Multiple Myeloma Treatment Evolution Expands Need for APP Education

Beth Faiman, PhD, MSN, APRN-BC, AOCN

With the emergence of new therapies in multiple myeloma, improving educational resources for advanced practice providers (APPs) is crucial, according to Beth Faiman, PhD, MSN, APRN-BC, AOCN.

Faiman is a nurse practitioner at the Cleveland Clinic in the Hematologic Oncology and Blood Disorders department. She is also the faculty advisor for POCN's Multiple Myeloma Center of Excellence. This center is the largest nurse practitioner (NP) and physician associate (PA) community in the United States, and will provide resources to help APPS keep up to date on the shifting treatment paradigm. The organization also provides CME/CE education programs.

“There are so many new drugs with various mechanisms of action that a lot of the advanced practitioners might not see in their clinic or use in their clinic if they don’t have many patients with multiple myeloma,” Faiman said.

“Advanced practitioner knowledge is critical in helping the patient and their caregiver navigate this complicated treatment landscape, and trusted advanced practitioners like the NPs and PAs are the ones that the patients [often] will go to—they might not see the physician in the office [so] the NP and PA might be the most trusted person on their health care team,” she added.

In an interview with Oncology Nursing News®, Faiman, a nurse practitioner and researcher in the Department of Hematology and Medical Oncology at Cleveland Clinic Taussig Cancer Institute, discussed the Multiple Myeloma Center of Excellence as well as changes and challenges nurses face when treating patients in the multiple myeloma space.

Oncology Nursing News: Please discuss the growing need for NP and PA education in multiple myeloma.

Faiman: There are so many [new] and effective therapies for the management of multiple myeloma, especially [for] patients who have relapsed disease. Regardless of where the NP/PA lives or works, there are many treatment paradigms for newly diagnosed myeloma or relapsed myeloma that have changed in the past few years.

We're using 4 drugs upfront instead of 3 or 2 and we are trying to look more at the sequencing. We have all these classes of drugs that are so effective, [so] we’re trying to figure out what’s the best way to sequence these drugs. Right now, we have [certain] drugs upfront, but which class do you go to next at relapse, first relapse, second relapse, third relapse (etc)?

Advanced practitioners need to know these important emerging strategies and stay abreast of the research so they can better counsel their patients. If they’re at a smaller community center, [I encourage] linking in early with the myeloma specialty hospital. They don’t have to see them every day or every month, or even every year, but [I encourage] having that affiliation so patients will have access to these new therapies.

In multiple myeloma, a patient in the community hospital will typically get 3 to 4 drugs upfront, they’ll go to transplant or stay on treatment, and then [they will] maintain that therapy. Supporting that patient [during] their maintenance phase—checking the blood counts, making sure their bones are strong and all those other supportive care [considerations] are so important for the advanced practitioners to understand and have knowledge of.

I continually will educate others on adherence, supportive care, and monitoring of the disease especially if [patients are] going back and forth to different health care providers. Who is in charge of checking the labs, making sure the patient is in remission, and making sure they’re up to date on immunizations and other aspects of their care?

What are some of the unique challenges that NPs and PAs face?

NPs and PAs face the typical challenges of any cancer care. In 2023, we still have a staffing shortage in many large hospital centers. We also have more electronic means of communication; the patient can type in a message and contact their provider by a health portal. [Although] that’s a wonderful means of communicating symptoms or adverse effects, it still can be very time consuming—especially if patients frequently email concerns rather than talking on the phone.

There is also an inpatient hospital shortage of beds in many institutions. During COVID-19, a lot of the COVID-19 beds were taken up and now admitting patients to the hospital for some of our newer therapies is a challenge. If you have a heavily pretreated myeloma patient on some of the new cellular therapies or the bispecific [antibody agents] that [require] them to be admitted to the hospital, we have to logistically manage who’s going to be admitted on what day, and when, so that we have that bed space available. Patients need to be taken care of, so we have to have staffing available as well.

How does the Multiple Myeloma Center of Excellence launched by POCN provide NPs and PAs resources?

The NPPA Center of Excellence supports the growing needs of the advanced practice provider. Nurses can opt in as well.

PAs and NPs are the ones that are at the forefront of patient care in most areas. What’s neat about POCN is you have a group of experts, and we regularly review the literature and highlight the key and important emerging therapies. Your peers are providing this information to stay on the cutting edge—and in verbiage that you can understand, [which] is important.

[The center can be viewed at] multiplemyeloma.pocn.com. POCN is the largest NP and PA network, and their Centers of Excellence expand into other areas beyond oncology, too. You might be viewing this as a hematology/oncology [practitioner], but there’s also different centers of excellence from rheumatology, sleep disorders, and other conditions that might be of interest to you, especially if you’re in the community or even the specialists in the large hospital setting. [The centers are] not just limited to myeloma and cancer care, although that’s what I’m passionate about, they have other components.

How has the approval of teclistamab-cqyv (Tecvayli) and the removal of belantamab mafodotin (Belamaf) from the market affected your practice?

Teclistamab and belantamab mafodotin are both B-cell maturation antigen [BCMA]-directed therapies. BCMA is a member of this tumor necrosis factor super family and we know that BCMA is expressed on late-stage myeloma cell development, but unlike the early cells or the healthy cells so it’s a strong target for myeloma.

We have 2 CAR T-cell therapies approved; idecabtagene vicleucel [Abecma] and ciltacabtagene autoleucel [Carvykti], off the shelf therapies [include] teclistamab and belantamab mafodotin. Teclistamab is a bispecific T-cell engager [which] is like a helping hand; the bispecific antibodies have 2 arms; [they] are engineered to have 1 arm grab onto the T cell, the other arm grab onto the myeloma cell, and they bring it together to cause cell death.

Belantamab mafodotin was just taken off the market because it was found to not meet primary endpoints; we used a lot of belantamab, it’s still in clinical trials [and] it still has some hope. In my experience, the nice thing about belantamab is it was [given as] an intravenous infusion every 3 weeks, it’s still directed against BCMA, and it was very well tolerated.

Teclistamab is different because it has a bit more serious adverse effects. Cytokine release syndrome and neurotoxicity can occur, so patients need to be hospitalized for 9 days. This is similar with CAR T therapy. At any rate, these are very effective therapies, in my experience. I look forward to belantamab possibly coming back on the market in combination with other drugs at different dose levels.

Is there anything else that you would like for NPs or RNs to know about the trajectory of multiple myeloma care?

Don’t ever underestimate your important role in the patient and caregiver journey; you have a voice to help with many things, such as making sure that their labs are drawn, making sure they come to the treatment. These basic things are so critical to myeloma patients. Suppressing the malignant clone through ongoing treatment is the way that we manage myeloma in 2023, so making sure that they’re coming to their appointments, scheduling their appointments, helping with financial reimbursement of medications [as] there are lots of support systems out there, and getting their buy in for referral to larger institutions if you’re at a small place [is important].

Many places, [such as] my institution at Cleveland Clinic, regularly partner with smaller hospitals, so [tell your patients that can] come see us once every year by telemedicine; if you're 3 hours away, do a virtual visit. We’ll review your labs, we’ll review the studies or treatment options. That way, you can have the best of both worlds, your local team who is the one that’s mostly taking care of you, and then you can get some opinions from time to time to make sure that you feel comfortable and confident in the types of care.

Reference

POCN. Accessed April 10, 2023. https://multiplemyeloma.pocn.com