Spotlight from JADPRO Live 2023

New Drug Updates in Hematologic Malignancies & Patient Perspectives on Returning to Cancer Care in a PostCOVID Environment

Ann McNeill, RN, NP, MSN, APN, of the John Theurer Cancer Center at Hackensack University Medical Center, discusses the advancements in ADC, BTKi, and bispecific antibodies drugs for R/R MM, lymphoma and AML. She also reviews the challenges faced by patients with cancer during the COVID-19 pandemic. Insights from these patients can help advanced practitioners better understand the hurdles to accessing cancer care in the post-pandemic healthcare environment in which inequalities and vulnerabilities remain (Abstract JL1112P).


Ann McNeill:

I just came from a presentation entitled “New Drug Updates in Hematologic Malignancies,” and this was a very impressive lecture talking about the recent advancements in drugs for relapsed/refractory multiple myeloma, for lymphoma, and also AML that led to FDA approvals of agents that really have improved outcomes for these patients. Some of the new drugs included antibody drug conjugates, BTK inhibitors, and the T-cell engaging by specific antibodies as well as other targeted agents. Again, these medications have really improved outcomes in our patients, improved overall response rates in a very challenging patient population. I'd like to focus on myeloma first and talk about teclistamab, which is a bispecific antibody. It is a CD3 and BCMA bispecific antibody, which means it brings in that immune effector cell on…the CD3 on the T-cell, the immune effector cell, in close proximity to the tumor cell, which is the BCMA on the myeloma cell.

By bringing them into close proximity, we have the release of pro-inflammatory cytokines, which eventually leads to tumor lysis, and that's the goal is to kill the malignant tumor cells. Bispecific antibodies are also approved in leukemia and lymphoma. Teclistamab has been the one that's been around in myeloma for the longest time. It was approved about a year ago, in October of 2022. The newest agents have been approved in the summer of 2023, elranatamab and talquetamab. Elranatamab is also a CD3 BCMA bispecific antibody. Talquetamab is a little bit different. It also brings in the immune effector cell, the CD3 T-cell, but it targets the GPRC5D on the myeloma cell, which is a different target. I think it's really important, and the lecture brought this out, that these are a very unique class of medications that can cause side effects that we're not too familiar with in frontline therapy for these blood cancers.

We don't really see CRS or ICANS in induction therapy for myeloma, or even in first-line for lymphoma and leukemia either. So it's a very important education piece for nurses, for patients, for caregivers. CRS is a potentially life-threatening toxicity of these agents, I want to say the immune system goes into overdrive. So you have a very profound immune system reaction, based on the mechanism of action of these drugs. So I think we need to focus on how to identify this syndrome, how to manage it, and to tell patients what to report and why. ICANS is another side effect that is very serious. It's the immune effector cell associated neurotoxicity. So again, educating our nurses and our patients and caregivers about what to potentially expect when they get this new class of agents is critical. In the area of lymphoma, specifically DLBCL, we have epcoritamab, which is also a bispecific antibody targeting CD3 and CD20.

So what I want to point out is not just the new different side effects like CRS and ICANS, but we also have to be mindful that many of these drugs require inpatient dosing for the ramp up dosing for these drugs. So it requires a hospitalization for a part or all of the ramp-up dosing for these patients. So again, new education for nurses, inpatient dosing, CRS and ICANS. Also, the increased risk of infection is something we have to be very mindful of. Patients need to be on prophylactic antimicrobials. We may need to use IVIG, but again, the risk of infection. Anytime you take an immune effector cell and retarget it or redirect it, the risk of infection is higher.

During the conference, I was happy to see a poster that I was interested in, “Patient Perspectives on Returning to Cancer Care in a Post-COVID Environment.” Nice summary of whether patients felt comfortable or not going back to the cancer center and seeking care for their cancer. So fortunately, only 8% did not seek care for their cancer in the past 12 months, and we're thinking in this post-COVID environment, that's fairly good. I think that cost, as in this poster cost, was the primary reason that people did not go back to get their cancer care, 57%. Unfortunately, there's a big racial disparity, and I think for nurses and APPs, I think it's important to remember that we have to use all our resources to help get patients' financial assistance to help them get their appropriate cancer care.