Treatment and disease-related complications in multiple myeloma: Implications for survivorship

Abstract

New treatments have transformed multiple myeloma into a chronic disease. Hence, optimal management of treatment and disease-related complications remains a critical component of survivorship care. Survivorship care model in cancers requiring a fixed-duration therapy may not be applicable to myeloma, since patients are exposed to multiple lines of continuous therapy along the disease trajectory. The two most common therapy-related causes of death, which require special consideration, are infection and second cancers. Identifying patients at a high risk of toxicities will facilitate individualized treatment selection and designing clinical trials for protective strategies targeting those patients. For example, prophylactic antibiotic or immunoglobulin replacement can be tested for primary prevention of infections in high-risk patients. Long-term follow up of ongoing trials and epidemiologic data will help identify the nature and trajectory of rare toxicities with a long latency, such as secondary cancers. Patients who are frail, have persistent renal insufficiency, and refractory to multiple lines of therapy need special attention regarding treatment toxicity and quality of life. In this review, we discuss the incidence, risk-factors, and management of treatment and disease-related complications in myeloma, discuss knowledge gaps and research priorities in this area, and propose a survivorship care model to improve health-care delivery to a growing pool of myeloma survivors.

Figure I.

Major treatment-related toxicities in multiple myeloma. Abbreviations: BCMA: B-cell maturation antigen. ADC: Antibody-drug conjugate. IMiDs: Immunomodulatory drugs. PIs: Proteasome inhibitors. CAR T: Chimeric Antigen Receptor T-cell therapy

Figure II.

Survivorship care model for patients living with multiple myeloma Primary responsibility for cancer-related care and complications from treatment or underlying cancer Primary responsibility for managing non-cancer co-morbidities Co-management with multiple myeloma specialist or primary care physician on special situations e.g. co-management with cardiooncology for carfilzomib-induced cardiotoxicity Communication time-points between multiple myeloma specialist, primary care physician, and other subspecialists: a) Discuss multiple myeloma diagnosis, planned induction and consolidation therapy, and anticipated adverse events. b) Discuss maintenance strategy, adverse effects of maintenance therapy, and plan for post-transplant immunization in transplant-eligible patients. c) Discuss disease relapse, treatment strategy, and anticipated adverse events of treatment d) Communication between multiple myeloma specialist, primary care physician, and subspecialist during periods of active subspecialty care needs.