What are the essential considerations in a survivorship plan for multiple myeloma?

FAQ Library published on August 26, 2015
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Philip L. McCarthy, MD
Professor of Oncology
Director, Blood and Marrow Transplant Program
Roswell Park Cancer Institute
Buffalo, New York
Welcome to Managing Myeloma. My name is Philip McCarthy. I am a professor of medicine at Roswell Park Cancer Institute in Buffalo, New York, and I am frequently asked, “What are the essential considerations in a survivorship plan for multiple myeloma?” Well, after primary treatment and if the patient is on maintenance, I think many patients should be monitored at least every 3 months by urine and serum to make sure that they do not have disease progression. There are very rare cases where patients can be monitored every 6 months if beyond 5 to 10 years from the last therapy, but in particular if you have patients who are on IMiDs, they need to have a CBC done at least monthly to make sure they are not having trouble with their blood counts as they can be relatively asymptomatic and yet be fairly neutropenic. DEXA scans or bone density scans are often done after bisphosphonates are stopped to look for early osteoporosis, and in particular you want to make sure that these patients are also sent to their dentist to make sure that they have adequate teeth hygiene and also to make sure they do not develop osteonecrosis of the jaw (ONJ). Immunizations are a real big deal for a lot of patients with myeloma because of the fact that this is an immunoglobulin disease. We will have loss of titers against a variety of different pathogens so we think after primary therapy, immunizations are very important especially after transplant. If the patient is on an IMiD, they often can be immunized. It actually enhances the effect of the vaccine. There is controversy as to what to do with live vaccine such as MMR and in particular the zoster vaccine. Note: currently, live herpes zoster vaccine is considered contraindicated in multiple myeloma patients. There is not a lot of data on this, but it is at least something to consider because if you have a patient who has no titer to varicella, they are going to be at very high-risk for developing shingles. The patient should stay on acyclovir prophylaxis since the patient will likely not be able to be vaccinated. If they are receiving bortezomib, the patient also should be on acyclovir because bortezomib interferes with immunoglobulin production in particular to varicella. So we are going to need more data regarding this, but we hope to see it in the future. This is an important point. We do know for example that Zostavax can be given after autotransplant at least 2 years afterwards and hopefully we are going to see that looked at so that we can better protect our patients. Of course for patients who are receiving IMiDs, venous thromboembolism prophylaxis or DVT prophylaxis is very important because these patients are at risk for developing thromboembolic events. Thank you very much for reviewing this activity. For additional resources, please view the other educational activities on ManagingMyeloma.com.

Reviewed on January 17, 2017 for clinical relevance.

Last modified: February 8, 2017
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