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August 2011, Supplement to Volume 15, Number 4
Article
Routine Health Maintenance in Patients Living With Multiple
Myeloma:
Survivorship Care Plan of the International Myeloma Foundation
Nurse Leadership Board
Elizabeth Bilotti, MSN,
APRN, BC, Charise L. Gleason, MSN, NP-BC, AOCNP®,
Ann McNeill, RN, MSN, APN,
OCN®, and the International Myeloma Foundation
Nurse Leadership Board
Patients diagnosed with
multiple myeloma are living longer because of new therapeutic options. Helping
patients with multiple myeloma maintain a good state of health from the time of
diagnosis and throughout their therapy leads to better quality of life.
However, patients with multiple myeloma are at risk for illnesses experienced
by the general population and at additional risk for illnesses related to
multiple myeloma and its treatment. Therefore, the International Myeloma
Foundation Nurse Leadership Board (NLB) has developed practice recommendations
to meet the particular needs of adult patients with multiple myeloma using
evidence-based recommendations for screening and disease prevention, as well as
nursing experience. The NLB recommendations are designed to address and
overcome barriers to health maintenance by educating and empowering nurses and
their patients.
At a
Glance
¨ Patients diagnosed with multiple myeloma are at risk
for illnesses other than side effects of their disease and treatment.
¨ Making health maintenance an integral part of
patients’ care plan will help them maintain a good state of health and provide
a better quality of life.
¨ Practice recommendations have been developed for
screening and disease prevention, emphasizing screening for cardiovascular
disease, malignancy, endocrine disorders, bone health, sensory changes,
psychosocial issues, addiction and substance abuse, nutrition, and other
important conditions
Patients with newly diagnosed
and relapsed multiple myeloma are living longer because of new therapeutic
options that did not exist a decade ago (Kumar, Rajkumar, & Dispenzieri,
2008). Therefore, nurses and patients need to understand the importance of
maintaining overall wellness through health promotion and disease prevention.
Health maintenance must commence from the time of diagnosis and extend
throughout therapy to improve survival by managing therapy appropriately within
the context of attendant drug toxicity and the patient’s preexisting or
therapy-induced comorbid conditions. The International Myeloma Foundation’s
Nurse Leadership Board (NLB) has developed a health maintenance schedule for
patients living with multiple myeloma. This health maintenance schedule is a
tool that can be used by nurses, patients, and their caregivers to provide
recommendations on the timing and frequency of screening evaluations (see Figure 1). These evaluations are based on age, gender,
and risk factors to facilitate primary and secondary prevention of disease
(Frame, 1996). Patients with multiple myeloma are not only at risk for the
illnesses experienced by the general population, but also are at additional
risk related to the disease and its treatment. Updated evidence-based practice
recommendations for screening and preventative services for the general
population, based on age, gender, and risk factor assessment, will be presented
in this article.
Multiple myeloma typically is
a disease afflicting older adults, although more than 30% of patients diagnosed
are younger than aged 65 years (National Cancer Institute, 2011). Therefore,
the NLB recommendations pertain to an adult population and include screening
for cardiovascular disease (i.e., hypertension and hyperlipidemia), other
malignancies (i.e., prostate, breast, and colon cancers), endocrine disorders
(i.e., type 2 diabetes mellitus and thyroid dysfunction), bone health, sensory
changes (i.e., vision and hearing), psychosocial issues, addiction and
substance abuse (i.e., tobacco and alcohol), nutrition, and other important
conditions (i.e., infection, immunization scheduling, and oral hygiene). The
screening recommendations are based on NLB patient treatment experience, have
been personalized to suit individual patient needs, and should be used as an
overview aimed at health promotion and disease prevention to meet the
particular needs of patients with multiple myeloma. These health maintenance
recommendations are a first description of the issues facing patients living
long term with multiple myeloma. The International Myeloma Working Group will
be reviewing the evidence and making consensus statements regarding numerous
topics, including the occurrence of secondary malignancies and recommendations
for immunization. Updates will be posted at www.myeloma.org.
The NLB is aware that many
barriers to health maintenance exist. Time constraints, lack of knowledge
regarding current guidelines and their application and relevance, and
skepticism all can contribute to a lack of focus on health maintenance for
patients with multiple myeloma. To institute change to prevent illness, nurses
and patients need to be motivated to embrace a health maintenance approach.
Collaboration with patients often is achieved through education. Helping
patients with multiple myeloma understand how they can help to improve their
overall survival by maintaining their health while undergoing therapy and
follow-up is imperative.
Cardiovascular
Hypertension
According to the American
Heart Association, 33% of Americans older than age 18 have been diagnosed with
hypertension (Roger et al., 2011). Men younger than age 55 have a higher
prevalence than women of the same age group, but the prevalence rate evens out
for those ages 55–64, and then the prevalence rate is higher for women age 65
and older. In addition, the prevalence in African Americans is highest among
racial groups at about 41%. (Roger et al., 2011). Most adults with hypertension
are aware of their condition and are using antihypertensive drugs, although
hypertension is controlled in only about half of these patients (Roger et al.,
2011). Essential or primary hypertension has no identifiable cause, whereas
secondary hypertension can develop from chronic kidney disease, coarctation of
the aorta (congenital defect), Cushing syndrome (glucocorticoid excess states),
chronic steroid therapy, obstructive uropathy, pheochromocytoma, primary
aldosteronism (mineralcorticoid excess states), renovascular causes, sleep
apnea, thyroid or parathyroid disease, and may be drug induced (Chobanian et
al., 2003). Undetected or uncontrolled hypertension over a period of time can
lead to stroke, heart attack, heart failure, and renal failure. Nonmodifiable
risk factors include age, ethnicity, family history of hypertension, and
genetics. Additional modifiable risk factors include lower education,
socioeconomic status, being overweight or obese, physical inactivity,
psychosocial stressors, sleep apnea, diet (high fat, high sodium, low
potassium), and excessive alcohol intake. Lifestyle modifications to prevent
primary hypertension are illustrated in Figure 2.
The diagnosis of hypertension
is made based on at least two blood pressure readings (systolic of 140 mmHg or
higher and diastolic of 90 mmHg or higher) on two separate occasions. Current
recommendations for primary prevention of hypertension include weight loss,
low-sodium diet, moderation in alcohol consumption, and increased regular
physical activity. The initial treatment for hypertension will vary depending
on the indication for initiation and comorbid conditions. Clinical trials have
determined the class of drugs (e.g., beta-blockers, angiotensin-converting
enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers,
aldosterone antagonists) that should be used for the management of hypertension
based on the compelling indication to treat, which includes heart failure, post
myocardial-infarction, high coronary artery disease risk, diabetes, chronic
kidney disease, and recurrent stroke prevention.
Current screening
recommendations by the U.S. Preventative Services Task Force ([USPSTF], 2010)
include screening adults age 18 and older and following-up on diagnosis after
two or more elevated readings obtained on separate occasions over a period of
one to several weeks. The frequency of screening includes
·
Normal: Recheck
in two years.
·
Prehypertension:
Recheck in one year.
·
Stage I
hypertension: Confirm within two months (systolic blood pressure of 140–159
mmHg or diastolic blood pressure of 90–99 mmHg) (Chobanian et al., 2003).
·
Stage II
hypertension: Evaluate or refer to source of care within one month (systolic
blood pressure of 160 mmHg or higher or diastolic blood pressure of 100 mmHg or
higher) (Chobanian et al., 2003).
·
Hypertensive
crisis: Evaluate and treat immediately (higher than 180/110 mmHg).
The various therapies used
for treatment of multiple myeloma can lead to either hypertension or
hypotension. Therefore, patients may require initiation of antihypertensive
medications or dose adjustment of their current regimen. Elevated blood
pressures may occur with the use of dexamethasone because of fluid retention
(Faiman, Bilotti, Mangan, Rogers, & the International Myeloma Foundation
NLB, 2008). The incidence of hypotension with single-agent bortezomib
administration is 13%, which may necessitate adjustment of antihypertensive
medications (Millennium: The Takeda Oncology Company, 2010). Continued
assessments with intervention as indicated are important for patient safety.
Hyperlipidemia
Of Americans older than age
20, 15% have a total cholesterol level greater than 240 mg/dl, which is
considered high risk. Nonmodifiable risk factors include age, sex (male), and
family history of premature coronary heart disease (CHD). Modifiable risk
factors include hypertension, cigarette smoking, diabetes, being overweight or
obese, physical inactivity, and atherogenic diet (National Cholesterol
Education Program [NCEP], 2002).
The diagnosis of
hyperlipidemia can be from the results of a fasting lipoprotein profile
including total cholesterol, low-density lipoprotein (LDL) cholesterol,
high-density lipoprotein cholesterol, and triglycerides. Patient testing and
intervention are stratified depending on an individual’s risk. The three risk
categories include (a) those with established CHD or CHD risk equivalent (i.e.,
diabetes, peripheral artery disease, other clinical atherosclerotic disease,
abdominal aortic aneurysm, symptomatic carotid artery disease, or more than 50%
stenosis on angiography or ultrasound), (b) those with two or more risk
factors, and (c) those with none or one risk factor. The risk factors to be
evaluated include cigarette smoking, hypertension, low LDL cholesterol (less
than 40 mg/dl), and family history of premature CHD (first-degree male relative
younger than age 55 or first-degree female relative younger than age 65) (NCEP,
2002).
Current recommendations for
the primary prevention of hyperlipidemia include lifestyle modifications, such
as weight control, dietary modifications, regular physical activity, and
smoking prevention or cessation. In addition, patients with elevated LDL or
multiple risk factors may use pharmacologic interventions as prevention against
CHD (NCEP, 2002). The initial therapy for dyslipidemia will depend on the
abnormal values and the risk stratification of the individual. The therapy is
described in NCEP (2002) and Grundy et al. (2004), with modifications based on
a review of five clinical trials published after initial recommendations from
statin clinical trial results. Current screening recommendations (USPSTF, 2010)
for men are older than age 35, screen for lipid disorder every five years if
results are normal; and ages 20–35, screen for lipid disorders only in those at
increased risk for CHD every five years if results are normal. For women older
than age 20, screen for lipid disorders if they are at increased risk for CHD.
USPSTF (2010) makes no
recommendation for or against routine screening for lipid disorders in men ages
20–35 or in women age 20 and older who are not at increased risk for CHD.
Malignancies
Breast Cancer
An estimated 232,620 cases of
breast cancer will be diagnosed in 2011, with about 2,140 of those cases
diagnosed in men (American Cancer Society [ACS], 2011a). An increased incidence
of breast cancer in Caucasians has been noted and thought to be related to
improved diagnosis, such as more frequent mammography, later age at first
childbirth, and greater use of hormone-replacement therapy (ACS, 2010a).
Nonmodifiable risk factors include age, personal and family history
(first-degree relative) of breast cancer, breast tissue changes (lobular
carcinoma in situ), genetic changes (BRCA1, BRCA2), younger than age 12 at
menarche, older than age 55 at menopause, menopausal hormone-replacement
therapy, race (Caucasian), dense breast tissue, and history of taking
diethylstilbestrol (ACS, 2010b). Modifiable risk factors include older age at
time of first live birth, nulliparity, radiation therapy to the chest for
treatment of lymphoma (risk increased if treated during adolescence, with no
increased risk seen after age 40), being overweight or obese following
menopause, lack of physical activity, or regular alcohol consumption.
Current USPSTF (2010)
screening recommendations include a screening mammography with or without
clinical breast examination (CBE) every one to two years for women age 40 and
older. Insufficient evidence exists to recommend for or against CBE alone and
for or against performing routine breast self-examination.
Current ACS screening
recommendations (for average risk) (Smith, Cokkinides, & Brawley, 2009)
include
·
The benefits or
limitations of breast self-examination should be taught to all women beginning
in their early 20s.
·
CBE should be
part of a periodic assessment (at least every three years) for women in their
20s and 30s.
·
Annual
mammography should begin at age 40.
Cervical Cancer
An estimated 12,710 cases of
cervical cancer are diagnosed each year in the United States, with more than
4,290 deaths annually (ACS, 2011a). Incidence and death rates for other racial
groups with cervical cancer appear to be higher than that of Caucasians, which
may be a reflection of access to screening and health care. Primary prevention
of cervical cancer can be successful with frequent Papanicolaou (Pap) tests,
safe sex practices, and human papillomavirus (HPV) vaccination in younger
women. Nonmodifiable risk factors include a weakened immune system (HIV,
immunosuppressants) and diethylstilbestrol exposure in utero. Modifiable risk
factors include HPV infection, failure to undergo routine screening (i.e., Pap
test), smoking, sexual history (increased number of partners), long-term use of
oral contraceptives, and multiparity (more than five births in conjunction with
HPV).
Current USPSTF (2010)
recommendations strongly recommend screenings in women who have been sexually
active and have a cervix; initiate screening within three years of onset of
sexual activity or at age 21 years, whichever comes first. The guidelines
recommend against routine screening of women older than age 65 if they have
adequate recent screening with normal Pap tests and are not otherwise at high
risk, and routine screening for patients with a total hysterectomy for benign
disease. Insufficient evidence exists to recommend for or against the routine
use of new technologies to screen for cervical cancer and the routine use of
HPV testing as a primary screening test for cervical cancer.
Current ACS screening
recommendations (Smith et al., 2009) include
·
Cervical cancer
screening should begin three years after a woman begins having vaginal
intercourse, but no later than age 21. Screening must be done annually with
conventional Pap tests or every two years using liquid-based Pap tests.
·
At or after age
30, women who have had three normal Pap tests in a row may get screened every
two to three years with cervical cytology, or every three years with an HPV DNA
test plus cervical cytology.
·
Women age 70 or
older who have had three or more normal Pap tests and no abnormal Pap tests in
the past 10 years and women who have undergone a total hysterectomy may choose
to stop cervical cancer screening.
Skin Cancer
Skin cancer (including
melanoma and nonmelanoma) is the most common cancer diagnosed in the United
States (ACS, 2011a; Woolfe, 2008) and, although not one of the most frequent
causes of death, incidence rates have been rising since the 1960s at 4%–8% per
year. About 70,230 new cases of melanoma and 8,790 deaths will be reported in
2011 (ACS, 2011a). Melanoma accounts for less than 5% of all skin cancers but
causes the most skin cancer deaths. Caucasians have a risk ratio of 1 in 50 (1
in 1,000 for African Americans and 1 in 200 for Hispanics). More than one
million nonmelanoma skin cancers (i.e., squamous cell carcinoma and basal cell
carcinoma), were diagnosed in 2009, with 80% of skin cancers diagnosed as basal
cell and 20% as squamous cell carcinoma.
USPTF (2010) and ACS (2009)
recognize the following known risk factors for skin cancer for the general
population and the myeloma population: ultraviolet (UV) light; moles (people
with many moles are more likely to develop melanoma); fair skin, freckles, and
red or blonde hair; family history of melanoma; and weakened immune system
(i.e., from treatment or transplantation, older age, male [men have higher
rate], and xeroderma pigmentosum, a rare inherited condition).
Risk factors for nonmelanoma
skin cancers include UV light, fair skin, older age, male (men are two times as
likely to have basal cell carcinomas and three times as likely to have squamous
cell carcinomas of the skin), exposure to chemicals (i.e., arsenic, industrial
tar, coal, paraffin, and certain types of oil), radiation exposure, previous
history of skin cancer, long-term or severe skin inflammation or injury,
psoriasis treatment, basal cell nevus syndrome (a rare congenital condition),
reduced immunity, HPV, smoking, and genetic susceptibility. Current screening
recommendations (USPSTF, 2010) include
·
The use of
sunscreens that block UV A and B are recommended, as is limiting intense or
chronic exposure to sun.
·
Avoid sun
exposure between 10 am and 4 pm and wear protective clothing such as wide-brimmed
hats, long-sleeved garments, long pants, and sunglasses; some clothing now
comes with built-in UV protection; sunscreen and lip balm should have an SPF of
at least 15 and should be applied 20–30 minutes prior to sun exposure and
reapplied every two hours and after swimming or sweating.
·
Comprehensive
skin examinations for patients with a personal history of skin cancer, those
with precursor lesions, and those with occupational exposure; follow the ABCDEs
of melanoma as recommended by the American Academy of Dermatology (2011).
– Asymmetry: one half unlike the
other half
– Border: irregular, scalloped, or
poorly circumscribed
– Color: Varies from one area to
another. May have shades of tan, brown, black, white, red, or blue
– Diameter: larger than 6 mm (the
diameter of a pencil eraser)
– Evolving: a mole or skin lesion
that looks different from other moles or lesions and is changing (evolving) in
size, shape, or color.
The ACS recommends a skin
examination along with the general periodic health examination. Although the
benefits of screening are unproven, people should remain alert for skin lesions
with malignant features.
Treatments such as
chemotherapy, stem cell transplantation, radiation, and immunosuppressive
agents, along with age and sun exposure, may place patients with multiple
myeloma at higher risk for developing skin cancer.
Colorectal Cancer
In 2011, an estimated 101,340
new cases of colon cancer and 39,870 new cases of rectal cancer will be
diagnosed (ACS, 2011a). The estimated number of deaths from colon and rectal
cancer combined for 2011 will be 49,380 (ACS, 2011a). African Americans have
the highest colorectal cancer incidence and mortality rates of all racial
groups in the United States (ACS, 2011b). African Americans also have a higher
incidence of multiple myeloma; therefore, it would be prudent for healthcare
practitioners to educate these patients about the benefits of colorectal cancer
screening. Jews of Eastern European descent (particularly Ashkenazi Jews) have
one of the highest colorectal cancer risks of any ethnic group in the world.
Several gene mutations leading to an increased risk of colorectal cancer have
been found in this group; the most common of these DNA mutations is present in
about 6% of Jews in the United States (those of Eastern European descent) (ACS,
2008). Other nonmodifiable risk factors include age, personal history of
colorectal polyps or colorectal cancer, personal history of inflammatory bowel
disease, family history of colorectal cancer, having an inherited genetic
susceptibility to the disease (particularly familial adenomatous polyposis and
hereditary nonpolyposis colon cancer [or Lynch syndrome]). Modifiable risk
factors also have been identified and include diets high in red meat and
processed meat, physical inactivity, obesity, smoking, heavy alcohol use, and
type 2 diabetes (ACS, 2010c). Current screening recommendations for colorectal
cancer (USPSTF, 2010) include
·
Fecal occult
blood testing, sigmoidoscopy, or colonoscopy beginning at age 50 and continuing
until age 75; in individuals at higher risk, initiating screening at an earlier
age is reasonable.
·
Based on modeling
evidence, this population should be screened using one of the following three
regimens (all equally effective in potential life-years gained).
– Annual
screening with high-sensitivity fecal occult blood testing
– Screening
every five years with sigmoidoscopy combined with high-sensitivity fecal occult
blood testing every three years
– Screening
colonoscopy every 10 years.
Prostate Cancer
After skin cancer, prostate
cancer is the second most common cancer in men in the United States and the
second leading cause of death. An estimated 240,890 new cases of prostate
cancer will be diagnosed in 2011, with an estimated 33,720 deaths from the
disease (ACS, 2011a). Prostate cancer occurs more often in African American men
than in men of other races. African American men also are more likely to be
diagnosed at an advanced stage and are more than twice as likely to die of
prostate cancer as Caucasian men. Prostate cancer occurs less often in Asian
American and Hispanic men than in non-Hispanic Caucasians. The reasons for
these racial and ethnic differences are unclear. As stated, African American
men are more frequently diagnosed with multiple myeloma than Caucasians.
Education regarding the screening recommendations for prostate cancer is
extremely important in the myeloma population.
Included in the nonmodifiable
risk factors are age, race, ethnicity, family history of prostate cancer, and
the inheritance of specific genes. The relationship of several modifiable risk
factors and the incidence of prostate cancer have been studied. Some studies
have shown that the following factors may increase the risk of prostate cancer:
diets high in red meats or high-fat dairy products, obesity, low levels of
physical activity, prostatitis, and infection (ACS, 2009).
The USPSTF (2010) concluded
that the current evidence is insufficient to assess the benefits of prostate
cancer screening in men younger than age 75 and recommends against screening
for prostate cancer in men age 75 years or older. However, current ACS
screening recommendations for prostate cancer (Snowden, 2010) include the
following.
·
African American
men and men who have a close family member with prostate cancer should have the
prostatic-specific antigen blood test and a digital rectal examination annually
beginning at age 45.
·
All other men
should be screened annually beginning at age 50, including prostate-specific
antigen blood test and digital rectal examination to check the prostate gland.
A discussion with the patient about the benefit or lack of benefit from
prostate cancer screening should be conducted so the patient can decide if he
wants to be tested or not.
Endocrine
Diabetes Mellitus Type 2
An estimated 8.3% of the U.S.
population (25.8 million) is living with diabetes, and about 90%–95% of those
cases are type 2 diabetics (American Diabetes Association, 2011). About 1.9
million new cases of diabetes are diagnosed each year (American Diabetes
Association, 2011), and diabetes is the seventh leading cause of death (about
71,380 per year) (Jemal, Siegel, Xu, & Ward, 2010). Common complications of
diabetes include damage to the heart, blood vessels, eyes, kidneys, and nerves.
Many of these comorbidities overlap with the common toxicity profiles of
antimyeloma therapeutics. Therefore, prompt recognition and intervention for a
preexisting or new onset diagnosis of diabetes mellitus type 2 is imperative
for quality care. Nonmodifiable risk factors for diabetes include race or
ethnicity (African American, Mexican American, Native American, Native
Hawaiian, and Asian American), age, and family history. Gender does not seem to
be a risk factor (National Institute of Diabetes and Digestive and Kidney
Diseases, 2007). Modifiable risk factors include being overweight or obese,
hyperglycemia, physical inactivity, and smoking.
Current recommendations for
the primary prevention of diabetes mellitus type 2 are based on lifestyle
modification. Dietary changes include a recommendation for moderate weight
loss, defined as a 7% reduction in body weight accomplished by a reduction in
daily calories and fat. Individuals also are advised to achieve the recommended
daily allotment for dietary fiber (14 g of fiber per 1,000 kcal), and that 50%
of grain intake comprise whole grain–containing foods. The incorporation of
regular exercise (150 minutes per week) at a moderate level also is strongly
advised (American Diabetes Association, 2011).
The treatment for diabetes
mellitus type 2 can vary dramatically, from conservative lifestyle
modifications to pharmacologic intervention with either oral or injectable
antidiabetic medications. Adequate management of plasma glucose levels and
screening for related complications can improve patient quality of life, reduce
comorbidities and death, and decrease the economic burden of diabetes.
Screening and treatment guidelines (American Diabetes Association, 2011) may be
recommended based on dietary and lifestyle modification, hypertension,
hyperlipidemia, CHD, neuropathy, retinopathy, smoking cessation, and foot care.
Current screening
recommendations from USPSTF (2010) include fasting plasma glucose in
asymptomatic adults with sustained blood pressure (treated or untreated)
greater than 135/80 mmHg; however, insufficient evidence exists to recommend
routine screening in asymptomatic adults with blood pressure greater than
135/80 mmHg.
According to study results,
patients receiving treatment for multiple myeloma can have an increased
incidence of hyperglycemia when dexamethasone is incorporated into their
regimen. Although the incidence of diabetes induced by steroid therapy in
patients with multiple myeloma is unknown, it might be beneficial to follow the
recommendations for hyperglycemia evaluation and management in patients on
prolonged steroid therapy.
Thyroid Dysfunction
Hypothyroidism is a metabolic
state resulting from an insufficient level of circulating thyroxine (T4)
(Gregerman, 2003). Primary hypothyroidism relates to a problem within the
thyroid gland itself rather than a different part of the
hypothalamic-pituitary-thyroid axis. Subclinical hypothyroidism is defined as
an elevated serum thyroid stimulating hormone (TSH) level despite normal levels
of serum-free T4. The prevalence is 3%–8% in the population not known to have
thyroid disease (Fatourechi, 2009). Subclinical hypothyroidism is seen more
frequently in women, and the prevalence increases with age. Clinical features
of hypothyroidism often are insidious at onset. Signs include hyponatremia,
elevated levels of cholesterol and triglycerides, electrocardiogram changes
(low voltage and/or T-wave abnormalities); symptoms include easy fatigability,
lethargy, cold intolerance, muscle aching, dry skin, hair loss, constipation,
facial and periorbital edema, voice changes, and poor memory. The diagnostic
work-up for primary hypothyroidism often will stem from the patient’s
subjective complaints in combination with their history and a physical
examination, and should include tests described in Table
1 (Fischbach & Dunning, 2004).
Although treatment for
hypothyroidism consists of thyroid hormone replacement with T4, some patients
may require the addition of triiodothyronine (T3) for relief of symptoms;
therapy should be individualized (Nygaarde, Jensen, Kvetzy, Jarlov, &
Faber, 2009; Wiersinga, 2009). Improvement in symptoms may take months. Serum
TSH, T4, free T4, and/or free T4 index should be monitored to titrate doses.
Thalidomide therapy often can
lead to subclinical hypothyroidism with normal T3 and T4 levels and slightly
elevated TSH levels (Dimopoulos & Eleutherakis-Papaiakovou, 2004). Some
hypothesized mechanisms of action include direct thyrotoxicity or the
provocation of an immune reaction against the thyroid. Badros et al. (2002)
tested those mechanisms in a study that assessed thyroid function in 174
patients with multiple myeloma assigned to receive chemotherapy alone or in
combination with thalidomide. The authors of that study found 20% of patients on
thalidomide had a serum TSH level greater than 5 uIU/ml three to four months
after enrollment. The study also evaluated an additional 169 patients with
relapsed multiple myeloma who had been treated with thalidomide; 75% of those
patients with normal baseline TSH levels had increases in their TSH two to six
months after starting therapy and 22% had a TSH level greater than 5 uIU/ml.
Many of the adverse effects associated with hypothyroidism also may be
associated with thalidomide, and include constipation, fatigue, lack of energy,
neuropathy, skin rash, and bradycardia.
Hypothyroidism has not been
reported in clinical studies of patients on lenalidomide, although it has been
reported in a retrospective new case (Figaro et al., 2011). Obtaining baseline
TSH, T4, free T4, and/or free T4 index levels prior to the initiation of
therapy with thalidomide or lenalidomide, and retesting at regular intervals,
may help to detect patients with subclinical hypothyroidism (Menon, Habermann,
& Witzig, 2007). Co-screening recommendations currently exist for routine
evaluation for thyroid disease in asymptomatic patients (USPSTF, 2010);
however, the NLB recommends a baseline screening prior to the initiation of
therapy, with regular interval screening every three months. Patients with
subclinical hypothyroidism also may benefit from replacement therapy at a lower
TSH level. More research is needed to establish evidence-based guidelines for
such a therapy.
Bone
Health
Because bone health is so
important, a companion article in this publication (Miceli et al., 2011)
addresses the subject in more detail. Risk factors for osteoporosis and
fractures, as well as screening tests and recommended calcium and vitamin D
supplementation, are discussed. The related topic of functional mobility and
safety is the subject of another companion article by Rome, Jenkins, Lilleby,
and the International Myeloma Foundation Nurse Leadership Board (2011), which
includes recommendations for maintaining bone strength as well as functional
mobility.
Sensory
Vision Screening
With the aging of the
American population, the number of Americans with major eye diseases is
increasing, and vision loss is becoming a major public health issue. Blindness
or low vision affects 3.3 million Americans age 40 and older and is projected
to affect 5.5 million people by 2020 (National Eye Institute, 2010). Low vision
and blindness increase significantly with age. People age 80 and older
currently make up 8% of the population but account for 69% of blindness.
Age-related macular degeneration, glaucoma, cataracts, and diabetic retinopathy
are the most common eye diseases in Americans age 40 and older (National Eye
Institute, 2008).
According to the National Eye
Institute (2008), a comprehensive eye examination should include at least three
diagnostic components: tonometry (to determine the fluid pressure in the eye),
a visual acuity test (to measure how well the patient sees at various
distances), and pupil dilation (in which eye drops are placed in each eye to
widen the pupil, allowing the doctor to see the interior of the eye to check
the retina for signs of disease). Current vision screening recommendations for
comprehensive medical eye examinations from the American Academy of
Ophthalmology (2005) for adults with no risk factors and for adults with
conditions or risk factors are shown in Table 2.
Patients at risk include
those with diabetes, hypertension, or a family history of ocular disease (e.g.,
glaucoma, macular degeneration) as well as individuals working in occupations
that are highly demanding visually or hazardous to the eye, those taking
prescription or nonprescription drugs with ocular side effects, those wearing
contact lenses, and those who have had previous eye surgery.
Patients being actively
treated for multiple myeloma have a high probability of receiving dexamethasone
as part of their treatment regimen. Dexamethasone can cause a wide range of
adverse events affecting many organ systems; one such side effect is ophthalmic
in nature and includes blurred vision and cataract formation (Faiman et al.,
2008). For that reason, patients with multiple myeloma are an at-risk
population because they are or have been treated with medications that have the
potential to cause ocular side effects.
Hearing Screening
Hearing loss is one of the
most common conditions affecting older adults. About 17% (36 million) American
adults say that they have some degree of hearing loss. Roughly 33% of Americans
ages 65–74 and 47% of those 75 and older have hearing loss. Men are more likely
to experience hearing loss than women (National Institute on Deafness and Other
Communication Disorders, 2009). However, adults generally ignore its effects,
delay their decision to seek audiologic services, and put off recommended
treatment (e.g., hearing aids). For many, a hearing aid is an unwelcome
reminder of the aging process or associated with a disability. A hearing aid
will not restore normal hearing. Many people have unrealistic expectations and
are, therefore, disappointed when difficulties arise. Finally, hearing aids are
expensive and usually are not covered by health insurance, making them cost
prohibitive for many patients.
Ototoxicity is commonly
medication-induced; ototoxic drugs include aminoglycoside antibiotics (e.g.,
gentamicin), loop diuretics (e.g., furosemide), and platinum-based chemotherapy
agents (e.g., cisplatin). The effects may be reversible and temporary or
irreversible and permanent. Individuals receiving these medications should be
aware of the potential ototoxicity and may be advised to undergo more frequent
screening examinations.
Hearing screening tests
provide a quick and cost effective way to separate people into two groups, pass
and fail. Those who pass hearing screenings are presumed to have no hearing
loss. Those who fail are in need of an in-depth evaluation by an audiologist,
and also may need follow-up care from other professionals.
No screening recommendations
currently exist for routine evaluation of hearing. Hearing screening is
performed when requested, when conditions occur that increase risk for hearing
loss, or when mandated by state or local laws. All hearing screening programs
should be conducted under the supervision of an audiologist holding the
American Speech-Language-Hearing Association’s (ASHA) Certificate of Clinical
Competence. Adults should be screened at least every 10 years through age 50
and at three-year intervals thereafter (ASHA, 2009). Most patients with
multiple myeloma are older adults with a median age at diagnosis between ages 68–70.
Education and communication between patients and healthcare providers is
crucial. Hearing loss represents a significant barrier to accurate evaluation
and management of the disease process in these individuals.
Psychosocial
Depression
Depression affects 19 million
Americans annually, with most studies indicating that 20%–25% of patients with
cancer will be afflicted at some point in their treatment (Passik, McDonald,
Dugan, Edgerton, & Roth, 1997). Diagnosing depression in a patient with
cancer can be challenging because various physical symptoms such as fatigue,
poor appetite, and difficulty sleeping can be attributed to the disease,
treatment, or depression. A clinician needs to distinguish the difference
between the symptoms associated with the patient’s medical illness or treatment
and depressive symptoms associated with syndromal depression (McDaniel,
Musselman, Porter, Reed, & Nemeroff, 1995). In the general population,
depression is the most common clinical psychiatric problem in primary care (Katon
et al., 2006). Although feelings of sadness and anxiety as well as other
emotions are typical with the diagnosis of cancer, using the Diagnostic and Statistical Manual of Mental
Disorders fourth edition (DSM-IV) and patient history is critical when depression
is suspected. Signs and symptoms of depression include persistent sadness,
anxious mood, sleeping too much or too little, decreased appetite, weight loss
or gain, restlessness, and feelings of despair or denial. Chronic disease such
as cancer, medication side effects, gender, family history, situational events,
biologic factors, and cognitive changes (e.g., poor self-esteem, negative
thinking patterns) all are risk factors for depression. In addition, the role
that steroids, as part of the treatment paradigm, may play in mood alteration
should be considered. Risk factors for depression found to be positively
correlated with advanced age include bereavement, sleep disturbance,
disability, female gender, and prior history of depression.
Screening: Several
questionnaires are available to assist the clinician in screening for
depression, such as the Zung Self-Rating Depression Scale, the Center for
Epidemiological Studies Depressions Scale, the Beck Depression Inventory, and
the Patient Health Questionnaire (PHQ-9) (Kroenke & Williams, 2001; Woolfe,
2008). The PHQ-9 is an easy-to-use patient questionnaire that is a
self-administered version of the PRIME-MD® diagnostic instrument for common
mental disorders. The PHQ-9 is the depression module, which scores each of the
nine DSM-IV criteria as 0 (not at all) to 3 (nearly every day). Validity has
been assessed against an independent structured mental health professional
interview and has been validated for use in primary care. The PHQ-9 score of 10
or higher had a sensitivity of 88% and a specificity of 88% for major
depression. Assessments via telephone are even possible with this tool (Kroenke
& Williams, 2001; Woolfe 2008). The PHQ-9 can be accessed at
www.phqscreeners.com.
Once depression is diagnosed
correctly, the clinician may find it necessary to start an antidepressant or
may refer the patient to a specialist such as a psychiatrist who focuses on
patients with cancer. Differentiating between depression and anxiety also is
important. Clinicians need to improve their assessment skills when diagnosing
cancer-related depression (Woolfe, 2008). The oncology social worker is a
valuable resource to assist patients with related challenges of financial
difficulties, such as insurance and housing issues, as well as social support.
Many social workers are licensed counselors and can provide their services for
patients and family members through counseling and group support sessions. The
International Myeloma Foundation offers support services and groups (both online
and face-to-face) and more information can be found at http://myeloma.org/SupportGroup.action?tabId=6&menuId=0&queryPageId=7.
Despite the high prevalence of depression in patients with cancer, it often is
underdiagnosed and, therefore, untreated (Portenoy & Itri, 1999).
Fatigue
Fatigue can be a major
obstacle in patients with cancer, affecting their overall quality of life.
Patients describe fatigue as decreased energy, weakness, and somnolence.
Fatigue can be cumulative as with radiotherapy, or can have an acute onset as
with patients receiving chemotherapy (Portenoy & Itri, 1999). Patients with
multiple myeloma often undergo a complicated treatment regimen that may produce
fatigue (Coleman et al., 2003). Fatigue has been reported in 80%–99% of
patients receiving treatment and may be a barrier to functional recovery (Curt
et al., 2000). Patients also may experience fatigue related to depression,
pain, anemia, or the chemotherapy; therefore, providers need to have good
assessment skills. In a quantitative study conducted by the Fatigue Coalition
of Patients Undergoing Chemotherapy, 18% reported fatigue (second to nausea) as
a complaint during chemotherapy, and 25% of patients reported fatigue as the
number one complaint post-treatment (Curt et al., 2000). Ninety percent of the
patients that reported fatigue considered themselves active prior to their
diagnosis of cancer, and 91% felt this impacted them in leading a normal life
(Curt et al., 2000). A study by Stone et al. (2000) showed that fatigue has a
major effect on quality of life and is underrecognized by healthcare
professionals. Risk factors for fatigue include anemia, dyspnea, loss of
appetite, weight loss, and pain medications.
Cognitive Changes
Patients with cancer may
experience cognitive changes also referred to as chemo brain. These changes can
have an effect on processing, organizational skills, memory, concentration, and
attention span, which may be mild to debilitating and last for up to 10 years
(Ahles & Saykin, 2002; Tannock, Ahles, Ganz, & van Dam, 2004),
affecting quality of life for the patient and his or her family members (Staat
& Segatore, 2005). Exposure to chemotherapy may affect cognitive function,
but it has been difficult to identify which agents exert the greatest effect.
Risk factors include chemotherapy, radiation therapy, and bone marrow or stem
cell transplantation.
Research continues at
evaluating treatment regimens and the attendant effect on patients’ cognitive
function and their quality of life. Clinicians must recognize the relevant
signs and symptoms and educate their patients and caregivers. The healthcare
team needs to be aware of the implications that treatment has on the lives of
patients. By recognizing the signs and symptoms of depression, fatigue, and
cognitive changes, appropriate interventions can be made to improve the overall
quality of life of patients.
Screening:
The NLB recommends asking the following questions during routine screening at
all provider encounters to detect depression or other cognitive changes: In the
past two weeks, have you felt down, depressed, or hopeless? In the past two
weeks, have you felt little interest or pleasure in doing things?
Addiction
and Substance Abuse
Smoking Cessation
The problem of smoking among
cancer survivors is substantial. About 20% of cancer survivors report that they
currently smoke, a rate only slightly lower than those without a history of
cancer (Hewitt, Greenfield, & Stovall, 2006). Many cancer survivors are
former smokers (38%) and, therefore, are at considerable risk for relapse of
their smoking habit (Hewitt et al., 2006). Persistent smoking following
diagnosis contributes to poor long-term outcomes. Cessation of cigarette
smoking has been associated with a reduction in treatment complications,
improved survival, and a decrease in risk for second cancers (Hewitt et al.,
2006). Benefits of smoking cessation also include reduction in risk of
cardiovascular and pulmonary disease (Hewitt et al., 2006). Current USPSTF
(2010) screening recommendations for smoking include
·
Screen all adults
for tobacco use and provide tobacco cessation intervention for those who use
tobacco products.
·
Oncology
providers should find “teachable moments,” and a failure to routinely assess
smoking status and provide smoking cessations counseling is a lost opportunity.
Guidance on how to provide
smoking cessation counseling is available and has been shown to be effective in
combination with pharmacotherapy. Counseling and clinical considerations to
prevent tobacco use follow (USPSTF, 2010).
·
Brief tobacco
cessation counseling interventions, including screening, brief counseling
(three minutes or less), and/or pharmacotherapy, have proven to increase
tobacco abstinence rates, although a dose-response relationship exists between
quit rates and the intensity of counseling. Effective interventions may be
delivered by a variety of primary care clinicians.
·
The “5-A”
behavioral counseling framework provides a useful strategy for engaging
patients in smoking cessation discussions.
– Ask about
tobacco use.
– Advise to
quit through clear personalized messages.
– Assess
willingness to quit.
– Assist to
quit.
– Arrange
follow-up and support.
Helpful aspects of counseling
include providing problem-solving guidance for smokers to quit and give social
support within and outside of treatment. Common practices that complement this
framework include motivational interviewing, the “5 Rs” used to treat tobacco use
(relevance, risks, rewards, roadblocks, and repetition), assessing readiness to
change, and more intensive counseling and/or referrals for those needing extra
help.
Telephone “quit lines” have
also been found to be an effective adjunct (see www.ahrq.gov/path/tobacco.htm for
resources). Clinics that implement screening systems designed to regularly
identify and document a patient’s tobacco use status increased their rates of
clinician intervention. However, limited evidence exists that supports the
effect of screening systems on tobacco cessation rates.
U.S. Food and Drug
Administration-approved pharmacotherapy includes several forms of nicotine
replacement therapy (i.e., nicotine gum, nicotine transdermal patches, nicotine
inhaler, nicotine nasal spray), sustained-release bupropion, and varenicline
tablets. Other medications, including clonidine and nortriptyline, have been
efficacious (Nides, 2008). Nonpharmacologic interventions such as hypnosis, acupuncture,
diet aids, smoking deterrents, and low-level laser therapy have been suggested
for smoking cessation. Evidence does not support improved quit rates with these
types of interventions. However, on an individual basis, these therapies may
provide the patient with added confidence to be successful in their quit
attempt (Williams, 2007).
Barriers to smoking cessation
among patients with cancer can include strong nicotine dependence because of a
long history of heavy tobacco use, fatalistic beliefs, psychological distress,
and social influences such as family members who smoke. Building smoking
cessation counseling into important cancer treatment care transitions has been
suggested as a way to promote smoking cessation. Teachable moments for smoking
cessation counseling and relapse prevention include at the time of diagnosis,
during active treatment, and during transition from inpatient to outpatient
care and follow-up visits. In each of these clinical settings, involvement of
family members is important given the likelihood that smoking is common among
the family members of patients with cancer (Hewitt et al., 2006).
Encouraging smoking cessation
is particularly important in patients with multiple myeloma because the
pathophysiology of the disease includes a susceptibility to infections,
particularly pneumonia. Cigarette smoking and exposure to environmental tobacco
smoke increase the risk of pulmonary infections in general and the risk to
contract invasive pneumococcal disease by a four-fold factor (Herr et al.,
2009). In addition, other pulmonary infections are more frequent in smokers,
including influenza and tuberculosis (Herr et al., 2009).
Smokers usually have a lower
physical endurance than nonsmokers. Smoking decreases lung capacity, whereas
exercise increases it. Patients with multiple myeloma are at risk for dyspnea
on exertion related to anemia and prior pulmonary infections. Smoking adds an
additional burden to the exercise tolerability. Healthcare practitioners caring
for patients with myeloma should screen patients for tobacco use and implement
tobacco cessation counseling guidelines.
Alcohol Misuse
Currently, about 14 million
people in the United States (one in every 13 adults) abuse alcohol or are
alcoholics (National Institute on Alcohol Abuse and Alcoholism, 2009) and
several million more engage in risky drinking that could lead to alcohol issues
(i.e., binge drinking and heavy drinking on a regular basis). In addition, 53%
of men and women in the United States report that one or more of their close
relatives have a drinking problem (National Institute on Alcohol Abuse and
Alcoholism, 2009). Alcohol misuse includes “risky or hazardous” and “harmful”
drinking, defined as more than seven drinks per week or more than three drinks
per occasion for women, and more than 14 drinks per week or more than four
drinks per occasion for men (National Institute on Alcohol Abuse and
Alcoholism, 2009). Harmful drinking describes people who currently are
experiencing physical, social, or psychological harm from alcohol use but do
not meet the criteria for dependence. Alcohol abuse and dependence are
associated with repeated negative physical, psychological, and social effects
from alcohol (USPSTF, 2010). The following risk factors may increase an
individual’s likelihood of abusing alcohol: gender (more common in men than
women), family history, genetic factors, cultural factors, psychological
vulnerability, and psychiatric disorders (American Psychiatric Association,
2000).
Identifying alcoholism may be
difficult because no detectable physiologic difference exists between a person
who drinks frequently and a person with alcoholism. Identification involves an
objective assessment regarding the damage that imbibing alcohol does to the
drinker’s life compared with the subjective benefits the drinker perceives from
consuming alcohol. Although many cases exist where an alcoholic’s life has been
significantly damaged, some borderline cases do occur that can be difficult to
classify. Screening tools for detecting a loss of control of alcohol use
include self-reports in questionnaire form and scores or tallies that sum up
the general severity of alcohol use (National Institute on Alcohol Abuse and
Alcoholism, 2009).
The CAGE questionnaire
(Ewing, 1984) is one such example that may be used to screen patients quickly
in a doctor’s office. Two “yes” responses indicate that the respondent should
be investigated further. The questionnaire asks the following questions: Have
you ever felt you needed to Cut down on your drinking? Have people Annoyed you
by criticizing your drinking? Have you ever felt Guilty about drinking? Have
you ever felt you needed a drink first thing in the morning (Eye-opener) to
steady your nerves or to get rid of a hangover?
Other screening tools include
the following.
·
The Alcohol
Dependence Data Questionnaire: A more sensitive diagnostic test than CAGE, it
helps distinguish a diagnosis of alcohol dependence from one of heavy alcohol
use.
·
The Alcohol Use
Disorders Identification Test: A screening questionnaire developed by the World
Health Organization. This test is unique in that it has been validated in six
countries and is used internationally. Like CAGE, it uses a simple set of
questions with a higher score earning a deeper investigation.
·
The Paddington
Alcohol Test: Designed to screen for alcohol-related problems in those
attending accident and emergency departments. It correlates well with the
Alcohol Use Disorders Identification Test, but is administered in less time.
Screening:
USPSTF (2010) recommends screening and behavioral counseling interventions to
reduce alcohol misuse by adults, including pregnant women, in primary care
settings. Patients with multiple myeloma who abuse alcohol are particularly
challenging for the healthcare team. Alcohol may exacerbate many of the
disease- or treatment-related symptoms. One of the most concerning is alcoholic
neuropathy, which typically presents as a generalized sensorimotor
polyneuropathy with numbness, weakness, and sensory ataxia. Because peripheral
neuropathy can be an adverse event associated with several pharmacologic agents
used to treat myeloma, it can be difficult to determine whether this is an
alcohol or treatment-induced finding.
Many types of inflammation
and irritation of the stomach are classified under the broad medical term
gastritis. A variety of factors or conditions can cause this disorder, one of
which is the consumption of alcohol. The use of certain medications,
particularly corticosteroids, also may induce this condition. Because
corticosteroids are drugs that are used commonly in the treatment of multiple
myeloma, patients should be cautioned that concomitant alcohol consumption may
exacerbate the symptoms of gastritis. Because of this, practitioners should
attempt to identify patients who have problems with alcohol.
An additional concern when
treating patients that abuse alcohol is the misinterpretation of laboratory
data. Liver function tests (i.e., total bilirubin levels and serum transaminase
values) can be abnormal in these individuals. That may mask potential adverse
events caused by drug treatments for myeloma. Some treatment regimens (e.g.,
those that contain bortezomib) require dose modifications for those individuals
with hepatic impairment.
Nutrition
Iron Deficiency
Iron deficiency is the most
common nutritional deficiency in the United States and the leading cause of
anemia (Killip, Bennett, & Chambers, 2007). The sources of iron deficiency
include blood loss (e.g., menstrual, gastrointestinal), an increase in requirement
that is unmet by dietary intake (e.g., pregnancy, growth), and malabsorption
(e.g., celiac disease, post-gastrectomy, vegetarian diet, poor diet, excessive
use of proton pump inhibitors or antacids) (Centers for Disease Control and
Prevention [CDC], 1998). Iron deficiency can lead to anemia and fatigue,
impairing the ability to perform activities of daily living. Adults may
complain of fatigue and weakness as well as decreased work performance,
difficulty maintaining body temperature, and decreased immune function (CDC,
2002). Patients also may report glossitis. The diagnosis of anemia is made by
laboratory evaluation, although a definitive diagnosis may come from a bone
marrow biopsy showing low to absent iron stores. The laboratory evaluation of anemia
is described in Table 3.
The current recommendations
for the primary prevention of iron deficiency anemia focus on dietary intake
and enhanced absorption. The recommended dietary allowance for adult men and
women, who are not of childbearing potential, is 8 mg per day; women of
childbearing potential should ingest 18 mg per day (Institute of Medicine Food
and Nutrition Board, 2001). Heme iron is found in sources such as lean red
meats, fish, and poultry, and is easier for the body to absorb. The nonheme
iron sources found in plant and fortified foods are not as easy to absorb, but
the process can be enhanced by ingesting an adequate amount of vitamin C during
meals. Polyphenols, phytates, and calcium also may decrease the amount of
nonheme iron that can be absorbed.
The treatment of iron
deficiency begins with identifying the cause. Malignant or benign lesions
producing blood loss must be identified and appropriately treated. A normal
dietary intake will only meet the needs of daily iron loss, but oral or
parental supplementation will be required to build back stores. The most common
cause of poor response to oral therapy is lack of adherence from side effects
(constipation, cramping, diarrhea, or nausea) or poor absorption (concomitant
antacid therapy). The side effects can be minimized by initially taking the
iron with food and titrating the dose as tolerated. It typically takes six
months of therapy to replete iron stores, although a rise in hemoglobin should
be seen within one to two months of adequate therapy. All oral supplements
should be taken between meals and spaced one to two hours from calcium or
antacid ingestion. The options for iron replacement include oral iron
replacement (e.g., ferrous sulfate, gluconate, fumarate, iron polysaccharide) and
parenteral replacement (for those with poor absorption or intolerance to oral
therapy).
No screening recommendations
currently exist for routine evaluation for iron deficiency anemia outside the
setting of children and women of childbearing potential. However, one of the
indicators to treat asymptomatic patients with multiple myeloma is the
observation of worsening anemia. Outside the setting of obvious disease
progression or other indications to initiate systemic therapy, a work-up to
determine the etiology of the anemia is warranted. Another indication to
evaluate for the adequacy of iron stores are those patients initiating or
continuing exogenous erythropoietin therapy (Katodritou, Zervas, Terpos, &
Brugnara, 2008).
Obesity
According to ACS (2006), obesity
has reached epidemic proportions and, in the past 15 years, obesity rates have
risen by 48%. Obesity can contribute to the development of several chronic
diseases from cardiovascular to cancer. About 1% of the adult population is
moving into the obese category, with a body mass index of greater than 30 kg/m2
every year (Woolfe, 2008). Risk factors associated with obesity include insulin
resistance, diabetes, hypertension, dyslipidemia, CHD, stroke, heart failure,
cancer, and early mortality. Current screening recommendations for obesity
(ACS, 2006; USPSTF, 2010) include the following.
·
Screen all adult
patients for obesity and offer counseling and behavior interventions.
·
Balance caloric
intake with physical activity.
·
Eat at least five
servings of fruits and vegetables daily.
·
Choose whole
grains over processed.
·
Limit red meat
intake.
·
Develop healthy
eating patterns.
Miscellaneous
Opportunistic Infections
Multiple myeloma and its
treatment can increase a patient’s risk of developing an infection by
interfering with normal immune function. The healthcare team must monitor
patients for infection and treat them appropriately. Risk factors for infection
include neutropenia, poor nutrition, surgery, chemotherapy, radiation,
biotherapy, or immunotherapy as well as bone marrow or stem cell
transplantation. Recommendations to prevent infections include the following:
monitor for signs and symptoms of infection; wash hands; avoid crowds if
neutropenic; avoid anyone with fever, influenza, or other infections; maintain
good dental hygiene; use prophylactic antibiotics; observe catheter care; and
discuss travel plans with the healthcare team.
Immunizations
Immunizations are an
important primary prevention that should be continued even when on active
treatment for cancer. For most adult patients with multiple myeloma who have
received childhood vaccinations, the seasonal influenza vaccine and the
pneumococcal vaccine should be administered. Varicella vaccine currently is
contraindicated for immunocompromised patients because of immunosuppressive
agents such as steroids and other antimyeloma therapy (Marin, Guris, Chaves,
Schmid, & Seward, 2007). However, healthcare providers might consider
vaccinating family members living with the patient and treating the patients
with prophylactic antiviral therapy for a period of time after vaccination.
After autologous or allogeneic transplantation, patients should follow the
guidelines and recommendations of their transplantation center as well as their
healthcare provider.
Influenza vaccine: For the general population, anyone with a medical condition, including
those immunocompromised such as patients with multiple myeloma, should receive
an annual influenza vaccination. The trivalent inactivated influenza vaccine
given via intramuscular (IM) injection is the recommended vaccine for
immunocompromised patients. The vaccination should be offered in early autumn,
although high-risk patients can still be offered the vaccine after an outbreak
is noted in the community. The CDC recommends chemoprophylaxis in individuals
at high risk who are vaccinated after influenza activity has begun, those who
provide care to high-risk populations, and those who have immune deficiencies
(Woolfe, 2008).
Pneumococcal vaccine: Immunocompromised patients with multiple myeloma are
at risk for developing pneumococcal disease. Two forms of the vaccination
exist: the pneumococcal polysaccharide vaccine, and the pneumococcal conjugate
vaccine. Those receiving the pneumococcal polysaccharide vaccine include
patients age 65 or older (in Alaska, for patients living in certain high-risk
areas where an increased rate of invasive disease is noted, it may be
recommended for those age 50 or older) and immunocompromised patients age 2 or
older. The vaccination can be administered either IM or subcutaneously and
should be repeated in five years for those at greatest risk. Severe adverse
events are rare with the vaccination.
Tetanus booster: The tetanus booster is recommended every 10 years.
Post-transplantation vaccinations: Patients post-transplantation remain
immunocompromised for about 6–12 months and, even after immune reconstitution,
they may not have continued immunity to pathogens for which immunizations have
previously been given. Antibody titers to vaccine-preventable diseases decline
during the one to four years after autologous or allogeneic transplantation if
not revaccinated (Dykewicz, 2001). Immunizations such as polio, tetanus toxoid,
diphtheria toxoid, pneumococcus, hepatitis B, haemophilus influenzae type B
conjugate, and measles, mumps, and rubella, should be initiated per the
guidelines and recommendations of the transplantation center at appropriate
intervals.
Oral Hygiene
The American Dental
Association’s (2009) recommendations for adults for general dental care include
brushing teeth twice daily, cleaning between the teeth daily with floss or an
interdental cleaner, and seeing the dentist regularly for examinations
(including x-rays if warranted) and professional cleaning. Most dental practices
and dental insurance companies cite twice yearly visits as the minimum required
to maintain good oral hygiene. The risk of osteonecrosis of the jaw associated
with the use of IV bisphosphonates and recommendations for prevention,
diagnosis, and treatment are discussed in Miceli et al. (2011).
Tobacco use in all forms is
the biggest risk factor for oral cancer. Alcohol use combined with tobacco use
increases this risk. Patients should be encouraged to avoid tobacco and to
limit alcohol use to decrease their risk for oral cancer (USPSTF, 2010). Direct
inspection and palpation of the oral cavity is the most commonly recommended
method of screening for oral cancer, which can be provided by dentists during
routine visits. However, little data exists on the sensitivity and specificity
of this method and, although other screening techniques are being evaluated,
they are still considered experimental.
Summary
Health promotion and disease
prevention to maintain overall wellness should begin at the time of diagnosis
and follow the continuum of care throughout the patient’s life span. Nurses are
in a unique position to play a pivotal role in the promotion of primary and
secondary prevention practices through education and collaboration with
patients and their caregivers.
Patients with multiple
myeloma are living longer because of the advent of new therapeutic options.
Preventing comorbid conditions from occurring or worsening through education
and support should enable nurses and other healthcare providers to offer
patients more treatment options, resulting in improved quality and quantity of
life for those living with multiple myeloma.
The authors gratefully acknowledge Brian G.M. Durie,
MD, and Robert A. Kyle, MD, for critical review of the manuscript; Lynne Lederman,
PhD, medical writer for the International Myeloma Foundation, for preparation
of the manuscript; and Lakshmi Kamath, PhD, at ScienceFirst, LLC, for
assistance in preparation of the manuscript.
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Elizabeth Bilotti, MSN, APRN, BC, is a nurse
practitioner in the Multiple Myeloma Division in the John Theurer Cancer Center
at Hackensack University Medical Center in New Jersey; Charise L. Gleason, MSN,
NP-BC, AOCNP®, is a nurse practitioner in bone marrow transplant in
the Winship Cancer Institute of Emory University in Atlanta, GA; and Ann
McNeill, RN, MSN, APN, OCN®, is a nurse practitioner in the Multiple
Myeloma Division in the John Theurer Cancer Center at Hackensack University
Medical Center. The authors take full responsibility for the content of this
article. Publication of this supplement was made possible through an
unrestricted educational grant to the International Myeloma Foundation from
Celgene Corp. and Millennium: The Takeda Oncology Company. Bilotti is a
consultant, advisory board member, and on the speakers bureau for Millennium:
The Takeda Oncology Company and Celgene Corp.; Gleason is a consultant and
advisory board member for Merck & Co., Inc., Celgene Corp., and Millennium:
The Takeda Oncology Company; and McNeill is a consultant for Millennium: The
Takeda Oncology Company and an advisory board member and on the speakers bureau
at Millennium: The Takeda Oncology Company and Celgene Corp. The content of
this article has been reviewed by independent peer reviewers to ensure that it
is balanced, objective, and free from commercial bias. No financial
relationships relevant to the content of this article have been disclosed by
the independent peer reviewers or editorial staff. (Submitted February 2011.
Revision submitted March 2011. Accepted for publication April 5, 2011.)
Author Contact: Elizabeth
Bilotti, MSN, APRN, BC, can be reached at ebilotti@humed.com,
with copy to editor at CJONEditor@ons.org.