APPs Focus on Education of Talquetamab Use and Administration in Multiple Myeloma

The expert panel

A recent Morning Rounds program focused on a patient case of a 63-year-old man who lived in a rural area and had limited treatment options. Donna Catamero, ANP-BC, OCN, CCRC, and her colleagues, who are all advanced practice providers (APPs), spoke about why talquetamab-tgvs (Talvey) would be the best option for this situation.

She was joined by Beth Faiman, PhD, CNP, and Tiffany Richards, PhD, ANP-BC, AOCNP, who offered their expertise on multiple myeloma, adverse effect (AE) management, and patient education. All panelists emphasized the importance of patient education and finding ways to create relationships and build rapport.

The patient case

Catamero / What are your thoughts on this patient? How do you typically approach treatment?

Faiman / This is a 63-year-old [man] who has some chronic kidney disease and [has] been through many different lines of treatment. When I’m considering the treatment options, I think about what worked [and didn’t work] before. What [caused their AEs]? What are their comorbid conditions in this scenario? We [look at previous treatments, and] he had an anti-CD38 monoclonal antibody, a proteasome inhibitor, and immunomodulatory drugs. He hasn’t had alkylating agents. With his chronic kidney disease, is he a candidate for a clinical trial? Many clinical trials will exclude him from participation because of stage IIIB [disease], you have to have an eGFR of between 30% and 44%. If you meet those parameters, very few of the clinical trials that are going on right now will include him.

If he has a clinical trial option, then that’s great if he’s willing to, but he also has some social and financial issues. He lives alone and is a widower, and his kids don’t live in the state. Looking at the picture of all that he’s going through [and] all that he’s been through—a novel approach, with or without a clinical trial—is super important. We’ll probably strategize later about how to get some social and caregiver support for him so he can partake in some of these newer therapies.

Richards / The APP is in a great position to help navigate all these complexities that you just spoke about. How does the patient navigate with barriers, whether it’s social or financial? The APP plays a key role in serving as that bridge. Not that our physician colleagues don’t think about that, but we’re a little more in tune. Patients disclose more to us because they trust us and are not as intimidated. For a patient to talk to a physician about how they may not be able to afford something can be difficult. Talking about financial toxicity is hard.

When we think about the social determinants of care, depending on where the patients live and their resources, APPs serve as that bridge. We also help patients find their voice. [Making sure their concerns are being heard is] something that sometimes patients have a hard time [with]…. APPs can play a role in that and help educate patients not only on their disease and treatment but also on what they can do to help manage their toxicity so they feel a little more in control of what’s going on with them and their disease. Beth, what types of patient education and resources do you provide to your patients?

Faiman / There are so many good patient education materials out there. There’s the International Myeloma Foundation, the Multiple Myeloma Research Foundation, and drug company websites. If the patient is interested in one of the newer drugs, [such as] a bispecific antibody or CAR [chimeric antigen receptor] T-cell therapy, we have lots of great handouts for those. For a long time, a lot of the institutions could not have branded materials [on disease websites]. The companies heard us, and they created materials that are nonbranded so the patients can access them. One of the other things I wanted to circle back on was the resources. We talked about the critical role of the APP being that ear and helping the patient find their voice, [but] we can also pull in our resource—
the social workers, nutritionists, pharmacists—there are just so many different resources.

If you’re at a smaller cancer center or in the community, you don’t feel like you have a lot of access to resources. Now with the virtual world, and since COVID-19, there have been a lot of Zoom-like telehealth and phone calls as a way to connect with patients and get them the resources. I would talk to the patient and say, “Your 3 children live out of state, but is there one you feel most comfortable with being your primary caregiver or primary point of contact? Or what if I can’t get a hold of you? What if you want somebody to have more information?” I just had a patient in my office yesterday, and her family lives all over the place. I said, “Why don’t you bring in your phone, and we’ll FaceTime them in the office.” It was a newer diagnosis, and we were discussing treatment options. That’s such a cool way to use technology. The patient feels so proud that they were able to make this happen. Those are the strategies that APPs can [use] to provide education [not only] for the patients but [also for] their caregivers—whether they’re formal or informal, here or not.

Patient case continued

Catamero / What we learned from COVID-19, especially with FaceTime and telehealth, is that geographical barriers may not be barriers anymore with this technology. We can connect [this patient’s] children to his care. APPs provide a great resource in referring our patients to other resources like nutrition, social work, and support groups. There are a lot of things we can refer our patients to do that we often have the bandwidth to provide.

Richards / This was a great plan. As he’s responding to therapy, his performance status [and renal function may] improve. If he decided that maybe he wanted to move closer to one of his children, and maybe there was a center where he could get CAR T-cell therapy, and he’s not had prior BCMA therapy, [other treatment options would become available]. Utilizing talquetamab at this point is a great idea, and it is a drug that he was able to receive at home. It only requires him to come to the center every 2 weeks. This was a great option for him. I liked that he was incorporated into that discussion.

CAR T is a great option for patients. But like you said, with limited resources and difficulty being able to stay closer, and now that he’s requiring full-time care, that makes it difficult. We see this with patients, especially if they’re coming from far away…. Bispecifics provided an option for patients, particularly those who may not be a good candidate for CAR T-cell therapy.

Faiman / I always try to discuss the different targets [with patients]. They might not get it, but I feel like I’m doing something by letting them know there’s the BCMA-directed targets and how the drugs work. This nice remission provides a good opportunity for him. The only other thing I would highlight is that he did have some toxicities and he’s able to hold his weight. We just learned from the phase 1/2 MonumenTAL-1 study [NCT03399799], and there was an updated [presentation] 2023 American Society of Hematology [ASH] about that.1 Dose reductions did not significantly affect the response. Those breaks in the treatment when patients had responded allowed them to get a better quality of life and fewer AEs.

Catamero / In our institution, the gold standard—or what you try to strive for—is getting that patient to CAR T. We have 2 BCMA products available for patients. Talquetamab is a great bridging therapy to get patients to CAR T. With this patient, prior to starting treatment, [we see] his performance status had suffered. With getting his disease under control, [I’m sure] his performance status is back to his baseline [by now]. If we can get into a CAR T-cell center and provide him with that social support, that would be great.

I also want to circle back to the ASH abstract…. A lot of nurses will come up to me and say that [oral toxicities] are the most challenging of the toxicities. In our institution, I find [that] the best way to manage these toxicities is with dose holds. We see that once we get a patient into a deep response and these are durable responses, I will hold a patient until they recover. And looking at the frequency, these are such durable responses that may be going into monthly dosing, so patients will improve. We’re still learning about [these drugs] and trying to understand what the appropriate dosing frequency for these drugs [is]. Managing some of these oral toxicities would behoove us to look at dose holds and frequency adjustments.

We’re always [wondering about] what’s next. And what’s next after that? We’re always trying to keep those options open for patients.

Richards / There are so many different options available for patients, even [those] who have relapsed/refractory disease. The future in myeloma is so bright, even the drugs that are in development. As we get more familiar with these drugs, we get to know how to sequence them better. And as time goes on, we’re going to have a wealth of information. For patients with myeloma, I can think about what it was like when I first started in myeloma [vs] now, and all the changes that have happened [are mind-blowing]. It’s just an exciting time in myeloma.

Faiman / We have so many drugs in development, and the drugs that we’re using today are like science fiction. We’re taking your T cells, manufacturing them as killers, and then reinfusing them with cellular therapy. These immune therapies have changed the trajectory of our patients; they’re living longer than ever, even those with the (del17p) or (Amp1q). These used to be a death sentence for our patients. Now we’re [often] seeing them live a normal life span if we’re sequencing correctly.

There are some unmet needs, though, in enhancing clinical trial participation for racial and ethnic disparities. We still need to do better in the United States with that, and we still need to find resources for those underserved people. I keep talking about telehealth, but there are people with flip phones out there, so maybe we meet them and then call them on the phone instead of the virtual world.

Catamero / I remember when I first came into this field, I was recycling the same drug over and over again. We are so fortunate to have a toolbox of options we can offer our patients. These past 1.5 years have been quite amazing for our patients because with a single-agent drug, we can achieve a very deep and durable response in our patients, and they’re living a quality of life that I couldn’t offer them just 8 years ago. I’m excited to be working with patients with myeloma, and I’m excited for the future. I believe we’ll see cures [in my lifetime].

Reference

1. Jakubowiak AJ, Anguille S, Karlin L, et al. Updated results of talquetamab, a GPRC5D×CD3 bispecific antibody, in patients with relapsed/refractory multiple myeloma with prior exposure to T-cell redirecting therapies: results of the phase 1/2 MonumenTAL-1 study. Blood. 2023;142(suppl 1):3377. doi:10.1182/blood-2023-187242