with statistically lower ambient particle levels (376±857 #/L) vs floors without HEPA filters (7432±9207#/L). Mixed-effects modeling demonstrated that particle reduction with the Splashblocker in place was significant regardless of floor level (1 through 18), room type (inpatient vs outpatient), geographical state, or flush volume.

Particle counts were measured with a TSI 9306-04 v2 optical particle counter (OPC), which was programmed for a 15-second delay, allowing study personnel to exit the room to reduce further airflow disturbances. The 

 was placed at a distance of 66 cm above the floor to represent the breathing zone of a nurse leaning to flush a toilet.

Measurements were taken for 60 seconds per flush to simulate the greatest amount of time a healthcare worker would typically remain in the room after flushing a patient’s urine. Six bin sizes were studied: 0.3-0.5 µm, 0.5-0.7 µm, 0.7-1.0 µm, 1.0-2.0 µm, 2.0-5.0 µm, and 5.0-25 µm. Particles smaller than 300 nm were not measured.

In an interview with Oncology Nursing News, Eisenberg recounted some of the more remarkable observations he and study personnel found in the differences in rooms when measuring.

“One bathroom we measured…we measured it uncovered first, and then we go back in, usually about 15 minutes later, and measure the ambient [particles] to make sure it went back down to baseline,” said 

. “It never went down. And we actually opened up the door and propped it open with a trash can to try to get it to ventilate. And even after 45 minutes, that bathroom still had a high concentration of particles.”

Researchers examined rooms where patients were not present in order to reduce the effect of airflow disturbances and reduce interruptions to regular care.

Eisenberg S, Cai C. Reducing the particles generated by flushing institutional toilets. Part II: Assessing a portable and reusable toilet cover in U.S. hospitals. 

. 2024;21(12):847-856. doi:10.1080/15459624.2024.2398752

While ambient particle levels differed by HEPA filter status, Splashblocker significantly reduced particles emitted from toilet plume aerosols regardless. 

Splashblocker May Reduce Toilet Plume Aerosols in Oncology Setting 

Seth Eisenberg, ASN, RN, OCN, BMTCN, discusses real-world findings on a portable toilet seat cover for hospital toilets

Seth Eisenberg, ASN, RN, OCN, BMTCN, discusses real-world Splashblocker data

A real-world study across 15 hospitals demonstrated that the Splashblocker, a reusable toilet barrier, significantly reduced aerosolized particles from urine, minimizing potential exposure to harmful drugs for oncology nurses and advanced practice providers, among other healthcare professionals.

Journal of Occupational and Environmental Hygiene

, researchers took into account HEPA filtering, floor elevation, and building age among other factors when 

 of the Splashblocker toilet cover in the clinical setting, according to lead investigator Seth Eisenberg, ASN, RN, OCN, BMTCN.

Oncology Nursing News spoke with Eisenberg about the real-world study’s key considerations and results. The study examined toilets at 15 hospitals across the country and tested particle number concentrations before and after flushing, with and without the toilet cover.

Eisenberg noted that factors including the age of the building and HEPA filtering made a difference at baseline, but after using the Splashblocker, reductions in particle count was similar across bathrooms.

Well, there’s been an ongoing concern over, I’d say, the decades about potential exposure in oncology, particularly to drugs that are excreted in urine. And so an oncology nurse actually came up with the concept of designing a solid, removable and 

 that could actually prevent or minimize the amount of exposure of the aerosols that come out of a toilet.

. What happens in the laboratory is great, but we need to get this out and see what's happening clinically as well.

So we designed a large scale, multi-center study, and we ended up enrolling 15 different hospitals across the country, and there was no statistical difference in the elevation of the buildings.

What we did find, however, [was] that there was a definitely a difference in the design of the ventilation in the bathrooms. Older facilities tended to be less efficient at removing aerosols from bathrooms. We found several bathrooms that had ventilation was totally nonfunctioning.

[In] one bathroom, we measured it: it was an outpatient facility, a shared bathroom. We were there, we measured it uncovered first, and then we go back in, usually about 15 minutes later, and measure the ambient to make sure it went back down to baseline, because you need to know where you're starting from.

It didn't go down. It never went down. We actually opened up the door and propped it open; even after 45 minutes, that bathroom still had a high concentration of particles because the vent in the ceiling was not doing anything at all.

HEPA-filtered bathrooms tend to have fewer ambient particles. So it means, when you made a baseline, it was statistically significantly lower.

Once we put the cover on, all bets were off. With a Splashblocker in place, it was [a] 99% reduction, which is almost as if the toilet was never flushed at all. It's like it never happened.

This transcript has been edited for clarity and conciseness.

Eisenberg S, Cai C. Reducing the particles generated by flushing institutional toilets. Part II: Assessing a portable and reusable toilet cover in U.S. hospitals. 

Seth Eisenberg, ASN, RN, OCN, BMTCN, explained his research on a toilet cover for oncology nurses to potentially reduce exposure to infectious pathogens and hazardous drugs.

Toilet Cover May Significantly Reduce Aerosol Exposure in Hospital Bathrooms

When compared to standard of care, ciltacabtagene autoleucel (cilta-cel; Carvykti) displayed improvements in patient-reported outcomes including greater health-related quality of life (HRQOL) and delayed worsening of symptoms in patients with relapsed, lenalidomide (Revlimid)-refractory multiple myeloma in findings from phase 3 trial CARTITUDE (NCT04181827) published in 

At a median follow-up of 15.9 months (IQR, 12.4-17.8), the Multiple Myeloma Symptom and Impact Questionnaire (MySIm-Q) compliance post-baseline score was 70% to 81% for patients who received cilta-cel and 79% to 89% for patients who received standard of care; the MySIm-Q median time to sustained worsening of symptoms was 23.7 months with cilta-cel and 18.9 months with standard of care (HR, 0.42; 95% CI, 0.26-0.68; 

European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Core C30 (EORTC QLQ-C30) global health status (GHS) 12-month score mean changes were +10.1 points (95% CI, 7.0-13.1) for cilta-cel and −1.5 points (95% CI, −5.3 to 2.3) for standard of care; for EuroQol 5-Dimension 5-Level (EQ-5D-5L) visual analogue scale mean changes were +8.0 (95% CI, 5.2-10.7) and +1.4 (95% CI, −1.9 to 4.7), respectively.

“In CARTITUDE-4, cilta-cel provided greater improvements than standard of care in overall HRQOL, including multiple functional domains and patient-reported pain and fatigue, in patients with lenalidomide-refractory multiple myeloma after 1 to 3 previous lines of therapy,” Roberto Mina, MD, at the University of Turn, and author of the study, and fellow authors, stated. “Improvements were sustained until at least month 12 and encompassed overall health status, functioning, and multiple myeloma-specific symptoms including pain and fatigue.”

A total of 419 patients were randomly assigned, in a 1:1 ratio, to receive cilta-cel (n = 208) or standard of care (n = 211). Those in the cilta-cel arm underwent apheresis, 1 or more cycles of bridging therapy depending on clinical status and cilta-cel manufacturing time, and lymphodepletion consisting of 300 mg/m

 fludarabine daily for 3 days. Then, 5 to 7 days after lymphodepletion, patients were given a single cilta-cel infusion at a target dose of 0.75x10

 CAR-T cells/kg. Standard of care was either 1800 mg of subcutaneous daratumumab (Darzalex), 4 mg of oral pomalidomide (Pomalyst), and 40 mg of oral or intravenous dexamethasone in 28-day cycles (n = 182), or 4 mg of oral pomalidomide, 1.3 mg/m

 of subcutaneous bortezomib (Velcade), and 40 mg of oral dexamethasone in 21-day cycles (n = 26).

To be included in the study, patients needed to be lenalidomide-refractory or relapsed/refractory multiple myeloma who received 1 to 3 prior lines of therapy with a proteasome inhibitor and an immunomodulatory drug, as well as an ECOG performance status of 0 or 1. Those who received prior CAR T-cell or anti-BCMA therapies were not permitted enrollment.

Clinical efficacy was previously reported with progression-free survival (PFS) as the primary end point, however, time to sustained worsening of patient-reported symptoms, change from baseline in the MySIm-Q, the EORTC QLQ-C30, and the EQ-5D-5L, were key secondary end points.

The median time to improvement on the MySIm-Q total symptom scale was 2.8 months (IQR, 0.3-6.2) for cilta-cel and 1.7 months (IQR, 1.2-3.0) for standard of care; on the total impact scale, it was 2.8 months (IQR, 0.4-6.5) and 1.4 months (IQR, 1.1-3.0). At month 12, 35% of the cilta-cel group and 14% of the standard of care group achieved clinically meaningful improvements in total multiple myeloma score compared with 11% and 33%, respectively, who achieved worse scores.

EORTC QLQ-C30 physical functioning, role functioning, and social functioning were all improved in the cilta-cel group, though they were not improved in the standard of care group.

In the cilta-cel group, EQ-5D-5L visual analogue scale scores fell from baseline to month 3, then increased over time to a least-squares mean of +8.0 points (95% CI, 5.2-10.7) at month 12 compared with a +1.4-point increase in the standard of care group. Results were similar at 18 months.

At the median follow-up of 15.9 months (IQR, 12.4-17.8), the primary analysis from the CARTITUDE-4 trial showed that cilta-cel “significantly improved” PFS over standard of care (HR, 0.26; 95% CI, 0.18-0.38; 

<.001), increased the overall response rate (ORR; 85% vs 67%, respectively), depth of response (73% vs 22%), and rate of minimal residual disease negativity (61% vs 16%).

“With previously reported data showing that cilta-cel significantly improves PFS, ORR, and depth of response vs standard of care, the improvements in HRQOL that we observed support the use of cilta-cel in earlier lines of treatment for lenalidomide-refractory multiple myeloma,” the authors concluded.

Mina R, Mylin AK, Yokoyama H, et al. Patient-reported outcomes following ciltacabtagene autoleucel or standard of care in patients with lenalidomide-refractory multiple myeloma (CARTITUDE-4): results from a randomised, open-label, phase 3 trial. 

. 2025;12(1):e45-e56. doi:10.1016/S2352-3026(24)00320-X

Median time to sustained worsening of symptoms was 23.7 months with cilta-cel, compared with 18.9 months with SOC.

Cilta-Cel Associated With Higher HRQOL for Lenalidomide-Refractory MM

While high-risk multiple myeloma can be difficult to treat with aggressive therapies, treatment considerations with the help of diagnostic tools may prove helpful when determining when to de-escalate treatment for certain patients.

At a recent Community Case Forum hosted by Oncology Nursing News, Mark Davis, PA-C, a physician assistant from Texas Oncology, Southwest Forth Worth Cancer Center, and colleagues discussed disease burden and diagnostic tools, as well as risk stratification and treatment approaches in high-risk multiple myeloma.

“In terms of risk stratification, we use the International Staging System [ISS], which is more or less the old way of doing it…” Davis explained during the event, adding that providers use the revised ISS with lactate dehydrogenase (LDH) levels and high-risk cytogenetics of chromosomal abnormalities. “So somebody who has a double-hit myeloma, that means they have 2 chromosomal abnormalities, and that is going to put them at a higher risk classification.”

Factors associated with high-risk disease or the progressive relapse setting include those with newly diagnosed myeloma who have a revised ISS of III, extramedullary disease, circulating plasma cells, and cytogenic abnormalities. For patients with newly diagnosed multiple myeloma, cytogenic abnormalities associated with high risk for disease progression or relapse include Del(1p32), t(4;14), t(14;16), t(14;20), Del(17p) or monosomy 

 mutation, 1q21 gain or amplification, and MYC translocation.

“As an [advanced practice provider (APP)] we can really help clinicians not only identify high-risk patients based on cytogenetics but also those who have a short course of remission and identify them as high risk as well,” Davis said in an interview with Oncology Nursing News. “And so patients who have disease progression within 2 years of their induction therapy, [that] automatically puts them in a subgroup of high-risk disease. And we are trying to tailor therapies differently in those patient populations that have more aggressive disease.”

Factors that may impact treatment for patients include their personal preferences, physical activity, work productivity, comorbidities, quality of life, disease symptoms and control, treatment-related toxicities that could lead to discontinuation, treatment convenience (oral vs intravenous), and financial toxicity.

With high-risk myeloma, it is a disease that can be difficult to treat. To further complicate management, many patients are unable to receive intense treatment because of comorbidities.

At the Community Case Forum, Davis presented a case of a 76-year-old female with ISS stage II myeloma, who is not eligible for a transplant and also presents with early-stage Parkinson’s disease that is currently controlled with treatment. At diagnosis, she presented with severe lower back and neck pain, has experienced increasing fatigue and mobility challenges, and reported with an ECOG performance status of 1.

The case, Davis noted, highlights certain patients’ inability–for example, older, frail, or transplant-ineligible patients–to receive aggressive therapy, whether considered high risk or not, and, in turn, the need for treatment de-escalation.

The attendees were polled on what regimen should be prescribed for the frontline treatment of this patient, including:

bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone (VRd), which included CRd lite;

daratumumab (Darzalex) plus lenalidomide and dexamethasone (Dara-Rd);

ixazomib (Ninlaro) plus lenalidomide and dexamethasone (Ixa-Rd); or

a quadruplet regimen like Dara-VRd or Dara-VMP)

Results were evenly divided-50% of respondents said that they would consider VRd while the other half were in favor of Dara-Rd.

“Both of those responses are on par to what we would expect,” Davis said. “…Frail and elderly patients are technically considered high-risk patients because historically, they’re unable to go with more aggressive therapies that include transplants.”

He added that these patients will also often be offered, in the community setting, a doublet that has inferior results due to concerns of toxicity. “More recent data from the MAIA study [NCT02252172]

 showed similar tolerance in older patients who were treated with Dara-RD vs Rd. Hopefully, this data will encourage clinicians to move further away from doublets even in our frail patients.”

Similarly, he added, often patients who are elderly or frail would not be offered a quadruplet regimen either. “You're often going to have to de-escalate [treatment] in some form or fashion.”

To aid in predicting long-term remission, the use of minimal residual disease (MRD) is growing in the multiple myeloma landscape.

“There's now studies ongoing about de-escalating therapy based on MRD, but also just even outside of that, from a prognostic value, it's more accurate than our M spikes,” Davis explained. “…MRD is most valuable when patients are wanting to de-escalate, and this could be a leverage point.”

In the case study, the patient was treated with frontline Dara-Rd. Following 9 months of treatment, she presented with an ECOG performance score of 2, a complete remission that was followed by a partial response at month 1 and very good partial response at month 8, with stable chemistry labs. In addition, the patient experienced grade 3 neutropenia that lasted for 1 cycle of treatment and appeared refractory to a single dose of granulocyte colony-stimulating factor. Her imaging revealed no new findings.

At 12 months, the patient’s ECOG performance score was 1 and she is stable in CR, chemisty and hematology labs, and continuance of no new findings on her imaging. Of note, her Parkinson’s disease remained in control with daily functioning that was consistent with baseline findings.

“MRD negativity at 12 months alone has also been associated with overall survival improvement. So again, it just highlights, for us, the relevance of deepening responses and maintaining somebody in a state of undetectable disease,” he said, highlighting that MRD negativity led to a median progression-free survival of 63 months, compared 27 months among patients with CR achievement, based on data from a pooled analysis of 3 Pethema/GemDavis clinical trials.

NCCN. Clinical Practice Guidelines in Oncology. Multiple myeloma, version 1.2025. Accessed December 12, 2024. 

https://www.nccn.org/professionals/physician_gls/pdf/myeloma.pdf

Facon T, Kumar S, Plesner T, et al. Daratumumab plus Lenalidomide and Dexamethasone for Untreated Myeloma. 

. 2019;380:2104-2115. doi:10.1056/NEJMoa1817249.

Lahuerta JJ, Paiva B, Vidriales MB, et al. Depth of Response in Multiple Myeloma: A Pooled Analysis of Three PETHEMA/GEM Clinical Trials. 

. 2017;35(25):2900-2910. doi:10.1200/JCO.2016.69.2517.

“Treatment effectiveness can have different meanings to patients,” a physician assistant said when discussing therapy for high-risk myeloma. 

MELISSA KALARCHIAN, PHD, Duquesne University School of Nursing

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