Personalizing Neurotoxicity Monitoring After CAR T-Cell Therapy

Asking patients questions about their usual daily activities can help nurses and APPs better assess if a patient has developed neurotoxicities.

For patients with multiple myeloma receiving CAR T-cell therapy, monitoring for neurotoxicities is essential in ensuring that patients can continue treatment long term. Gauging patients’ regular activities is key in personalizing that monitoring, according to Mary Steinbach, DNP, APRN.

Following a Community Case Forum with Oncology Nursing News on the use of CAR T-cell therapies in relapsed/refractory multiple myeloma, a nurse practitioner at the Huntsman Cancer Institute at the University of Utah in Salt Lake City, Utah, shared that she checks in with patients periodically, even once they are in the care of their community clinic. In these well visits, Steinbach assesses patients for late-onset neurotoxicities by inquiring whether daily activities have been affected.

Additionally, she recommends that nurses and advanced practice providers (APPs) be proactive in educating patients on what to look for and how to report signs of neurotoxicities.

Oncology Nursing News: How do you ensure that patients living alone stay ahead of neurotoxicities?

Steinbach: The late neurotoxicity is the window during which patients might be alone most of the time and experience that. I don’t know that there is a way to ensure it is reported, but in most of those situations, the onset is a little slower, so if a patient is still being seen at least once a month or once every couple of months, hopefully it’s captured. If a patient is not going to report how they’re feeling or symptom changes, there’s no way to improve upon that once they’re in an outpatient setting past a certain time point, other than educating them to do it. The risk for those who don’t have support is the fact that then they might not have access to the therapy in the first place.

What education can help patients report symptoms of neurotoxicities early on?

I work at an academic center, and our practice is to still see these people every few months, even if they’re back home in their communities. When we can do that virtually, we do. During all those well follow-up visits where you look at labs and markers, but the patients are probably thriving and doing very well, the patient still gets the reminder that they are still in this window.

After like 1 year, if the person has received cilta-cel, they probably feel a lot better that they’re out of any risk window. But from day 90 to 1 year, it’s still something that we bring up every visit. Constantly reinforce that education and provide that education with community practices where these patients may get seen more frequently or seen in person more frequently.

How do you assess a patient’s risk for late-onset neurotoxicities?

It’s all part of a review of systems questioning, which should be standard for everyone. You don’t need to do a very detailed neurology exam to discover late-onset neurotoxicity. I ask people about what their activity level is. How are they walking? Have they noticed a shuffled gate? Are they tripping over their feet? Do they [feel] they are thinking clearly?

We try to determine what their activity is. Are they a reader? Do they do the crossword puzzle? What do they do? I always ask if they’re still able to participate in [their regular tasks]. For a patient who plays tennis or is a golfer, I say, “Are you able to do that on a daily basis, or however often you want to? Do you have any limitations in the things you want to do?” This questioning for symptoms isn’t super specialized, but it is what we all should be doing in practice anyway in a good review of systems. [Sometimes we need] the reminder to do it.

This transcript has been edited for clarity and conciseness.