Kathleen Colson, RN, BSN, BS, from the Jerome Lipper Multiple Myeloma Center at Dana-Farber Cancer Institute
Kathleen Colson, RN, BSN, BS, from the Jerome Lipper Multiple Myeloma Center at Dana-Farber Cancer Institute, talks about techniques for managing myelosuppression in patients taking multiple myeloma therapies.
Hello, I’m Kathleen Colson, and welcome to the Multiple Myeloma Center for Nurses video: Managing Myelosuppression in Patients Taking Multiple Myeloma Therapies. In this video, we will address the symptoms and management of myelosuppression.
Many anti-myeloma agents can cause myelosuppression.1 It is a condition in which bone marrow activity is decreased, resulting in fewer red and white blood cells and platelets.2 Consequences include anemia, leukopenia, specifically, neutropenia, and thrombocytopenia.1,3 Let us examine each in turn, including assessment tools, symptoms, and consequences to the patient.
The severity of anemia can be quantified using the National Cancer Institute’s Common Terminology Criteria for Adverse Events, or CTCAE, grading system.4 This is a 5-grade scale, where grade 1 is mild, grade 2 is moderate, grade 3 is severe, grade 4 is life-threatening or disabling, and grade 5 is death related to the adverse event.4 This grading system, along with nurse assessments, can help healthcare professionals to determine which medical and nursing management strategies to employ and how to deal with adverse event reporting.5
General guidelines for the management of anemia should take into account that different patients have different degrees of tolerability, and that its assessment is a multi-dimensional evaluation.5 The Nurse Leadership Board developed a consensus statement for the management of myelosuppression.5 You must assess both the results of a complete blood count, or CBC, and the symptoms that affect your patient’s quality of life.5 The Nurse Leadership Board consensus statement includes the National Cancer Institute’s toxicity grading system along with nursing management strategies for expected side effects of antimyeloma therapies.1,5
While the decision to transfuse will be made by your patient’s healthcare professional, you play a vital role in determining whether a need for transfusion exists.5 In addition to findings from a CBC, consider interviewing the patient using a tool that asks about symptoms that impact his or her quality of life, for example fatigue.5 Also, consider explaining the signs and symptoms of anemia and the need for a transfusion to the patient.5 The Brief Fatigue Inventory is a tool that can help assess a patient’s fatigue.5 In addition, asking about performance status, shortness of breath, and chest pain on exertion can help determine the need for transfusion.5
Patients with neutropenia are at risk of infection.1 Low neutrophil count and absence of cytokine activity may mask classic symptoms of infection.7 Fever may be the only sign of an active infection.1,7 Assess your patients for fever and associated symptoms such as chills, myalgia, malaise, nausea, hypotension, and hypoxia.5 It is also important to assess your patients for the history of infections and conduct a physical exam focusing on other signs from all systems including respiratory, urinary, and gastrointestinal.1,5 Your assessment is crucial to reduce the risk of febrile episodes.5 Handwashing by patients, caregivers, and healthcare professionals is the single most important precaution for preventing infection.1,7 Therefore, handwashing reminders are critical.
Patients with multiple myeloma are susceptible to infections and institutional precautions and standards should be initiated.1,5 When your patient is at risk for neutropenia, or becomes neutropenic, notify the patient’s healthcare professional of the need for medical intervention.5 If a patient with neutropenia is found to be febrile, it is considered an emergency situation because the patient can progress quickly to septic shock; prompt intervention in the event of a febrile episode is paramount.5,8 Administer prescribed antibiotics after blood cultures have been obtained, and within 1 hour of presentation.1,5 If IV hydration and antipyretics have been prescribed, they should be administered in a timely manner.1,5 Nurses have a responsibility to coordinate care delivery to ensure timely evaluation and treatment.7
When platelet count drops to levels less than 100,000, patients are classified as thrombocytopenic and are at risk of serious bleeding, even from minor scrapes, cuts, or bruises.5,9 In addition to reviewing the patient’s CBCs, your nursing assessment should include evaluations of a patient’s mucosal or gastrointestinal bleeding, increased bruising, or difficulty stopping bleeding.1,5 Physical examinations should note any bleeding in the mucous membranes or sclerae.5 Additionally, skin should be checked for petechiae, large or multiple bruises, or any oozing from a venous catheter site.1 Include a neurologic symptom assessment to check for intracranial bleeding.5
It is generally accepted that healthcare professionals will try to minimize invasive procedures in patients with thrombocytopenia; however if that is not possible, they should transfuse platelets prior to invasive procedures, or if bleeding is present.1,10
In addition to managing thrombocytopenia, healthcare professionals may want to educate patients and their caregivers about the basic concepts of myelosuppression.5 Education should occur prior to patients becoming myelosuppressed and should be reinforced frequently.5
This concludes the Managing Myelosuppression in Patients Taking Multiple Myeloma Therapies video. To find out more on this and other topics related to multiple myeloma, please visit www.MMCenterforNurses.com. There you will also find a number of educational tools to help you discuss these topics with your patients, answers to common questions, and other downloadable materials.
Thank you.
References
1. Brigle K, Pierre A, Finley-Oilver E, et al. Myelosuppression, bone disease and acute renal failure, evidence-based recommendations for oncologic emergencies. Clin J Oncol Nurs. 2017;21(Suppl 5):60-76.
2. National Cancer Institute. NCI dictionary of cancer terms: myelosuppression. http://www.cancer.gov/dictionaries/cancer-terms/def/myelosuppression. Accessed June 10, 2019.
3. Durie BGM. Patient Handbook: Multiple Myeloma: Cancer of the Bone Marrow. 2012/2013 ed. North Hollywood, CA: International Myeloma Foundation; 2012.
4. National Cancer Institute. Common Terminology Criteria for Adverse Events (v4.03). US Department of Health and Human Services, National Institutes of Health; June 14, 2010. NIH Publication no. 09-5410.
5. Miceli T, Colson K, Gavino M, Lilleby K; IMF Nurse Leadership Board. Myelosuppression associated with novel therapies in patients with multiple myeloma: consensus statement of the IMF Nurse Leadership Board. Clin J Oncol Nurs. 2008;12(3 suppl):13-20.
6. National Cancer Institute. Common Terminology Criteria for Adverse Events (v5.0). US Department of Health and Human Services, National Institutes of Health; Nov 27, 2017. Available at: https://ctep.cancer.gov/protocolDevelopment/electronic_applications/docs/CTCAE_v5_QuickReference_8.5x11.pdf. Accessed June 10, 2019.
7. West F, Mitchell SA. Evidence-based guidelines for the management of neutropenia following outpatient hematopoietic stem cell transplantation. Clin J Oncol Nurs. 2004;8(6):601-613.
8. Burney KY. Tips for timely management of febrile neutropenia [letter]. Oncol Nurs Forum. 2000;27(4):617-618.
9. American Cancer Society. What Is Multiple Myeloma? https://www.cancer.org/cancer/multiple-myeloma/about/what-is-multiple-myeloma.html. Accessed June 3, 2019.
10. Schiffer CA, Bohlke K, Delaney M, et al. Platelet transfusion for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2017;36:283-299.
