Optimizing Multiple Myeloma Care: Insights From a Nursing Expert

The landscape of multiple myeloma (MM) treatment is shifting rapidly, moving toward more intensive frontline therapies and the integration of highly specialized immunotherapies. Kevin Brigle, PhD, ANP, an oncology nurse practitioner at VCU Massey

Comprehensive Cancer Center who has specialized in hematologic malignancies since the turn of the century, recently participated in an Oncology Nursing News case-based roundtable to discuss these transitions.

Drawing from his experience in a high-volume academic center, Brigle, in an interview with Oncology Nursing News following the event, highlighted the clinical necessity of early aggressive intervention and the critical role of the nursing team in managing the unique toxicity profiles of modern regimens.

Frontline therapy: The move to quads

Brigle emphasized that the historical distinction between transplant-eligible and transplant-ineligible patients is becoming increasingly "fuzzy" due to the rise of deferred transplants. Regardless of eligibility, the standard of care is moving toward quadruplet therapy.

“If I would say any take-home message now is that regardless whether they’re transplant eligible or ineligible ... pretty much any patient with the proper monitoring and proper dosing should be getting a quad up front and that should include an anti-CD38,” Brigle stated.

Managing complex toxicity profiles

As quadruplet therapies and bispecific antibodies move into earlier lines of treatment, oncology nurses must adapt to evolving toxicity profiles, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). At VCU Massey, Brigle and his team have leveraged a decade of experience with CAR T-cell therapy to establish standard operating procedures for managing these events.

To manage these risks, the institution has implemented an outpatient monitoring system that relies heavily on patient and provider education. Because VCU does not have a dedicated 24-hour outpatient clinic, they utilize a "pre-emergency department" to handle calls after hours. Brigle noted that success in this area stems from “understanding when CRS can occur and what the symptoms are and how they might mimic something else.”

Through proactive management, his team has avoided significant CRS or ICANS that could not be brought under control.

Tailoring care for frail and high-risk patients

For older or frail patients who may not tolerate full-dose aggressive regimens, Brigle stresses the importance of dose modifications to maintain quality of life without sacrificing efficacy. While nurses are well-versed in adjusting immunomodulatory agents like lenalidomide or proteasome inhibitors, the addition of anti-CD38 antibodies introduces new challenges, particularly regarding infection risk.

Brigle emphasized that monitoring for infection is “imperative” during the first months of combination therapy. This includes starting patients on proper antivirals and initiating intravenous immunoglobulin (IVIG) if IgG levels are low. He noted that since advanced practice providers may not see the patient as frequently as the bedside or clinic nurses, continuous communication between the team is vital for tracking potential side effects and implementing timely dose modifications.

Bridging the academic and community gap

A persistent challenge in MM care is the coordination between academic medical centers and community oncology clinics, especially regarding specialized therapies requiring Risk Evaluation and Mitigation Strategy (REMS) certification. Brigle identified the "sticking point" as the process of transitioning patients back to the community after they receive advanced therapies like bispecific antibodies.

VCU Massey often manages the high-risk first cycle of bispecific therapy — when the risk of CRS and ICANS is highest — before handing the patient back to their community provider. Brigle stressed that a successful handoff requires ensuring the community team is prepared to continue essential supportive care, such as immunoglobulin replacement, antivirals, antibacterials, and PJP prophylaxis.

Empowering patients and nurses

To help patients navigate the complexities of modern treatment, which often involve a mix of oral, subcutaneous, and intravenous medications, Brigle advocates for the use of paper calendars. “Education up front is a big, big thing — letting them know this is going to be complicated,” he explained. His team also conducts follow-up calls the day after a patient receives their first few doses to ensure they are adhering to home medications and understand their schedule.

As bispecific antibodies move into second-line and frontline clinical trials, Brigle encourages oncology nurses to take a leadership role in mastering these drugs. “Grasp it. It’s coming,” he urged.

By gaining experience with these unique side effects now, nurses can position themselves as experts in a field moving toward deeper responses and better long-term outcomes for patients with multiple myeloma.