The coronavirus disease-19 (COVID-19) pandemic hit healthcare hard, but with the longest lockdown in Australia, the state of Victoria was particularly affected. In order to learn from this experience, we sat down with Professor Simon Harrison, Director of the Centre of Excellence in Cellular Immunotherapy and Chair of the Medical and Scientific Advisory Group to Myeloma Australia and Hayley Beer, a myeloma clinical nurse consultant at the Peter MacCallum Cancer Centre in Victoria and manager of programs and services at Myeloma Australia to discuss how their approach to multiple myeloma management changed throughout the lockdown.

Both Professor Harrison and Ms Beer acknowledged that the lockdown forced healthcare professionals to reconsider the risk vs benefit analysis of patients receiving healthcare outside of the hospital setting. In terms of patient care, the uptake of telehealth and the ability to deliver and administer medications within the community are some of the positives that have come out of these difficult times. In patients living with multiple myeloma who have secondary  immunodeficiency in particular, being able to continue therapy and maintain supportive care measures such as their immunoglobulin therapy, is essential to maintaining control of their disease and mitigating risks of infection. Enabling patients to continue their treatment at home was a key goal in this group.

The rise of telehealth

Before the COVID-19 pandemic telehealth was a scarcely used commodity. Prof. Harrison explained that “when it came to managing patients with a condition like multiple myeloma, the lockdowns forced a swift change in the culture and perception of face-to-face reviews and their necessity. For example, with patients who were stable on treatment and with whom you already had an established rapport, telehealth became a way to check-in on them as well as a way to minimise their visits to hospital.”

Reducing the number of hospital visits potentially reduces the stress levels of patients in more ways than one. As Ms Beer noted, “hospital visits are one of the most stressful things for patients – but not necessarily for the reasons you might think. One of the biggest things is actually trying to find a carpark!” Reducing hospital visits also saves time – something that a patient with a terminal diagnosis may appreciate. Of course, there will be the occasional patient who might avoid a telehealth appointment, but on the whole the experience seems to have been positive.

People who are diagnosed with cancer or other incurable diseases tend to have a different perspective of time.  As Ms Beer explained, “waiting an hour in a hospital waiting room for an injection that takes 30 seconds may be perceived differently by someone who is counting their every moment.” Which brings us to the next major change in treatment of multiple myeloma to come out of the lockdowns: delivery and administration of medications.

Home delivery for the win

“As soon as the pandemic hit, the Peter MacCallum Cancer Centre ramped up its home delivery programs,” explained Ms Beer. Where possible, medications were delivered to the patient’s door – bortezomib and other self-administered therapies were switched to home delivery. “We had already completed a pilot self-administration project for bortezomib so with that experience, when the pandemic hit, we were able to quickly expand the program to include more people,” Ms Beer commented, “of course there were initial concerns that some patients would have difficulty with the process, but that wasn’t the case. For our patients at Peter Mac, the pandemic expedited the development of its existing home delivery system to allow it to become more flexible in its care of patients, which meant we could keep many of our patients at home.”

“For some of the self-administered therapies,” explained Ms Beer, “being able to have their treatment at home or being given by the general practitioner (GP) saved patients up to 3 out of 4 trips per treatment cycle to the hospital for their treatment. Even for intravenous (IV) immunoglobulin (IVIg), there was the flexibility to get patients onto subcutaneous injections at home rather than starting on the in-hospital, intravenous administration. For patients who had previously been reluctant to or deterred from the idea of self-administration, particularly of injections, the lockdowns provided them with the drive to give it a go.” Ms Beer recalled several patients who were reluctant to self-administer injections before the pandemic who found a fresh perspective through the pandemic. “They surprised themselves [and us]  how well they could do it in hindsight.”

To help get patients used to the idea of self-administration of subcutaneous immunoglobulin injections, start with a conversation. Assess how they feel about self-injecting, what their concerns may be and what the expectation is. Be clear on how simple it can be but open to hearing their thoughts. Once they agree to trial it you can either teach them how to self-administer SCIg yourself or your medical staff can take over and help them learn. Ensure the patient feels comfortable and knows how to contact someone for support or assistance when or if they need it.

Professor Harrison emphasised that “what this shift in healthcare practices during the pandemic has shown us is that at home or self-administration is a treatment option for the majority of patients. Before the pandemic there was an assumption by doctors, nurses and pharmacists that this was only an option for a limited number of confident patients. Now we know it’s actually the reverse – there’s only a few patients who really and truly might not be suitable for it.” Patients with a support person or carer or an engaged GP can really benefit from this style of treatment.

The environment of 2020 forced the hands of healthcare professionals to shift how they approached patient management. They had to quickly change their perspective on how flexible they could be and still maintain the appropriate level of care. These lessons will hopefully be carried on into the future of medical practice in Australia.

Reference:

1. Rasmussen DM and Elverdam B, J Adv Nurs 2007;57(6):614–22.