Brown Bag Consult®: Patients With Multiple Myeloma Need Support Throughout Challenging Time

MN is a 63-year-old woman who has multiple myeloma and frequents your health care system. Her diagnosis has been a huge emotional burden. MN continuously struggles to understand her treatment options and worries about what her diagnosis means for her quality of life and her family.

Patients with multiple myeloma need resources, help, and hope every step of their journey. They will endure a grueling process of coping with diagnosis, treatment, and changes in treatment, as well as the fear of recurrence in cases of recovery. Each stage will affect the patient both emotionally and physically.

As the most accessible member of the health care team, the pharmacist can provide patients with cancer with the information and support necessary to get through what might be the most challenging time of their lives. Willingness to help at this crucial time demonstrates a caring and concern that patients likely will never forget.

The diagnosis threw a curveball at MN, a newly retired teacher with no family history of cancer. Her support system is limited because she is divorced and her children live out of state. MN relies on her pharmacy team and other members of the local community to help her through this rough patch.

Originally, MN presented to the pharmacy complaining of extreme fatigue. The pharmacist on duty told MN to follow up with her primary care provider, given that the fatigue was out of the ordinary and not the result of a lifestyle change.

Upon evaluation, MN received a diagnosis of symptomatic International Staging Symptom stage III high-risk multiple myeloma. MN’s laboratory results at the time included corrected calcium, greater than 11mg/dL; bone marrow, 20% plasma cells; b2 microglobulin, 5.7 mg/L; and deletion 17p, translocations in t(4;14). She had an ECOG status score of 0 and was eligible for autologous hematopoietic stem cell transplant (aHSCT). MN was prescribed bortezomib (Velcade), lenalidomide (Revlimid), and dexamethasone (VRd) as first-line treatment for induction and awaited transplant.

Today MN returns for follow-up treatment after completing 3 cycles of therapy and aHSCT. She is complaining of worsening back pain, to the point that she cannot stand straight or walk well. She feels short of breath. MN also experiences neuropathy and says that she can no longer knit or write well.

Laboratory values show that MN has normal liver and renal function. Post aHSCT, MN refused maintenance therapy and is now found to have recurrent disease, with an ECOG performance status of 1. She is rechallenged with VRd because guidelines recommend this option if relapse occurs less than 6 months from initial therapy.

MN wonders why she is not getting the same multiple myeloma treatments that the people in her therapy group get.

Why does she need both oral and injectable medications, whereas others get just oral drugs? Why do others seem to live normal lives but she struggles to perform basic functions? Are there other multiple myeloma treatments that cause less neuropathy? She explains that neuropathy prevented her from wanting to take maintenance therapy.

MN is sad and possibly clinically depressed. She feels anxious all the time about the future, she says, and has a hard time being positive. You encourage her to share these feelings with her immediate care team.

In this situation, as the pharmacist, you are not a primary decision maker on the care team, but you know of many nonpharmacologic ways you can help MN and recommendations you can make to her health care providers. You are MN’s most accessible resource.

You set aside some time to talk with MN and discuss the different types of multiple myeloma treatments. She appreciates your patience as you explain things in a way she can understand.

As you review MN’s as-needed medications, you realize she is overusing her prescribed anxiety and pain medications. You offer to follow up with her care team, address the issue, and help her develop a plan with more lasting effects.

MN is not drinking water, so she is dehydrated, and she is not eating a balanced diet or getting any exercise. You help her find some recipes specifically for patients with cancer who have issues with taste and give her the name of a local dietitian.

Although she has documented dyslipidemia and hypertension, MN says she no longer takes medications for those chronic conditions. You check her blood pressure, and it is high. You suggest that she follow up with her provider and get back on her prescribed medications, if necessary, after an evaluation.

During your discussion on exercise, you learn that MN’s support group has a walking club and encourage her to participate. You assure her that when her pain is better managed, she should find it easier to move around and perform daily activities. In addition, you emphasize the importance of important bone health and deep vein thrombosis prevention.

What else can you do for MN, and how will you follow up with her in a month, when she needs refills? Are her providers following National Comprehensive Network guidelines for her treatment? What supportive care could you recommend so that MN feels better managed?