Expanding Role of Bortezomib in Multiple Myeloma: Nursing Implications

Kathleen Colson, RN, BSN, BS; Deborah S. Doss, RN, OCN; Regina Swift, RN, BSN; Joseph Tariman, RN, APN, MN, BC, OCN

Disclosures

Cancer Nurs. 2008;31(3):239-249. 

In This Article

Abstract and Introduction

Multiple myeloma is the second most common hematologic malignancy and remains incurable, despite advances in chemotherapy and stem cell transplantation. Bortezomib, a novel proteasome inhibitor, is approved for the treatment of patients with multiple myeloma who have received at least 1 prior therapy. In the assessment of proteasome inhibition for extending remissions phase III trial of bortezomib versus high-dose dexamethasone, bortezomib led to significantly longer survival and time to progression and higher response rate in patients with relapsed multiple myeloma. The principal adverse events were gastrointestinal effects, fatigue, transient thrombocytopenia, and reversible peripheral neuropathy. The side effect profile of bortezomib is extensively characterized, predictable, and generally manageable; retreatment or extended bortezomib therapy seems well tolerated. Nurses play a unique role in bortezomib treatment: they are often closest to the patients and are most able to educate patients about side effects and, if necessary, take appropriate action, independently or collaboratively with healthcare team members. In this review, we present the latest efficacy and safety data for bortezomib in relapsed multiple myeloma and characterize common side effects associated with bortezomib and the implications for nursing. We also highlight practical strategies for preventing and managing side effects, thereby enhancing the clinical benefit of bortezomib-based therapies to patients.

Multiple myeloma (MM), a cancer of the plasma cells, is the second most common hematologic malignancy: approximately 19,900 new cases and 10,790 deaths are estimated for the United States alone in 2007.[1] Approximately two-thirds of patients are 65 years or older at diagnosis.[2] The most common symptoms at presentation are bone pain, fatigue, and recurrent infections.[3] Bone fractures are also very common.[4] In addition, up to 50% of patients have renal dysfunction and reduced creatinine clearance.[5] Despite advances in chemotherapy and stem cell transplantation, which have improved survival rates, MM remains incurable.[3] Treatment options may be limited in patients with renal dysfunction or failure and in high-risk and elderly patients.

Recently, there has been a shift toward targeted therapies, such as the proteasome inhibitor bortezomib (VELCADE, Millennium Pharmaceuticals, Inc, and Johnson & Johnson Pharmaceuticals, Research and Development, L.L.C.). In MM, cancer cells depend on proteasomes, which degrade proteins, for their proliferation, metastasis, and survival. Bortezomib inhibits the proteasome, thereby preventing the degradation of intracellular proteins and affecting multiple signaling cascades in cancer cells, and ultimately leading to programmed cancer cell death (Figure 1).[6]

Effect of proteasome inhibition on myeloma cells and the bone marrow microenvironment. βFGF, β-fibroblast growth factor; IGF-1, insulin-like growth factor; IL-6, interleukin-6; NF-κB, nuclear factor κB; TNF-α, tumor necrosis factor-α; VEGF, vascular endothelial growth factor.

At the time of our previous review on the implications for bortezomib in oncology nursing,[7] bortezomib was approved in the third-line setting or later. Bortezomib has since received full approval for the treatment of MM patients who have received at least 1 prior therapy, based on the results of a phase III trial assessment of proteasome inhibition for extending remissions (APEX) in which bortezomib provided a significant survival benefit over high-dose dexamethasone.[8] To date, more than 55,000 MM patients have been treated with bortezomib. This review describes the techniques and strategies developed from this broad clinical experience that are important in optimizing the care of MM patients receiving bortezomib.

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