An interview with Beth Faiman, PhD, CNP, and Kimberly Noonan, NP
Finding the right treatment pathways is essential, and this is perhaps most true in the treatment of uncommon, complex, and incurable diseases. Multiple myeloma (MM) is a cancer formed by malignant plasma cells, and more than 30,000 new cases will be diagnosed in 2016 with more than 12,000 deaths estimated (American Cancer Society, 2016). Faiman and Noonan discuss exciting new therapies and preview topics of interest for oncology nurses in 2016, including tackling tough conversations with patients and caring for yourself as an oncology nurse.
Kimberly Noonan, NP: To start, what is your impression of the MM disease state?
Beth Faiman, PhD, CNP: Before we had newer drugs and treatments, when I started taking care of patients in the mid- 1990s, everybody was treated only through a transplant or chemotherapy. Nowadays, such a plethora of treatments are available. And that is one of our challenges: when people are newly diagnosed with MM, there is no clear standard of care. It is hard for people to make decisions about their treatment. But it is promising, at time of diagnosis, to be able to say, “Multiple myeloma is incurable, but it is highly treatable for most patients.”
KN: Yes, patients can now live a long time with MM; this is a very exciting time to be involved with the disease. Things are really happening for MM in 2016—we had three drugs approved by the U.S. Food and Drug Administration (FDA) in one week, each drug better than the next. Are there any new treatment options or clinical trials about which you are excited?
BF: A recent trial, called the ENDEAVOR trial, compared the standard of care of bortezomib and dexamethasone to carfilzomib and dexamethasone. The results showed that at a higher dose of carfilzomib than was currently approved (the dose in the trial was 56 mg/m2 IV), patients who received carfilzomib and dexamethasone had a longer progression-free survival. So what we are really excited about is that, even though this is a drug that has been FDA approved since July 2012, we now have a new indication that allows us to give a higher dose, which is extremely safe, if not safer, especially when it is given earlier on in the treatment.
KN: There is also ixazomib, which is proteasome inhibitor and an oral agent, which has also been very well-tolerated. And then there are two monoclonal antibodies, elotuzumab and daratumumab. We haven’t used elotuzumab in our clinic as much because it hasn’t been available as long as daratumumab.
BF: The important thing about the first two drugs, elotuzumab and ixazomib, is that both drugs are FDA approved in combination with lenalidomide and dexamethasone. They are also approved for earlier lines of treatment, earlier on in the disease.
So we now have all these treatments—such as elotuzumab, which is an IV monoclonal antibody—and the increased number of drugs can make the treatment decision-making difficult for patients. Sometimes, they come in and expect to be on a pill or shot once a week. Now, if we go to some of these more complicated monoclonals with longer infusion times, it can create these quite challenging discussions for many patients.
KN: I have been on the other side of this, as well. Patients coming in for maintenance bortezomib, for example, sometimes are switching from the injectible bortezomib to the oral therapy, ixazomib, which is taken three doses in a month on days 1, 8, and 15 of a 28-day cycle. So we see it going both ways.
BF: Yes, for patients on maintenance bortezomib, transitioning them to ixazomib is a nice benefit because, now, they don’t have to drive to the clinic and receive the sometimes-painful subcutaneous injections, especially if they have been on the drug for a long time. So patients are actually coming to us asking, “I’ve heard about this drug and would this be right for me?” Because of where we practice—the Cleveland Clinic and the Dana-Farber Institute—our patient base tends to be very educated. So trying the new therapies can be difficult if you have a patient who isn’t necessarily requesting it, or insurance can be an issue. So there are a lot of different factors in the decision-making as to whether or not we can change the treatment.
KN: We’re also finding those kinds of clinical situations. We sometimes have patients on maintenance therapy who seem very stable for a number of years. Then we start to see a little bit of progression, and we are able to keep them on an oral therapy and their usual schedule with the newer oral agents. They can continue to come in on a monthly basis as opposed to weekly for an injection. So we are able to give patients a quality of life with this new oral proteasome inhibitor.
When discussing starting, changing, or ending treatments with patients, of course, there are always sensitive conversations that take place—“elephants in the room,” if you will. What are some of your strategies for addressing these tough talks?
BF: There is always going to be a “hot” topic about which you are never quite comfortable, despite your 20 years’ experience with it. Three topics come to my mind: sexuality, palliative care, and medication side effects. Sexuality would be one, for example; because of the drugs we prescribe, we constantly have to bring up sexual activity protection, which gets at the interpersonal relationships for the patient. Discussions regarding sexuality can make some individuals uncomfortable, so it is my job to provide an environment where patients can express concerns with sexuality and intimacy. Another difficult topic relates to hospice and palliative care. I have patients whom I’ve been taking care of for 15 years—I’m always optimistic and encouraging. But, ultimately, they relapse or become refractory to therapies. That’s a little bit more challenging. My strategy for helping address that “elephant in the room,” where the wife, partner, or caregiver is concerned, is to try to take a one-on-one focus with the patient. Patients, oftentimes, do not want to talk about how they are doing with medications while others are present. So try to approach them in private, close the door, turn off your pager, and give them your time. Then, hopefully, that will open them up. I also try to interact with each family member, too, bringing up these tough topics and answering questions as we go along.
KN: You want family members there when having these kind of conversations. But I start with bringing the question back to patients, ask them about palliative care, end of life, quality of life at home. Family members are usually able to interject and tell me, for example, “Well, they are sleeping a lot. They are in bed a lot. Their quality of life isn’t what it used to be.” So then you try to build information on that. This is all about the quality of life and getting the family on the same page. I try to have an open, transparent conversation about these tough issues, and it includes the patient and the entire team that is caring for the patient.
I think it is important to mention that, in addition to caring for the patient, nurses need to also care for themselves, especially in oncology and working with MM patients. What are some of your thoughts on this?
BF: I am very fortunate to have a strong interpersonal relationship with my family and friends, which allows me to see that maintaining that work-life balance is super important. So whether that is taking walks with my family, finding friends to exercise with, eating a healthy diet, or getting adequate amounts of sleep, I try to turn the brain off and disassociate from work best I can. That is just really my strategy for coping and preventing the burn out and anger that is associated with dealing with patients with cancer.
KN: I often think about what I learn from the patients—at the age of 45, for example, you can be diagnosed with MM, and your life is never the same again. Your body is just never the same again. I often just focus on what a great life I have and maintain a healthy lifestyle. We, as healthy people, are so fortunate; I have learned all I have about life through our patients: life is precious.
BF: I completely agree; every day is a gift, and that’s what our patients have taught us. On a daily basis, nurses face these difficult situations and try to be there for their patients because they are going to have this cancer whether we are there or not. So one of our mechanisms is that we help them navigate through the treatment trajectory, answering their questions and steering them to what we believe to be the right path.
KN: As nurses, it’s important to have relationships with our colleagues because situations and stress build up over time. You need a balance in your life, but it is also good to be able to talk through tough clinical situations and ethical dilemmas we see on a consistent basis with your colleagues.
BF: Yes, I agree. A long time ago, I was told by a mentor to surround yourself with people whom you can trust and with whom you have a really good relationship. I’ve been with some of my team for 15–20 years. If somebody has an interesting case, we can run it by them, whether it is an RN or a nurse practitioner or a physician. A team like this is your second family. So, for young nurses, if you are in a job that doesn’t seem like the right standard, and you do not feel like you are part of a team, maybe it’s not right for you—looking for another job or hospital where you feel that relationship might be something to consider.
At our clinic, we really try to mentor younger nurses. We are fortunate to have all of these drugs in our toolbox and the next step is figuring out how to use them. Hopefully, anytime there is a nurse out there who would want to contact me, I am always happy to share my experiences as well.
This content was developed by ONS, Beth Faiman, PhD, CNP, and Kimberly Noonan, NP, and is sponsored by Amgen. Faiman and Noonan received no payment for their participation.