International Myeloma Foundation

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1 What You Need To Know To Overcome Side Effects From Novel Therapies Beth Faiman PhD, APRN-BC, AOCN Cleveland Clinic Taussig Cancer Institute And Kevin Brigle PhD, NP Massey Cancer Center Virginia Commonwealth University

2 Multiple Myeloma: A Cancer of the Plasma Cells Healthy plasma cells produce immunoglobulins (antibodies) in response to foreign body invasion Cancerous plasma cells (i.e., myeloma cells) produce abnormal antibodies Test for these abnormal antibodies in the blood and/or urine: (SPEP, 24-hr UPEP, serum free light chains) SPEP = serum protein electrophoresis; UPEP = urine protein electrophoresis Kyle RA, et al. Mayo Clin Proc. 2003;78:21-33; Faiman and Bilotti, 2013; Mikhael et al, 2013; NCCN, 2016; Kurtin et al 2016 JADPRO ; SEER.gov. 2

3 2014 IMWG Active Myeloma Criteria Clonal bone marrow 10% or bony/extramedullary plasmacytoma AND any one or more of the CRAB criteria or Myeloma Defining Events (MDE) C R A B alcium elevation enal complications nemia one disease BM Clonal bone marrow 60% FLC MRI sflc ratio >100 >1 focal lesion by MRI sflc = serum free light chain Rajkumar SV, et al. Lancet Oncology. 2014; 15:e538-e548. Kyle RA, et al. Leukemia. 2010; 24(6):

4 Multiple Myeloma is Typically Preceded by Pre-Cancerous Conditions Pre-Cancer Cancer Condition MGUS 1-4 Monoclonal Gammopathy of Undetermined Significance SMM 1-5,8 Smoldering Multiple Myeloma Active Multiple Myeloma 6-8 Clonal plasma cells in bone marrow Presence of Myeloma Defining Events Likelihood of progression <10% 10%-60% >10% None None Yes ~1% per year ~10% per year Not Applicable Treatment No; observation Yes for high risk*; No for others Yes In clinical trial (preferred) or offer treatment for those likely to progress within 2 years 1. Kyle RA, et al. N Engl J Med. 2007;356: International Myeloma Working Group. Br J Haematol. 2003;121: Jagannath S, et al. Clin Lymphoma Myeloma Leuk. 2010;10(1): Kyle RA, et al. Curr Hematol Malig Rep. 2010;5(2): Mateos M-V, et al. Blood. 2009;114:Abstract Durie BG, Salmon SE. Cancer. 1975;36: Durie BG, et al. Leukemia. 2006;20(9): Rajkumar SV, et al. Lancet Oncology 2014; 15:e538-e548.

5 Symptoms May be from Myeloma or Treatment or Both Myeloma cells in excess numbers cause symptoms Calcium elevation Renal dysfunction Anemia Bone pain Fatigue Infection Other symptoms Treatments for myeloma can cause symptoms Myelosuppression Peripheral neuropathy Diarrhea Fatigue Deep vein thrombosis Shingles Other symptoms How You Feel

6 How to Decide on Treatment? Considerations - Clinical trial participation, if eligible Current results of clinical trials Lifestyle and Quality of Life (IV or oral) Previous treatment Response and Duration? Retry? Tolerability and Side Effects? Consultation with a myeloma specialist Clinical Experience DECISION Patient Preference Data from Research Philippe Moreau, ASH 2015 Discuss options with your provider. Decisions should be individualized and will change through the course of the disease. 6

Managing Multiple Myeloma: A Balancing Act Data and Experience Disease characteristics (high/low risk) Clinical Data from Experience DECISION

Healthy? (Fit or frail)? Comorbidities? Insurance? Support systems? Desires?

7 Managing Multiple Myeloma: A Balancing Act Data and Experience Disease characteristics (high/low risk) Clinical Data from Experience DECISION Patient Research Preference Patient Preference Administration, chair time Individualize Multiple Myeloma Care: Is the patient working or retired? Healthy? (Fit or frail)? Comorbidities? Insurance? Support systems? Desires? Efficacy of regimen Comorbid conditions Finances Social status/support Each can affect the balance and must be considered Faiman B, et al. J Adv Pract Oncol 2016; 2016: 7(suppl 1):17-29; Philippe Moreau, ASH

Patients with Myeloma are Treated by a Team

Pharmacist Orthopedist Physical Therapist

Financial Counselor Social Worker Ancillary

Referring Providers Oncology Care Provider

Patient Primary Care Provider Registered

8 Patients with Myeloma are Treated by a Team Oncologist Advanced Practice Provider Nurse Pharmacist Orthopedist Physical Therapist Transplant Team Primary Care Provider Financial Counselor Social Worker Ancillary support (Social work, Office Staff) Referring Providers Oncology Care Provider (Physician or Advanced Practice Providers Patient Primary Care Provider Registered Nurses Pharmacy Kurtin S, et al. JADPRO; 2016: 7(suppl 1):

9 Adherence: Sticking to the Planned Treatment Adherence means receiving the therapy as planned. Patients who stay on therapy have better outcomes. Goal of therapy: reduce MRD (minimal residual disease) Patient Factors Health System Factors Emotional Response: denial of diagnosis or the need for treatment Lack of understanding of the disease and treatment Lack of confidence in the provider Inadequate expectations of the therapy Lack of access to medications & providers, including expense issues Forgetfulness Confusion due to pill burden Complex dosing regimens Inadequate follow-up and discharge planning Poor patient-provider relationships and communication Cost Lack of institutional guidelines and protocols for oral cancer treatments Inadequate management of side effects 9 Faiman BM. J Adv Pract Oncol. 2012;2:26-34; Miaskowski C, et al. Clin J Oncol Nurs. 2008;12(2): ; Gleeson T, et al. Osteoporos Int. 2009;20(12): ; Accordino MK and Hershman DL. Am Soc Clin Oncol Educ Book. 2013: ; Kurtin S, et al. JADPRO; 2016: 7(suppl 1):71-77.

Nurse/Provider and Patient/Caregiver Roles in Treatment Nurse/Provider roles: Reinforce the reason for the ongoing treatment plan Myeloma is a chronic condition Patients who receive therapy usually

10 Nurse/Provider and Patient/Caregiver Roles in Treatment Nurse/Provider roles: Reinforce the reason for the ongoing treatment plan Myeloma is a chronic condition Patients who receive therapy usually live longer Encourage shared discussion of goals Prevent and/or reduce side effects Provide tools (calendars) and education for side effect awareness and management Patient/Caregiver role: Ask questions!! Report side effects and reasons for not wanting to take medications Combat treatment fatigue A pill that remains in the bottle or at the pharmacy is not able to kill myeloma cells 10 Faiman BM. J Adv Pract Oncol. 2012;2:26-34; Miaskowski C, et al. Clin J Oncol Nurs. 2008;12(2): ; Gleeson T, et al. Osteoporos Int. 2009;20(12): ; Accordino MK and Hershman DL. Am Soc Clin Oncol Educ Book. 2013: Kurtin S, et al. JADPRO; 2016: 7(suppl 1):71-77.

11 2015 was an Amazing Year in Expanding Treatment Options for Multiple Myeloma Alkylator Steroid Anthracycline Proteasome inhibitor ( mib ) Immunomodulator ( imid ) Antibody ( mabs ) HDAC inhibitor 2015 Daratumumab 2015 Ixazomib 2015 Elotuzumab Panobinostat 1958 Melphalan 2003 Bortezomib 2013 Pomalidomide 1962 Prednisone 1983 Auto Transplantation 2006 Lenalidomide 2006 Thalidomide 2012 Carfilzomib 1986 High-Dose Dex Auto = Autologous; Dex= Dexamethasone DRUGS@FDA.gov 2007 Doxorubicin What to treat with at diagnosis or relapse? 11

12 Classes: Mides, Mibs, MAbs and Others to Treat Myeloma -Mides -Mibs -MAbs Others Immunomodulatory Drugs (IMIDs) Proteasome Inhibitors Proteasome Inhibitors Monoclonal Antibodies Thalidomide (PO) Bortezomib (IV/SQ) Daratumumab (IV) IMiDs Steroids (IV/PO) Dexamethasone Prednisone Lenalidomide (PO) Carfilzomib (IV) Elotuzumab (IV) Alkylating Agents (IV/PO) Melphalan Bendamustine Cyclophosphamide Pomalidomide (PO) Ixazomib (PO) Denosumab (IV) ihdac (PO) Panobinostat Oprozomib (PO) SAR (IV) Anthracyclines p-doxorubicin Siltuximab (IV) 12

13 Newly Diagnosed Multiple Myeloma Treatment: Study Results 1- FIRST trial: Continuous Revlimid and dexamethasone (Rd) significantly extends remission for non-transplant patients Dose adjust Revlimid for kidney impairment and dexamethasone for age 2- SWOG 0777 Trial: Three drug therapy with Velcade, Revlimid and dexamethasone (VRd) is better than two drug therapy (Rd). Patients did better with 3 drugs than two but had more peripheral neuropathy 3- Chemotherapy combinations are not recommended in the elderly (e.g., cyclophosphamide, melphalan) Hulin C, et al. ASH 2014 #81; Facon T, et al. ASH 2013 #2; Durie B et al. ASH 2015 #25; Magarotto V et al. Blood. 2016;127(9):

14 Relapsing Nature of Multiple Myeloma ASYMPTOMATIC SYMPTOMATIC REFRACTORY RELAPSE 10 - Myeloma Clones change over time. M-Protein g/l 5 2 MGUS or SMOLDERING MYELOMA ACTIVE MYELOMA PLATEAU REMISSION RELAPSE - Maintenance therapy can suppress clones but relapse can occur. A different treatment may then be needed. Therapy MGUS = monoclonal gammopathy of undetermined significance Time 14 Adapted from Dr. Brian Durie

15 Better Worse How do I know the treatment is working, or I am progressing? 2014 Immunophenotypic CR scr Molecular CR CR VGPR PR MR SD PD IMWG Myeloma Response Criteria IN GENERAL: 1) Know your M protein. - Is the protein in the blood, urine or both? 2) Myeloma labs should be checked regularly. The lower the protein, the better. Look for reduction in the M protein numbers: - 50% reduction: Partial Response - 90% reduction: Very Good Partial Response - Disappearance of protein: Complete Response Disease Progression: - If the proteins increase by 25% - If there are signs of organ damage (e.g., kidney, bone) scr= Stringent Complete Response; CR = Complete Response; VGPR = Very Good Partial Respnse; PR = Partial Response; SD = Stable Disease; MR = Minimal Response (only in relapsed); PD = Progressive Disease Palumbo A, et al. International Myeloma Working Group. J Clin Oncol. 2014; 32: Durie BM, et al; International Myeloma Working Group. Leukemia. 2006; 20(9):

16 Oral immunomodulatory agents (IMiD): Approved to be given to patients with newly diagnosed myeloma (Revlimid) or relapsed myeloma (Pomalidomide) in combination with dexamethasone Administration: Oral; Recommended with low-dose dexamethasone Pomalyst: Take without food (2 hours before or 2 hours after a meal) Do not crush, chew or open capsules Smoking reduces Pomalyst exposure Side effects: IMiDs : Revlimid (lenalidomide) and POMALYST (Pomalidomide) Take aspirin for blood clot prevention Watch blood counts: Get regular CBC s POMALYST (pomalidomide) prescribing information 16

17 Options with approved therapies DRUGS USED TO TREAT EARLY RELAPSE 17

18 MIBS Proteasome inhibitors are good options at relapse Common MIBS: Velcade (bortezomib) Retreatment: Approved in newly diagnosed and relapse For patients who initially responded to Velcade with at least a partial remission and relapsed > 6 months after treatment. Effectiveness: 38.5% response rate Kyprolis (Carfilzomib): For patients who have received at least one prior therapy Three drug therapy with Carfilzomib, Revlimid and dexamethasone (KRd) is better than two drug therapy with just Revlimid and dexamethasone (Rd) Higher overall response rate with KRd (87.1% vs 66.7%) Petrucci et al. Br J Haematol. 2013; 160(5):649-59; FDA News Release Nov. 30, 2015; Liu Y-C, et al. Blood Lymphatic Cancer: Targets Therapy. 2014; 4:

Carfilzomib: Patient Pearls Avoid starting the first cycle at the end of the week in case of side effects Let providers know of any heart or lung issues Take aspirin for blood clot prevention Take

19 Carfilzomib: Patient Pearls Avoid starting the first cycle at the end of the week in case of side effects Let providers know of any heart or lung issues Take aspirin for blood clot prevention Take acyclovir or valacyclovir for shingles prevention Be cautious about over-hydration Use a diuretic or water pill or inhalers if needed Kyprolis prescribing information; FDA.gov; Faiman B, et al. J Adv Pract Oncol 2016;7:

20 Indication: Patients who have received at least one prior therapy. It is given in combination with Rd A pill taken once weekly Do not crush or chew capsules and keep them separate from other medications Take on an empty stomach: 1 hour before or 2 hours after food Side effects: Ixazomib: An Oral Proteasome Inhibitor Low platelets (Thrombocytopenia) Stomach upset (Take anti-nausea medicine) Peripheral neuropathy Swelling in the legs or hands (edema) Ixazomib+Rd FDA approved November 2015 Rd = lenalidomide, dexamethasone; NINLARO (ixazomib) prescribing information; Faiman B, et al. J Adv Pract Oncol 2016;7:

21 Suggested Ixazomib (Ninlaro) Dosing Calendar Ixazomib (Ninlaro) Dosing 28-day Cycle Recommended starting doses: Ixazomib 4 mg Revlimid 25 mg Dexamethasone 40 mg NINLARO (ixazomib) prescribing information; Faiman B, et al. J Adv Pract Oncol 2016;7:

22 Empliciti (Elotuzumab): A New Antibody for Early Relapsed Myeloma Elotuzumab: A Monoclonal Antibody For patients who have received 1-3 prior therapies. Given in combination with Revlimid and dexamethasone Binds to and enhances NK (natural killer) cells or immunity Antibody administration Risk of a temporary infusion reaction with first dose, but most are mild after premedication with dexamethasone and acetaminophen Initially infused at a slow rate and then escalated over time Give weekly for 8 weeks, then twice monthly Pearls Take aspirin for blood clot prevention (Revlimid) Infection prevention (wash hands, avoid colds and report symptoms) Take as long as it is working and if side effects are manageable

23 Elotuzumab: Dose and Schedule ELOTUZUMAB (IV) CYCLES 1 AND 2 (28-Day Cycles) Week 1 Week 2 Week 3 Week 4 D 1 D 2-7 D 8 D 9-14 D 15 D Elotuzumab Lenalidomide QD QD QD Dexamethasone D 22 D Prescribing information, 2015 ELOTUZUMAB (IV) CYCLES 3 AND BEYOND (28-Day Cycles) Week 1 Week 2 Week 3 Week 4 D 1 D 2-7 D 8 D 9-14 Elotuzumab D 15 D Lenalidomide QD QD QD Dexamethasone D 22 D 23-28

24 Options with approved therapies TREATMENT OPTIONS FOR PATIENTS WITH 3 OR MORE PRIOR TREATMENTS 24

25 Daratumumab: A Monoclonal Antibody for Relapsed Myeloma Approved for patients who have received at least 3 prior lines of therapy including a proteasome inhibitor and an immunomodulatory agent Antibody administration Risk of a temporary infusion reaction with first dose, but most are mild following premedication with dexamethasone, acetaminophen Requires post-medication with oral steroid for 2 days to prevent late reactions. Initially infused at a slow rate and then escalated over time Schedule: Weekly x 8, then every 2 weeks x 8, then every 4 weeks Pearls for Patients: Can cause interference with tests for blood cell type matching Take as long as it is working and if side effects are manageable Darzalex (daratumumab) Prescribing Information; Gleason C, et al. J Adv Pract Oncol 2016; 7 (suppl 1):

26 Farydak (Panobinostat) for Relapsed Myeloma Histone Deacetylase Inhibitor (HDAC) A pill taken three times weekly x 2 weeks, then stop. Given in combination with Velcade and Dexamethasone Side effects/patient Pearls: Stomach upset and diarrhea Can cause heart problems (prolongs QTc interval ) Take acyclovir or valacyclovir for shingles prevention (Velcade) Neuropathy (Velcade) 26

27 Farydak (Panobinostat) + Velcade (bortezomib), Dexamethasone Schedule Novel Agents in MM PANOBINOSTAT (Oral) CYCLES 1-8 (28-Day Cycles) Week 1 Week 2 D 1 D 2 D 3 D 4 D 5 D 6 D 7 D 1 D 2 D 3 D 4 D 5 D 6 D 7 Panobinostat Bortezomib Dexamethasone PANOBINOSTAT (Oral) CYCLES 9-16 (28-Day Cycles) Week 1 Week 2 D 1 D 2 D 3 D 4 D 5 D 6 D 7 D 1 D 2 D 3 D 4 D 5 D 6 D 7 Panobinostat Bortezomib Dexamethasone Panobinostat. PI

28 Side Effects of Commonly Used Myeloma Drugs thalidomide lenalidomide pomalidomide bortezomib carfilzomib Neuropathy (PN) * Thrombosis (DVT, PE) Myelosuppression Cardiopulmonary Low white blood cells slow heart rate Low white blood cells, hemoglobin, platelets Low white blood cells shortness of breath Low blood, platelets hypotension Low white blood cells, platelets shortness of breath, other Fatigue, weakness Sedation Rash GI disturbance constipation diarrhea, constipation diarrhea, constipation nausea, vomiting, diarrhea nausea, vomiting, diarrhea, constipation * Subcutaneous or weekly administration of bortezomib reduces risk of PN PN = peripheral neuropathy; DVT = deep vein thrombosis; PE = pulmonary embolism; dex = dexamethasone; Neutro = Neutropenia (low white blood cell) count; Thrombo = thrombocytopenia (low platelets); GI = gastrointestinal 28

29 Side Effects of Newly-Approved Myeloma Drugs Peripheral Neuropathy (PN) panobinostat elotuzumab daratumumab ixazomib Infusion reaction Myelosuppression Cardiopulmonary Low white blood cells, platelets irregular heart beat Low white blood cells, platelets Low platelets Fatigue, weakness Rash GI disturbance diarrhea, nausea, vomiting diarrhea, nausea diarrhea PN = peripheral neuropathy; GI = gastrointestinal 29

30 Peripheral Neuropathy (PN) Management Prevention and Management: Adjust chemotherapy schedule or dosing Massage feet regularly with cocoa butter Try OTC supplements or acupuncture For cramping, try mustard, pickle juice or tonic water Provide a safe environment: rugs, furnishings, shoes If symptoms worsen, your provider may: Change your treatment Prescribe medications: pregabalin, gabapentin, duloxetine, or amitriptyline Suggest physical therapy Report symptoms early to your health care provider. Nerve damage from PN can be permanent if unaddressed. Tariman, et al. Clin J Oncol Nurs. 2008;12(3 Suppl):

31 Managing Side Effects of Steroid Therapy Things to consider while taking steroids: Creative scheduling: morning vs evening Stomach protection: Take with food Take OTC or prescription medications Concern for infection: Medications to prevent infections Report fever of more than F, shaking chills even without fever, dizziness, shortness of breath, or low blood pressure Weight gain Increased blood glucose (Hyperglycemia) Do not stop or adjust steroid doses without discussing with your health care provider! Faiman B, Bilotti E, Mangan PA, Rogers K; IMF Nurse Leadership Board. Clin J Oncol Nurs. 2008;12(3 Suppl):

32 Diarrhea Prevention & Management Medications and supplements may cause diarrhea: Laxatives and antacids with magnesium Antibiotics, antidepressants and others: check with your provider or pharmacist OTC supplements: milk thistle, aloe, cayenne, saw palmetto and ginseng Increase fluid intake to reduce risk of dehydration, kidney problems Avoid caffeinated, carbonated, or heavily sugared beverages Use anti-diarrheal medication Colestid, Imodium or Lomotil if recommended by a clinician Fiber binding agents Metamucil, Citrucel, Benefiber Cholestyramine (Questran, Prevalite) Discuss diarrhea with health care provider to identify causes and make adjustments to medications and supplements. Smith LC, Bertolotti P, Curran K, Jenkins B; IMF Nurse Leadership Board. Clin J Oncol Nurs. 2008;12(3 Suppl):

Infection Prevention: Crucial in Myeloma Patients Compromised immunity from both the disease and treatment Good personal hygiene (skin, oral) Environmental control (wash hands, avoid crowds and sick

33 Infection Prevention: Crucial in Myeloma Patients Compromised immunity from both the disease and treatment Good personal hygiene (skin, oral) Environmental control (wash hands, avoid crowds and sick people, etc.) Prompt medical attention at signs of infection (e.g. fever, chills) Medications (antibacterial, antiviral) Growth factor (e.g. filgrastim) Immunizations (NO live vaccines) Pneumonia vaccines (13 and 23) and seasonal inactivated influenza Intravenous immunoglobulin for hypogammaglobulonemia Faiman B, Mangan P, Spong J, Tariman JD, IMF Nurse Leadership Board. Clin J Oncol Nurs. 2011;15(Suppl):66-76; Miceli TS, et al. Clin J Oncol Nursing. 2011;15(4):

Disease- Related Effects: Bone At diagnosis and at relapse, bone imaging (MRI, x-rays, PET or CAT scans) is

$fractures Nurses should: Coordinate the treatment team; Educate patients about bone health and symptoms of bone$ disease Patients should: Report new or worsening pain; Remain active; Perform weight bearing exercise; Get regular

disease Patients should: Report new or worsening pain; Remain active; Perform weight bearing exercise; Get regular

34 Disease- Related Effects: Bone At diagnosis and at relapse, bone imaging (MRI, x-rays, PET or CAT scans) is important Type of imaging depends on symptoms Bone Disease in Myeloma ~85% of MM patients develop bone disease Bone damage may lead to high blood calcium and contribute to kidney impairment Bone builders (bisphosphonates) prevent fractures Nurses should: Coordinate the treatment team; Educate patients about bone health and symptoms of bone disease Patients should: Report new or worsening pain; Remain active; Perform weight bearing exercise; Get regular dental exams Miceli TS, et al. Clin J Oncol Nursing. 2011;15(4)suppl:9-23; Dimopoulous M, et al. Leukemia. 2009; 23(9):

Bone Health: Supportive Care All patients getting anti-myeloma therapy should receive bisphosphonates Pamidronate Zoledronic acid (zol) bisphosphonates Ongoing Phase 3 Trial: denosumab vs zol for

Other bone-related interventions: Kyphoplasty, vertebroplasty, surgery Radiation Terpos E, et al. J Clin Oncol. 2013;31:2347-2357; NCCN Multiple Myeloma Guidelines v3.2015; Miceli TS, et al.

35 Bone Health: Supportive Care All patients getting anti-myeloma therapy should receive bisphosphonates Pamidronate Zoledronic acid (zol) bisphosphonates Ongoing Phase 3 Trial: denosumab vs zol for myeloma What to be aware of with bisphosphonates: Acute phase reaction: 11% fever, chills Dental health (dental exams every 6 months) Kidney damage over time (24-hr urine) Osteonecrosis of the jaw Other bone-related interventions: Kyphoplasty, vertebroplasty, surgery Radiation Terpos E, et al. J Clin Oncol. 2013;31: ; NCCN Multiple Myeloma Guidelines v3.2015; Miceli TS, et al. Clin J Oncol Nursing. 2011;15(4)suppl:9-23; Coleman RE. Br J Cancer. 2008;98(11): ; Morgan GJ, et al. ASH 2010 #311; Witzig T, et al. ASH 2010 #3053; Berenson J, et al. Lancet Oncol. 2011;12: ; Medtronic, Kyphon Products Division. Kyphoplasty for Vertebral Compression 35

36 Protecting Bones, Kidneys & Preventing Blood Clots Bones: Are you receiving bone strengtheners (pamidronate, zoledronic acid) Vitamin D and Calcium discuss with provider Annual metastatic skeletal survey Avoid lifting heavy objects Participate in weight bearing exercise (even swimming) Kidneys: Avoid use of non-steroidal antiinflammatory drugs such as ibuprofen, Stay hydrated Blood clots: Having myeloma places you at risk for blood clots. Stay hydrated Discuss use of aspirin or blood thinners if you have a previous blood clot or are taking an imid or carfilzomib to treat myeloma Report swelling, limb pain, or new shortness of breath to your provider immediately

Risk Factors for kidney damage Active multiple myeloma High blood calcium level Other medical issues (hypertension, diabetes) Symptoms Changes in urination, pain Prevention Avoid certain medications

37 Risk Factors for kidney damage Active multiple myeloma High blood calcium level Other medical issues (hypertension, diabetes) Symptoms Changes in urination, pain Prevention Avoid certain medications (IV contrast, NSAIDs) Stay hydrated DRINK WATER Treatment Kidney Health Correct the underlying causes (treat myeloma, control high blood pressure and high blood sugar) Faiman B, Mangan P, Spong J, Tariman JD, IMF Nurse Leadership Board. Clin J Oncol Nurs. 2011;15(Suppl):66-76; Miceli TS, et al. Clin J Oncol Nursing. 2011;15(4):

38 Summary: Key points The way we treat and monitor MM continues to evolve! Length of therapy matters. The longer you stay on treatment, often the better the remission will be. Nurses and healthcare providers want to help you remain on treatment and achieve your goals. DO: Open the lines of communication with your healthcare team Share your goals, desires for treatment. Write down side effects and concerns in a notebook to discuss with your providers at your next visit. Make sure your myeloma is regularly monitored with blood and urine tests. DON T be afraid to ask questions or seek a second opinion from a myeloma specialist.

Nutrition, activity & exercise Get restful sleep Maintain a healthy weight Healthy Lifestyle & Complimentary Alternative Medicine Living Well with Myeloma:

v= PYdhpABCx4U Prevent falls, injuries and infections Stop smoking Complementary & Alternative Medicine: What Myeloma Patients and Caregivers Need to Know

39 Nutrition, activity & exercise Get restful sleep Maintain a healthy weight Healthy Lifestyle & Complimentary Alternative Medicine Living Well with Myeloma: Stopping to Breathe While Moving Forward! Beth Faiman, PhD, APRN-BC, AOCN PYdhpABCx4U Prevent falls, injuries and infections Stop smoking Complementary & Alternative Medicine: What Myeloma Patients and Caregivers Need to Know Sandra E. Kurtin, RN, MS, AOCN, ANP-C ction?articleid=4196 Some supplements can interact with your prescription medications. Discuss with your health care provider before starting supplements. 39

40 Tips on How to Help Yourself Self Advocacy Be a consumer of health care Ask questions! Seek the opinion of a myeloma specialist Get a second opinion if needed Update your Health Care Team of any changes You are ultimately the person who will live with your health care decisions. Make your choices thoughtfully! 40

Larger trials open at more centers Often randomized Standard of care regimen vs.

41 Clinical Trials: Access to New Agents and Regimens Phase 1 or 2 Smaller trials open at fewer centers Often not randomized Single arm: all patients get the same regimen Multi arm: multiple dose levels of active drug Phase 3 Larger trials open at more centers Often randomized Standard of care regimen vs. experimental regimen Regimen ± experimental drug IMF Myeloma Matrix: Clinical Trials for MM by Phase Treatment Options Clinical Trials 41

Resources Myeloma is a very individual disease.

best approach in your individual situation.

doctor or advanced practice nurse Nurses are a

42 Resources Myeloma is a very individual disease. Your medical team will help you determine the best approach in your individual situation. What is the best treatment option for me? How do I manage my side effects? Treatment must always be discussed with your doctor or advanced practice nurse Nurses are a key part of your health management team and can discuss and help manage recommended therapy. 42

43 IMF Resources IMF: Website, Infoline, and Publications are Sources for Additional Information CURE (2873) Infoline: US & Canada 9:00 am to 4:00 pm Pacific Website: Nurses, patients, caregivers, others welcome to call 43

44 You Have Questions We Have Answers 44

Management of Multiple Myeloma: The Changing Paradigm

Management of Multiple Myeloma: The Changing Paradigm Supportive Care for Patients With Multiple Myeloma Brittany Wolfe, PA-C University of Chicago Multiple Myeloma Program www.cancer.gov Effects of Myeloma