More Early Palliative Care May Be Needed to Individualize Pain Management in MM

The causes, types, and severity of pain in patients with multiple myeloma (MM) were found to differ according to disease stage, suggesting that early palliative care (EPC) delivered by a specialized PC team could improve pain management in patients with MM, according to a recent study.

The retrospective single-center study, published in Supportive Care in Cancer, concluded that more randomized clinical trials using larger populations and multiple centers should investigate whether standardizing access to EPC for patients with hematological malignancies, especially those with MM, are needed to improve their quality of life.

“Our study suggests the usefulness of EPC to manage pain and symptoms in MM patients and to facilitate the decision-making process for the most appropriate end-of-life setting, thus reducing the need for intensive treatments or for access to emergency departments,” wrote the investigators.

Over two-thirds of patients with MM experience myeloma bone damage and pain from osteolytic bone lesions at diagnosis and nearly all throughout the course of their disease. However, different types of pain often occur at different disease stages, such as bone pain, which is more frequent at diagnosis and relapse, and certain types of pain stemming from receiving chemotherapy treatments for prolonged periods of time. Over time, survivors may have to deal with late effects of treatments, including chronic pain, neuropathy, asthenia, or psychological symptoms.

New evidence has suggested that establishing timely and close collaboration between hematologists and PC specialists could help address pain, fatigue, anorexia, nausea, depression, and anxiety. EPC could also improve quality of life by enabling patients to manage symptoms more effectively and reducing the need for treatment discontinuation.

“It would provide much needed support for caregivers and could help to establish a relationship of trust between patients and PC clinicians, facilitating the development of advance care planning….For those in poorer clinical conditions or with a higher symptom burden, a PC homecare visit or hospice admission is proposed by a multidisciplinary team (physician, nurse, social worker, psychologist, and physiotherapist),” the investigators wrote.

For the present analysis, patients were identified through electronic medical records from 1 institute in Italy; they had to be at least 18 years old, have an MM diagnosis, and at least 1 PC consultation. Overall, 325 patients were followed between January 2017 and June 2020, of whom 43 (13.2%) were referred for a PC consultation, 23 (53.3%) were women, and the median age was 71 years.

The main reason that patients were referred for PC was pain management (n = 39; 90.7%). Of those referred for pain, 17 had somatic pain, 9 had neuropathic pain, and 13 had mixed pain. During the first PC clinic visit, 24 patients had MM bone disease–related pain, 6 had chemotherapy-induced neuropathic pain, 1 had postherpetic neuralgia, and 8 reported pain for other reasons.

A majority of patients had a median of 2 PC consultations and 3 were seen more often by the PC team.

After the consultations, 4 patients were assessed to identify the most appropriate PC settings for their individual needs, of whom 3 were referred to hospice care and 1 was assigned to home-based PC. Of the patients who were referred for pain management, 5 required evaluations for the best PC setting, of whom 3 were referred for hospice care and 2 for palliative homecare.

The study had some limitations, including that that data were collected with suboptimal completeness, with some minor symptoms potentially left out. Also, the small sample size from a single-center design limits the generalizability of the results.

“We consider our paper a starting point to encourage closer collaboration between hematologists and PC physicians in an effort to find the answers to the many open questions remaining in this area,” wrote the investigators.

Reference

Pallotti MC, Rossi R, Scarpi E, et al. Patients with multiple myeloma referred for palliative care consultation: from retrospective analysis to future directions to improve clinical outcomes. Support Care Cancer. 2021;30:2293-2298. doi:10.1007/s00520-021-06560-8