Connecting Patients With Multiple Myeloma to Larger Institutions for CAR T-Cell Therapy

Nurses at local and specialized centers can work together to create a pathway for patients throughout treatment.

Over the 30 years Beth Faiman, PhD, MSN, APN-BC, AOCN, BMTCN, FAAN, FAPO, has worked at Cleveland Clinic as a PhD researcher and adult patient nurse practitioner, she’s seen how treatments for patients with multiple myeloma have evolved. When Faiman began working at Cleveland Clinic in 1994, there were few good treatments available for multiple myeloma, a rare blood cancer that develops in plasma cells in the bone marrow. It wasn’t unusual for patients to live only 2 to 3 years after receiving a diagnosis. Today, the outlook for patients with multiple myeloma has greatly improved, with treatments going beyond surgery, chemotherapy, and radiation to include new immunotherapies, such as chimeric antigen receptor (CAR) T-cell therapy.

Although many patients are diagnosed with multiple myeloma by their local oncologist, they receive CAR T-cell treatment at a larger medical center, such as Cleveland Clinic, where experts are trained and certified on how to manage CAR T-cell therapy. These new advances have also expanded the role of nurses, who are involved in the planning, assessment, administration, and posttreatment monitoring of patients receiving CAR T-cell therapy.

CAR T-cell therapy has not only revolutionized the treatment process for patients with multiple myeloma, but it’s also underscored the importance of oncology nurses working together in both the community and at specialized cancer centers to ensure patients receive the best possible care. A 2023 study found that collaboration between oncology nurses is critical as patients migrate between community oncology providers and specialized treatment centers.

Although CAR T-cell treatments for multiple myeloma have only been around for a short time, they’re a game changer for many patients who don’t respond to other treatments. In 2021, the first B-cell maturation antigen CAR T-cell therapy, idecabtagene vicleucel (Abecma), was approved by the FDA for treating relapsed or refractory multiple myeloma.

In 2022, a second CAR T-cell therapy, ciltacabtagene autoleucel (Carvykti), was approved. Faiman says the treatment involves extracting T cells from a patient’s immune system, reengineering them in a lab, and infusing them back into a patient’s blood- stream, where they identify and attack cancer cells.

The Importance of Early Referrals

According to Faiman, oncology nurses play an important role in identifying patients who may be good candidates for CAR T-cell therapy. Because early referrals to a specialized CAR T-cell treatment program are critical to achieve the best outcomes, oncology nurses need to be aware of the eligibility criteria for CAR T-cell therapy.

“Patients who have relapsed and have been exposed to at least 1 or 2 prior therapies may be candidates for CAR T-cell therapy,” she says. “Also, patients who are no longer responding to chemotherapy or who have previously undergone stem cell transplants [may be candidates].”

At Cleveland Clinic, Faiman says community outreach events are regularly held for oncology nurses and providers, inviting them to participate in advisory boards to learn about new medications and clinical trials.

“In addition to a physical assessment and a pretreatment workup that measures factors such as pulmonary function and echocardiography, it’s important to [consider] the financial and social factors that play into whether a patient is a candidate for CAR-T cell therapy,” she says.

Helping Patients Get a Second Opinion

Local oncology nurses can also guide patients who would like to pursue a second opinion on their treatment options. “Second opinions are recommended for any patient [who] receives a diagnosis of blood cancer,” Faiman says. “Multiple myeloma is a very rare blood cancer, and the reality is some community doctors are more familiar with the most common cancers, such as prostate, lung, and breast cancer treatments.”

With so many treatment advances, Faiman says it’s important for nurses to ensure patients with multiple myeloma get the best possible care.

“Second opinions are totally appropriate, and bringing in patient care organizations such as the International Myeloma Foundation and the Multiple Myeloma Research Foundation [is] important because they help support patients and give them the language and confidence they need to talk with their provider,” she says. “If a nurse in a community hospital has established trust with their patients, they can reassure them [that] it’s OK to get a second opinion.”

Because community oncology nurses are at the forefront of patient education, Faiman says the subject of second opinions and the possibility of CAR T-cell therapy can be easily broached. Nurses often feel more comfortable discussing these topics after attending an oncology nursing conference or undergoing training on CAR T.

“Nurses are among the most trusted members of the health care team. By sharing experiences of what they recently learned at a live meeting or webinar and discussing this information with a patient, they can begin discussing second opinions and treatment options,” Faiman says. “A nurse might be giving their patient [chemotherapy] and ask [whether] they’ve ever thought about getting a second opinion, not because they aren’t getting good treatment but because there are a lot of new treatments out there.”

A Network of Support

Faiman says patients who qualify for CAR T-cell therapy are required to have a care partner, such as a family member, friend, or member of their community. This is critical, as patients need to be monitored for about a month after receiving their treatment. She says that, as part of the multidisciplinary care team, nurses can work together to ensure patients have a support system in place throughout each stage of the treatment process.

“CAR T is a lengthy procedure,” Faiman says. “We need to get patient approval from the insurance company and then reserve a slot for them to undergo treatment at our facility.”

Because manufacturing takes 4 to 6 weeks after the harvesting of stem cells—some- times even 8 weeks before they get their cells back—Faiman says it can take 3 to 6 months before the procedure is done.

“That’s why starting this early—at time of diagnosis, if possible—is so important,” she says. “This gives patients time to form a network of trust with that larger referral center so it’s not overwhelming when their local clinic says they need to travel to a big city to learn about treatment.”

Fortunately, Faiman says much of the preliminary work can be conducted via telehealth before the patient comes to the center. When a patient is at the point where they want a CAR T consult, Faiman says they can schedule a consult and meet with their provider in person over the course of 1 day.

“If they have other needs, such as peripheral neuropathy [and] they want to see a neurologist, or if they’re having heart problems and want to see a cardiologist, we try to get all these visits conducted within 24 hours,” she says. “It’s really geared toward what that patient wants and what they need clinically, but we’re mindful of their travel time, so they don’t have to travel
4 to 5 hours multiple times to our center.”

Before receiving CAR T, Faiman says nurse coordinators will speak with a patient’s local nurse about when to stop treatment before they travel to a specialized center, what kind of immunizations patients should receive after treatment, and how patients should be monitored.

Staying in Touch Throughout the Treatment Process

Brittney Baer, BSN, RN patient care coordinator for the Immune Effector Cell Program at Vanderbilt University Medical Center in Nashville, Tennessee, says nurse coordinators at specialized treatment centers and local oncology nurses can work together to bridge any communication gaps.

“Picking up your entire life for almost 40 days can be very stressful on a patient,” Baer says. “Nurses can help make it easier for the patient by looking at their entire well-being rather than just their disease process.”

After receiving CAR T-cell therapy, patients must remain close to the specialized center of care for at least 4 weeks to be checked for low blood counts and possible infections.

“I see the role of nurse coordinators at specialized centers as air traffic controllers who oversee the whole CAR T procedure,” Baer says. “I handle everything from insurance approvals [to] getting [patients] scheduled for evaluation, and then [I] keep patients and their local provider up to date with education and what to expect along the way."

A 2024 study found that nurses are instrumental in educating patients and caregivers on the acute and long-term risks and benefits of CAR T-cell therapy before treatment. Nurses can also help patients understand the financial and logistic requirements of treatment and inform them of the general treatment process and expectations at each stage.

After patients with multiple myeloma return home after CAR T-cell treatment, Baer says the specialized center and their local oncologist will continue to monitor them. Oncology nurses are taught to look for adverse effects such as cytokine release syndrome, which is a common adverse effect that can include fever, fatigue, and nausea. Patients are also monitored for neurotoxic effects and possible infections.

“We see patients after they’re 30 days [out of] our outpatient program, and then we see them every month until they’re 3 months out,” she says. “After that, we’ll see them in 6 months and then once every year, depending on how they’re doing.”

At Cleveland Clinic, Faiman says nurses and providers stay in touch with patients who underwent CAR T-cell therapy through both in-person and virtual visits.

“We have survivorship programs that help patients live well after CAR T-cell treatment,” she says. “We look for long-term [adverse] effects, stay current on health maintenance, [and] give patients a list of the immunizations they need and a list of their supportive care medications.” Although nurses at specialized care centers will follow up with patients, they also work to bridge care with a patient’s local care team. “I had a patient today [who] lives 60 miles away. I’ve been seeing him since 2002 for [multiple myeloma], and they really liked to come every 6 months [for] in-person visits and do virtual visits every 3 months,” Faiman says. “After the appointment, I communicate with the [nurse who] cares for him locally, doing regular treatments and lab draws.”

Baer says it’s important for patients to continue to keep the lines of communication open with their local oncology staff, who can immediately address any issues that arise.

Because CAR T-cell treatment is a marathon and not a sprint, Faiman says
it’s important for local nurses and those at specialized centers to work in tandem to create a pathway for patients throughout their treatment.

“Patients [with multiple myeloma] are now living 5- to 10-plus years. I just spoke with a patient [who] I’ve seen for 22 years,” she says. “Studies have shown that when people receive CAR T-cell treatment earlier, they can have a longer remission and enjoy a good quality of life.”

_References

[1]. Steinbach M, Zitella LJ, Florendo E, et al. Nursing care throughout the chimeric antigen receptor T-cell therapy process for multiple myeloma. Semin Oncol Nurs. 2023;39(6):151505. doi:10.1016/j.soncn.2023.151505

[2]. Nwozichi C, Ogunmuyiwa AO, Ojewale MO. Nurses’ roles in CAR-T therapy for B-cell malignancies and managing associated cytokine release syndrome. Asia Pac J Oncol Nurs. 2023;11(2):100367. doi:10.1016/j.apjon.2023.100367