In the treatment of multiple myeloma, supportive care is essential to mitigating the risks of infection and bone disease. However, a study published recently in Cancer by Smith Giri, MD, MHS, and colleagues found that guideline-recommended supportive care measures are underutilized in older patients with multiple myeloma. In this interview with i3 Health, Dr. Giri discusses supportive care for patients with myeloma, as well as interventions that could increase the use of these measures.
Can you comment on the significance of your findings?
Patients with multiple myeloma have significant symptom burden at diagnosis and during the course of their disease, including bone pain, fractures, and infections. As the field is moving towards continuous therapy, most patients are exposed to untoward therapeutic toxicities. Certain supportive care interventions such as bisphosphonates, influenza vaccinations, or antiviral prophylaxis are proven to minimize pain, bone fractures, and infections and have been uniformly recommended by national and international guidelines, yet it was previously unknown how these supportive care elements were incorporated in routine clinical care in the United States. By using data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset, we have found that many older patients with myeloma are not receiving the above supportive care therapies. Future interventions and quality improvement strategies are needed to address this gap in myeloma care.
What interventions could increase the utilization of guideline-recommended supportive care measures for older patients with multiple myeloma?
There are multiple national and international guidelines that recommend anti-resorptive agents among patients with myeloma, yet our study has shown that just making guidelines is not enough to change practice. This pattern is seen across other cancers, too. We need to figure out strategies to better disseminate these guidelines to practicing oncologists.
There is literature suggesting that decision support tools or electronic medical record (EMR)-based interventions can standardize and improve guideline adherence. For example, the American Society of Clinical Oncology (ASCO) is leading a quality initiative, CancerLinQ®, using big data that can provide EMR-based real-time audit and feedback to improve quality of care. There are of course other ways, too, such as financial incentives, distribution of educational materials, and continuing medical education meetings. As we transition into value-based oncologic care, financial incentives for providing high-value cancer care are also likely to bring about significant improvements.
What supportive care-related questions do you commonly get from patients? How do you counsel them?
As denosumab has now been approved for myeloma bone disease, patients often ask if it is better to use denosumab or intravenous bisphosphonates. This question has been answered in a large phase 3 study, where denosumab was shown to be non-inferior to zoledronic acid for patients with multiple myeloma. We generally prefer denosumab for patients with impaired renal function.
Another frequent question that comes up is the utility of vaccinations in myeloma survivors. While it is true that myeloma patients may not always mount a proper immunological response to influenza vaccinations, these are safe and effective. Since our patients are at a much higher risk of influenza than average adults, we routinely recommend that all patients consider influenza vaccinations. Pneumococcal vaccines are important as well. However, we generally discourage use of live vaccine in cancer patients getting active treatment. Lastly, there is a new dead varicella vaccine, the zoster vaccine recombinant, adjuvanted (Shingrix®, GlaxoSmithKline). This seems to be safe and effective for myeloma patients, although we certainly need more data before we incorporate this vaccine in routine clinical practice instead of using prophylactic antivirals.
Do you have any advice for community oncologists, hematologists, and hematology/oncology nurses as they seek to provide supportive care for older patients with multiple myeloma?
We have come a long way in terms of improving survival in patients with multiple myeloma. However, we should not forget about symptom burden and quality of life in survivors of this disease. Certain supportive care measures such as those raised in our study are really important for our patients and should be incorporated in day-to-day clinical practice.
About Dr. Giri
Smith Giri, MD, MHS, is an Assistant Professor in the Division of Hematology/Oncology and a member of the Institute for Cancer Outcomes and Survivorship at the University of Alabama at Birmingham (UAB) School of Medicine. Dr. Giri has contributed more than 100 peer-reviewed publications to journals such as the New England Journal of Medicine, JAMA, Cancer, the Journal of the National Comprehensive Cancer Network, and Blood. His clinical and research interests focus on the care of patients with plasma cell disorders, with a particular emphasis on refining treatment strategies for the management of older adults, taking into account biologic frailty, toxicity, health-related quality of life, and racial and ethnic disparities.
For More Information
Giri S, Zhu W, Wang R, et al (2019). Underutilization of guideline‐recommended supportive care among older adults with multiple myeloma in the United States. Cancer. [Epub ahead of print] DOI:10.1002/cncr.32428