Advances and New Challenges in Multiple Myeloma

Multiple myeloma (myeloma) is a highly treatable disease, but it remains incurable in the majority of cases. It is a heterogeneous disease with variability in its clinical presentation, treatment options, and prognosis. The majority of patients newly diagnosed with myeloma are over 65 years of age, and most of these patients have one or more comorbid conditions.[1,2] Systemic chemotherapy is the treatment of choice, with local radiotherapy indicated for treatment of skeletal disease or plasmacytomas.

Documented studies in myeloma treatment date back to the early 1960s, when oral melphalan and prednisone were found to be effective in producing remissions in about 30% of treated patients.[3] During the last 15 years, a number of novel agents have been developed based on improved understanding of the pathobiology of the disease and identification of potential targets, offering improvements in response rates, overall survival, and disease control.

Death rates have decreased by 11.3% for women and 7.25% for men between 1991 and 2005.[2,3] Yet there are wide variations in treatment response and survival, ranging from a few months in some cases to more than 10 years. Twenty percent of patients survive longer than 10 years, irrespective of therapy. High-risk attributes are thought to play a primary role in the expected survival of patients with myeloma.[4] Novel agents such as bortezomib (Velcade), lenalidomide (Revlimid), and thalidomide (Thalomid) may neutralize the effects of some high-risk features. Numerous ongoing clinical trials offer promising therapies for their future use, either as single agents or in combination. There were 46 different clinical trials with 6,149 patients enrolled internationally between 1999 and 2009 for induction therapy alone.[5] The present challenges are how to integrate the best combinations of new and old drugs used for initial induction therapy, determine transplant eligibility at the time of diagnosis, and more recently, how best to incorporate maintenance therapy to achieve long-term disease control.

Refinement of the diagnostic evaluation and application of prognostic criteria has led to a risk-adapted treatment approach that introduces the concepts of personalized or precision medicine.

Critical to instituting the most effective therapy early in the course of disease is application of an organized, evidenced based, risk-adapted treatment plan; this plan needs to incorporate key diagnostic elements using a lifespan approach that considers individual patient attributes, including comorbidities. Selection of pretransplant therapies for eligible patients is important, to limit the potential for bone marrow damage and inadequate stem cell collection.

Understanding novel mechanisms of antitumor activity, associated toxicities, and clinical strategies related to myeloma is critical to safe and effective patient management. Many of the emerging therapies may be administered over extended periods of time, and most allow patients to be treated in an outpatient setting. Their toxicities are manageable; an understanding of the unique mechanisms of action and associated side effects of these agents is required.

Effective treatment of the disease-related systemic problems presents another challenge for the patient with myeloma. Supportive care strategies are critical to achieving the best clinical outcome when treating myeloma. However, even supportive care strategies may be associated with adverse events. Elderly patients are particularly at risk of these symptoms and should be monitored carefully while receiving treatment.

Much of the nursing care provided to patients with myeloma is targeted at treating the skeletal, hematological, renal, and infectious complications of the disease. Management of treatment-related adverse events including fatigue, thromboembolism, neuropathy, pain, osteonecrosis, and gastrointestinal toxicities presents additional challenges. The oncology nursing professional is critical to effective management of these disease- and treatment-related adverse events. Oncology nurses also play a central role in coordinating the complex diagnostic process, translating the results for the patient and family, including setting expectations for the immediate treatment plan. Given the chronic nature of this disease, early identification and prompt intervention for disease- or treatment-related adverse events will preserve future treatment options and promote improved quality of life. The article by Sandra Rome provides a clinically relevant and concise overview of the diagnostic staging, risk-adapted treatment selection, and current strategies for supportive care of the patient with multiple myeloma.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References1. Kurtin S: Laboratory measures for the diagnosis, clinical management, and evaluation of treatment response in multiple myeloma. J Adv Pract Oncol 1(3):197–206, 2010.
2. Jemal A, Siegel R, Ward S, et al: Cancer Statistics 2009. CA Cancer J Clin 59(4):225–249, 2009. 
3. Badros A: In the age of novel therapies, what defines high-risk multiple myeloma? J Natl Compr Canc Netw 8(Suppl 1):S28–S34, 2010.
4. Kurtin S: Risk analysis in the treatment of hematological malignancies in the elderly. J Adv Pract Oncol 1:119–129, 2010.
5. Durie BG: Role of new treatment approaches in defining treatment goals in multiple myeloma -the ultimate goal is extended survival. Cancer Treat Rev 36(Suppl 2):S18–S23, 2010.