Donna D. Catamero
ANP-BC, OCN®, CCRC
Associate Director
Multiple Translational Research
Mount Sinai School of Medicine
New York, New York
Abbey Reiser MS, RD, CDN, CSO
Clinical Nutrition Coordinator
Ruttenberg Treatment Center of Tisch Cancer Institute
The Mount Sinai Hospital
I. T-Cell Redirecting Immune
II. The Importance of Nutrition
III. Integrating Nutrition with Treatment
IV. Questions
Donna D. Catamero, ANP-BC, OCN®, CCRC
Direct T-cells to identify specific surface antigens on myeloma cells and stimulate a polyclonal T-cell response
BCMA (B-Cell Maturation Antigen)
• Ide-cel available for patients after 2 prior lines of therapy
• Cilta-cel is available for patients after 1 prior line of therapy and who are no longer responding to lenalidomide
• BCMA plays a role in survival of long-lived plasma cells
• BCMA is expressed more abundantly on malignant plasma cells (Myeloma cells) than on normal ones
• Cytokine-release syndrome
• Immune effector cell–associated neurotoxicity syndrome
• Cytopenias (low blood counts)
• Hemophagocytic lymphohistiocytosis/ macrophage activation syndrome
• B-cell aplasia/hypogammaglobulinemia
• Prolonged cytopenias
• Late infections
• Long-term neurologic events/ movement and neurocognitive treatment-emergent AEs
• Transient cardiac toxicities
Elranatamabbcmm SC August 2023 GPRC5D Talquetamab-tgvs SC August 2023 Target on MM cells Target on Myeloma Cells Bispecific Antibody in Development
BCMA Teclistamab-cqyv SC October 2022
ABBV-383 (TNB-383B) Linvoseltamab
GPRC5D Forimtamig (RG6234) FcRH5 Cevostamab
BCMA = B-cell maturation antigen; FcRH5 = Fc receptor-homolog 5; IV = intravenous; FDA = US Food and Drug Administration; GPRC5D = G-protein coupled receptor family C group 5 member D; MM = multiple myeloma; SC = subcutaneous.
O’Neill C, van de Donk NWCJ. EJHaem. 2023;4(3):811-822.Cho S-F, et al. Front Oncol. 2022;12:1032775. TECVAYLI® (teclistamab-cqyv) Prescribing Information. ELREXFIOTM (elranatamab-bcmm) Prescribing Information. TALVEY (talquetamab-tgvs) Prescribing Information.
Similar to CAR T, CRS and neurotoxicity management important for all bispecific antibodies
• More likely during step-up and early doses; unlikely later
Step-up dosing and premedication to mitigate CRS and is specific to each bispecific antibody
• May need to repeat step-up dosing after a dose delay Particular side effects tend to be related to target
• BCMA – infections
• GPRC5D – skin, nail, oral side effects
● Explain the role of nutrition in supporting myeloma treatment
● Review dietary recommendations during treatment
● Help you manage side effects of novel therapies through nutrition and OTC medications/products
● Maintain energy, strength, and weight
● Boost the immune system
● Reduce inflammation
● Fight infection
● Better tolerate treatment-related side effects
American Cancer Society. Accessed October 6th, 2024. https://www.cancer.org/cancer/survivorship/coping/nutrition/benefits.html.
● If not experiencing any symptoms or side effects;
- Follow recommendations for cancer prevention and survivorship
● If experiencing symptoms or side effects;
- Discuss nutrition recommendations for symptom management with your dietitian
● Follow food safety guidelines
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
AICR Guidelines:
● Maintain healthy body weight
● Eat a diet rich in whole grains, vegetables, fruits, and legumes
● Choose lean animal-based and plant-based proteins
○ Limit intake of red meat to <18 oz/week
○ Avoid processed meats
● Choose low-fat and non-fat dairy products
● Limit intake of processed foods that are high in fat, starches, and sugars
● Limit intake of sugar-sweetened drinks
● Avoid or limit alcohol
● Be physically active: 30 minutes of moderate to vigorous activity, ≥5 days/week
● Do not use supplements for cancer prevention
1. American Institute for Cancer Research. Accessed August 24, 2024. https://healthy10challenge.org/cancer-prevention/.
2. American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-prevention/healthy-eating/supplements-nutrients/
Parikh, Richa, et al. “Pre-diagnosis dietary patterns and risk of multiple myeloma in the NIH-AARP cohort.” Journal of Clinical Oncology, vol. 41, no. 16_suppl, 31 May 2023, https://doi.org/10.1200/jco.2023.41.16_suppl.10635. Rose S, Strombom A. Multiple Myeloma – Prevention
● Fill ⅔ (or more) of your plate with plant-based foods
● Fill ⅓ (or less) of your plate with animal protein
How can I eat when I don’t feel well?
● Dysphagia
● Dry mouth
● Mucositis and Thrush
● Taste changes
● Often lead to decreased appetite and weight loss
● Consume small, frequent meals
● Choose blended, soft, moist foods
● Try smoothies, shakes, oral nutrition supplements
● Avoid hard, tough, stringy, or dry foods
● Take small bites and chew well
● Take sips of beverage with food
● Eat upright
Catamero, D., Ray, C., Purcell, K., Leahey, S., Esler, E., Rogers, S., ... & Shenoy, S. (2024, August). Nursing Considerations for the Clinical Management of Adverse Events Associated with Talquetamab in Patients with Relapsed or Refractory Multiple Myeloma. In6.5
● Try OTC dry mouth rinses, sprays, lozenges
● Rinse your mouth before and after meals with plain water or a mild mouth rinse
- Homemade mouth rinse: ¾ tsp salt + 1 tsp baking soda + 1 qt water
- Alcohol-free mouthwashes
- Floss regularly
● Chew sugar-free gum or suck on sugarless candy to stimulate saliva
- Try citrus-flavored candies such as lemon drops
● Choose soft foods that are room temperature or cold
● Add broth, soup, sauces, gravy, oils, or butter to moisten foods
● Drink 8 to 10 cups of fluids daily
● Limit alcohol and caffeinated beverages
Academy of Nutrition and Dietetics. Accessed October 6th, 2024. https://www.med.upenn.edu/lung2022/assets/user-content/documents/drymouthorthicksaliva.pdf
● Early initiation of nystatin swish and spit (swallow if pharyngitis)
● Good oral hygiene and fluid intake
- Drink liquids with a straw
● Eat soft, moist, bland foods that are easy to swallow
● Eat chilled foods and fluids
● Avoid hard, dry or crunchy foods
● Avoid very salty, spicy, acidic or sugary foods and alcohol
1. American Cancer Society. Accessed October 6th, 2024. https://www.cancer.org/cancer/survivorship/coping/nutrition/benefits.html
2. Catamero, D., Ray, C., Purcell, K., Leahey, S., Esler, E., Rogers, S., ... & Shenoy, S. (2024, August). Nursing Considerations for the Clinical Management of Adverse Events Associated with Talquetamab in Patients with Relapsed or Refractory Multiple Myeloma. In6.5
● Good Oral Hygiene:
- Rinse mouth with a baking soda and salt solution throughout the day
- Alcohol -free mouthwash
- Brush teeth & tongue after meals and before bed
- Xylitol -containing gums
● OTC products:
- Miracle Berry
- MetaQil
● Cryotherapy
1. Catamero, D., Ray, C., Purcell, K., Leahey, S., Esler E., Rogers, S., ... & Shenoy, S. (2024, August). Nursing Considerations for the Clinical Management of Adverse Events Associated with Talquetamab in Patients with Relapsed or Refractory Multiple Myeloma. In Seminars in Oncology Nursing (p. 151712). WB Saunders.
2. Mancia, S. S., Farrell, A., Louw, K., Florendo, E., Aronson, E., Purcell, K., ... & Chari, A. (2021). Characterization and management of oral and dermatological toxicities in patients receiving the CD3 X GPRC5D bispecific antibody talquetamab (JNJ-64407564) for the treatment of relapsed and/or refractory multiple myeloma. Blood, 138
3. Mberry https://mberry.us/pages/faq. Accessed October 6th, 2024.
4. MetaQil. https://metaqil.com/the-science/. Accessed October 6th, 2024.
● Use non-metal utensils and cookware
● Fresh/frozen foods vs. canned foods
● Serve meat cold or at room temperature
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
● Experiment with different flavors, textures, temperatures, etc.
● Season foods with herbs, spices, condiments, and other seasonings
● Flavor foods and beverages with acids
○ Lemon, lime, orange, vinegar, tomato
● Soft, moist foods and beverages tend to be easiest to tolerate
○ Blend fresh fruits into smoothies
● Try using a straw with beverages to help bypass the mouth
● Marinate and cook meats in sweet juices, acidic dressings, or sauces
● There is no one-size-fits-all approach. Keep trying and retrying foods!
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
Breakfast:
● Cream of wheat, oatmeal, grits
o Add milk, butter, sugar, honey, fruit
● Cold cereal with milk
● Smoothies
● Eggs benedict (cooked through)
Lunch & Dinner:
● Soups
● Mashed potatoes
● Soft animal proteins: fish, egg, or tuna salad
● Pasta (cooked soft; with sauce or gravy)
● Vegetables (salads with vinegar dressing)
● Flavorful cuisines: Asian, Indian, Mexican, Mediterranean
● Smoothies, premade protein shakes, milkshakes, milk
● Yogurt, cottage cheese
● Pudding, ice cream, Jello
● Fruit
● Balsamic vinegar
● Lemon/lemon zest
● Mustard
● Mayonnaise
● Gravy
● Ginger
● Honey
● Mint
● Consume small, frequent meals every 2-3 hours instead of large meals
- Goal: 5 -6 small meals/day
● Add extra calories to food as tolerated
- Nuts, nut butters, avocado, hummus, etc.
● Drinks are often more appealing and can be easier to consume
- Choose smoothies, milkshakes, and/or high-calorie, high-protein nutritional drinks
● Move around when possible
- Walking or other gentle forms of exercise can increase appetite
● Appetite stimulants
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
● GI symptoms: - Nausea - Diarrhea - Constipation
● Fatigue
● Infections
● Consume small meals every few hours
● Eat bland foods (toast, yogurt, cream of wheat, potatoes, rice, or noodles)
● Avoid fatty, greasy, spicy, high-fiber, and gas-producing foods
● Sip liquids often, but avoid drinking during meals
● Cold or room-temperature foods may be easier to eat than hot foods
● Avoid foods that have strong odors or being around when food is being cooked
● Try foods and drinks that have ginger (chews, teas, ginger ale)
● Take your antiemetics!
● Manage/prevent constipation
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
● Drink at least 8 or more cups of low sugar fluids/day
● Drink hot liquids
● Eat foods such as prunes, warm prune juice, figs, and papaya
● Eat a diet high in fiber (whole grains, nuts, seeds vegetables, fruits and beans)
● Exercise often!
● Talk to your doctor about bowel regimen medications - Stool softeners and/or laxatives
1. American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
2. Johns Hopkins Medicine. Accessed August 24, 2024. https://www.hopkinsmedicine.org/health/wellness-and-prevention/foods-for-constipation.
● Eat small, frequent meals throughout the day
● Include foods that contain soluble fiber (mashed potatoes, noodles, bananas, rice, applesauce, toast, and cream of wheat)
● Hydrate with water, diluted juice, broth, coconut water, or electrolyte drinks
● Try a bulking agent containing psyllium fiber
● Use anti-diarrheal medications as prescribed
Limit:
● Sugar alcohols
● Fatty, greasy, fried foods
● Dairy products
● Foods that contain insoluble fiber: raw fruits and vegetables, whole grains, wheat bran, nuts
● Alcohol and caffeine
American Institute for Cancer Research. Accessed August 24, 2024. https://www.aicr.org/cancer-survival/treatment-tips/during-treatment/.
● Fatigue is a common symptom of myeloma and treatment
● Stay as active as you can
● Eat often and adequately
- Have small frequent meals, try not to go >4-5 hours without eating
● Plan ahead:
- Ask family/friends for help with meal prep
- Try grocery or meal delivery services
- Keep ready-to-eat and minimal-prep foods on hand
- Prepare large amounts of food when feeling well and freeze for later
● Stay well hydrated
- Aim for at least 6 -8 cups of low-sugar fluid easy day
- If you are losing weight, including protein shakes or milk
● Stress management
American Cancer Society. Accessed October 6th, 2024. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/getting-help-for-fatigue.pdf
● Cancer treatment can weaken your immune system
● Foodborne illness or “food poisoning” occurs when you eat food that’s been contaminated with disease-causing bacteria, viruses, or parasites
General Tips:
● Wash your hands well
● Separate ready-to-eat food and raw meats
● Check expiration dates
● Keep hot foods hot and cold foods cold
● Refrigerate leftovers immediately
● Avoid salad bars, buffets, and self-serve items
American Cancer Society. Accessed October 6th, 2024. https://www.cancer.org/content/dam/cancer-org/cancer-control/en/booklets-flyers/nutrition-for-the-patient-with-cancer-duringtreatment.pdf
Category Recommended
Protein
• Well-done meat, fish and eggs
• Commercially prepared cold cuts sold in a sealed package
• All raw, rare, and undercooked meat, fish, and eggs
• Smoked fish
• Freshly sliced deli meats
Fruits and Vegetables
Dairy
Beverages
• Fresh fruits and vegetables, washed well
• Frozen fruits and vegetables
• Pasteurized milk and milk products, cheese made from pasteurized milk
• Yogurt, including those made with cultures
• Water, coffee, tea, seltzer
• Pasteurized juices
• Oral nutrition supplements
• Poorly washed fruits and vegetables
• Unpasteurized milk and milk products
• Unpasteurized cheeses (soft and moldy cheeses)
• Unpasteurized juices
• Raw or unpasteurized honey
• Ask your doctor about alcohol
● Nutrition-related treatment side effects can lead to reduced food intake and weight loss
● The prevalence of malnutrition in cancer patients ranges from about 20% to more than 70%
● Malnutrition negatively affects the clinical outcomes, treatment response, and overall survival
● Cancer-related malnutrition may account for up to 20% of cancer deaths
● Early clinical nutrition interventions are associated with a reduction of therapyrelated toxicity, delays in cancer treatment, morbidity and mortality
● It is important to talk to your provider about side effects you are experiencing
● There are several ways to make treatment tolerable
- Supportive care or treatments to manage side effects
- Nutritionist involvement and dietary modifications are recommended to support patients
Donna D. Catamero, ANP-BC, OCN®, CCRC
Infection remains the leading cause of death in patients with multiple myeloma. Several factors account for this infection risk, including the overall state of immunosuppression from multiple myeloma, treatment, age, and comorbidities (e.g., renal failure and frailty).
IMWG Consensus guidelines and recommendations for infection prevention in multiple myeloma
Prevention Tips
Good personal hygiene (skin, oral)
Report fever of more than 100.4°F, shaking chills even without fever, dizziness, shortness of breath, low blood pressure to HCP as directed.
Environmental control (avoid crowds and sick people; use a high-quality mask when close contact is unavoidable)
As recommended by your healthcare team:
Flu, COVID, RSV & and pneumococcal vaccinations; avoid live vaccines
Preventative and/or supportive medications (next slide)
Type of Infection Risk
Viral: herpes simplex (HSV/VZV); CMV
Bacterial: blood, pneumonia, and urinary tract infection
PJP (P jirovecii pneumonia)
Fungal infections
COVID-19 and influenza
IgG < 400 mg/dL (general infection risk)
ANC < 1000 cells/μL (general infection risk)
Medication Recommendation(s) for Healthcare Team Consideration
Acyclovir prophylaxis
Consider prophylaxis with levofloxacin
Consider prophylaxis with trimethoprim-sulfamethoxazole
Consider prophylaxis with fluconazole
Antiviral therapy if exposed or positive for COVID-19, per institution recommendations
IVIG Recommended
Consider GCSF 2 or 3 times/week (or as frequently as needed) to maintain ANC > 1000 cells/μL and treatment dose intensity
Some people receiving BCMA-targeting therapies have experienced infections that are less common, such as CMV, PJP, and fungal infections
Taste Changes
Dexamethasone & Nystatin oral solutions “swish and spit” have been tried but with no proven benefit yet.
Sour citrus or candies before meals are recommended.
Dry Mouth
Dysphagia
OTC dry mouth rinse, gel, spray are recommended. Advise patients to avoid hot beverages.
Glossitis and Thrush
EARLY initiation of nystatin or clotrimazole is key to managing symptoms.
• Weight loss and anorexia are associated with taste changes. Nutritionist involvement and dietary modifications are recommended to support patients. An appetite stimulant with Marinol, if indicated, can also be utilized.
Dietary modifications, including taking small bites, eating upright, and sips of beverage with food, can help manage symptoms.
• Education and emotional support are key strategies for managing oral toxicities.
Dry Skin
Heavy moisturizers
Hand and/or
Foot Peeling
Nail Thinning and Peeling
Ammonium lactate 12% lotion to soles and palms twice daily
Pruritus
Nail hardeners, topical vitamin E oil, and triamcinolone 0.025% ointment
Injection Site Reaction Body Rash/ Drug Rash
Loratadine 10 mg by mouth daily for 3 to 5 days after talquetamab dose and triamcinolone 0.1% cream twice daily
Above, plus consider methylprednisolone taper and betamethasone 0.05% cream twice daily
• Consider dose HOLD for other serious dermatologic AEs
• Dermatology consults may be helpful as an early strategy
• These interventions were successful at reducing or resolving dermatologic AEs
Catamero D, et al. Presented at: 20th International Myeloma Society (IMS) Annual Meeting Nurse Symposium. September 27-30, 2023; Athens, Greece.
Consistent schedule (AM vs. PM)
Take with food
Stomach discomfort: Over-the-counter or prescription medications
Medications to prevent shingles, thrush, or other infections
Steroids enhance the effectiveness of other myeloma therapies
Do not stop or alter your dose of steroids without discussing it with your provider
• Irritability, mood swings, depression
• Difficulty sleeping (insomnia), fatigue
• Blurred vision, cataracts
• Flushing/sweating
• Increased risk of infections, heart disease
• Muscle weakness, cramping
• Stomach bloating, hiccups, heartburn, ulcers, or gas
• Weight gain, hair thinning/loss, skin rashes
• Increased blood pressure, water retention
• Increased blood sugar levels, diabetes
Sources of pain include bone disease, neuropathy and medical procedures
• Management
– Prevent pain when possible
• Bone strengtheners to decrease fracture risk
• Antiviral to prevent shingles
• Sedation before procedures
– Interventions depend on source of pain
Tell your healthcare provider about any new bone or chronic pain that is not adequately controlled
• May include medications, activity, surgical intervention, radiation therapy, etc
• Complementary therapies (Mind-body, medication, yoga, supplements, acupuncture, etc)
• Scrambler therapy for neuropathy
Faiman B, et al. CJON. 2017;21(5)suppl:19-36.
Peripheral neuropathy happens when there is damage to nerves in the extremities (hands, feet, limbs). Damage can be the result of myeloma, treatment or unrelated conditions (i.e. diabetes).
Symptoms:
• Numbness
• Tingling
• Prickling sensations
• Sensitivity to touch
• Burning and/or cold sensation
• Muscle weakness
Prevention / management:
• Bortezomib once-weekly or subcutaneous administration
• Massage area with cocoa butter regularly
• Neuroprotective Supplements:
• B-complex vitamins (B1, B6, B12)
• Green tea
• Safe environment: rugs, furnishings, shoes
If neuropathy worsens, your provider may:
• Adjust your treatment plan
• Prescribe oral or topical pain medication
• Suggest physical therapy
Report symptoms of peripheral neuropathy early to your health care provider; nerve damage from neuropathy can be permanent if unaddressed
• Risk Factors
– Active multiple myeloma (light chains, high calcium)
– Other medical issues (ex: Diabetes, dehydration, infection)
– Medications (MM treatment, antibiotics, contrast dye)
• Prevention
– Stay hydrated – drink water
– Avoid certain medications when possible (eg, NSAIDs), dose adjust as needed
• Treatment
– Treatment for myeloma
– Hydration
– Dialysis
Many myeloma patients will experience kidney issues at some point; protecting your kidney function early and over time is important
Have a Primary Care
Have Recommended Health Screenings
• Blood pressure
• Cholesterol
• Cardiovascular disease
• Diabetes
• Colonoscopy
• Vision
• Hearing
• Dental checkups & cleaning
• Women specific: mammography, pap smear
• Men specific: prostate
Maintain a healthy weight
• Good nutrition
• Activity or exercise
• Sufficient Sleep
An ounce of prevention is worth a pound of cure.
Benjamin Franklin
