Moving goal posts: a case of community management of multiple myeloma during COVID-19

Tuesday, 13 Jul 2021


In a previous issue we sat down with Professor Simon Harrison and Ms Hayley Beer of the Peter MacCallum Cancer Centre in Victoria to discuss how the coronavirus disease-19 (COVID-19) pandemic and lockdowns impacted how they treat patients living with multiple myeloma. In this issue Professor Harrison, who is the Director of the Centre of Excellence in Cellular Immunotherapy at Peter Mac. and Chair of the Medical and Scientific Advisory Group to Myeloma Australia , and Ms Hayley Beer, a myeloma clinical nurse consultant from Peter Mac., and Manager of Programs and Services at Myeloma Australia present a case study that showcases how the pandemic moved the goal posts for self-administration of treatment in a patient with multiple myeloma.  

Whilst an undoubtably difficult time for all healthcare professionals, the 2020 COVID-19 lockdowns in Victoria did bring a few positives. “At the Peter MacCallum Cancer Centre in Victoria we already had home delivery and administration programs for medications. We boosted these as well as turning to telehealth options to reduce the need for patients to visit the hospital as often as before the pandemic,” explained Ms Beer.

 Multiple myeloma in lockdown

“Multiple myeloma is an incurable disease whose treatment has rapidly evolved. There are now more options and changes in how previous treatments were utilised which led to a shift away from the ‘treat and wait’ approach to an ‘always on’ treatment approach. This evolution poses a challenge for keeping patients engaged in ongoing treatment. On the surface, this appeared to be even harder during the COVID-19 lockdowns, however, in practice it was not as hard a task as we first thought. The unique situation of the COVID-19 pandemic led us to take a test and learn approach,” said Ms Beer. Here’s how that worked out for one patient.

Meet our patient – a case co-presented by Ms Beer and Prof. Harrison

The subject of this case study was an 80 year old man living with multiple myeloma. As a retired electrician from the Royal Airforce, he was living independently in a retirement village. “I’d say he was one of those very engaged patients – a sharer,” explained Ms Beer. “You know the type – calls you up about even the small details – which is great, because you know if he’s not sure he’ll ask.” He also had a good community support network. His local general practitioner (GP) was great – very in tune with multiple myeloma and able to provide the supportive care this patient needed. While at first he wasn’t particularly keen about self-injecting, he was comfortable in having his GP do the administration.

Before the pandemic hit, this patient was initiated on bortezomib, cyclophosphamide and dexamethasone (VCD) as weekly treatments for 7 cycles, followed by 13 cycles of fortnightly treatment. With this he was able to achieve a complete response (CR) and his GP administered the bortezomib, though his treatment was ongoing when the pandemic hit and the lockdowns began.

This patient experienced bouts of immunosuppressive infections. Starting with pneumonia and presenting with other infections over several months. He was initiated on intravenous immunoglobulin (IVIg), which he had to come into hospital to receive monthly, spending a full day at the hospital at each visit. He also had to increase his visits to his GP, and after some time started to question the need for so many visits after he was back to feeling well again and had quite a clear picture of life before and after in-hospital treatment.

Then COVID-19 hit and while he had initially been opposed to self-administration of treatment, the landscape had changed and our patient was open to revisiting the best way to receive ongoing care. In order to give him a sense of control back and to limit his exposure to the hospital and GP environments, we thought he would be a good candidate for home delivery and self-administration of his medication.

We raised the idea of home delivery, self-administration and telehealth for follow-up appointments. Initially the patient was unsure, his first impression was that he “would never be able to do it.” So we walked through the process, any preconceptions we both had and discussed what was possible for his situation.

As well as the bortezomib, the patient learnt how to self-inject subcutaneous immunoglobulin instead of having to undergo infusion of intravenous immunoglobulin in hospital, gaining confidence in his abilities. This allowed him to continue to minimise his hospital visits even after the lockdowns ended. His follow-up appointments and regular reviews are conducted via telehealth services where possible. In addition, he was able to administer treatment himself when he developed pneumonia, so this experience has changed the way we treat and monitor this patient both during the pandemic and into his future.

Take home messages

While this case study showcases a relatively straight-forward case of multiple myeloma, it perfectly showcases how a patient can be encouraged and their confidence built to try self-administration. This allows them to spend quality time in their community, rather than in the hospital.

As we saw in this case, an engaged and supportive GP is an extremely valuable asset for transitioning patients to more at-home care over in-hospital care. Of course the most valuable asset here is an engaged patient – though as we saw even reluctant patients can be brought around if they have the right support and education.

The benefits of being comfortable self-administering a treatment like subcutaneous immunoglobulin cannot be overstated. As we saw with this immunocompromised patient, even following the lockdowns he was able to continue to administer this treatment at home, meaning less exposure to potential infections both during the pandemic and beyond.

Read the original feature article, available here.

 

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