Meredith’s treatment history traces the modern arc of myeloma therapy. She began with the standard triplet of bortezomib, lenalidomide, and dexamethasone, gaining weight from the steroid but otherwise feeling relatively normal, before undergoing an autologous stem cell transplant in December 2019. That transplant proved grueling: a two-week hospitalization in Milwaukee, a three-hour drive from her hometown, and three to four weeks living within a 45-minute radius of the hospital afterward. She spent her birthday in a motel. Maintenance lenalidomide followed, but she relapsed roughly two years after diagnosis, moving on to daratumumab and carfilzomib, a combination that triggered fevers, facial swelling, emergency room visits, and repeated admissions for sepsis. A second relapse in March 2022 led to elotuzumab, pomalidomide, and dexamethasone, and her disease progressed again within months.

The commentary accompanying her account notes that Meredith’s disease moved faster than typical. In one analysis of United States electronic health records, the median time from first treatment to a second regimen was 46.7 months, and in a referral-center study the median time to a third treatment in relapsed patients was 16.6 months, both roughly twice the pace of Meredith’s progression. In a clinical study of daratumumab, carfilzomib, and dexamethasone, serious infections occurred in 19 percent of patients, but sepsis was not reported, underscoring how individual responses to the same regimens can diverge sharply from trial averages.

With few options remaining, Meredith enrolled in a clinical trial of chimeric antigen receptor T cell, or CAR-T, therapy in 2022. Bridged with daratumumab, bortezomib, and dexamethasone while increasingly ill, she received the engineered cells and spent four weeks hospitalized, developing severe cytokine release syndrome, a systemic inflammatory reaction in which immune cells flood the bloodstream with signaling proteins, that required several days in the intensive care unit. A later readmission for neutropenic fever followed. Recovery took months, but she emerged symptom- and treatment-free for 18 months, until May 2024, when a lesion on her sternum signaled yet another relapse. Her hematologist recommended talquetamab, a bispecific antibody she had never heard of, and with no clinical trials available to her, she agreed to try it.

Talquetamab works differently from CAR-T. It is a bispecific antibody that redirects T cells against GPRC5D, a protein abundant on myeloma cells, and it is approved for triple-class exposed relapsed/refractory multiple myeloma. Nurse practitioner Donna Catamero, who cares for myeloma patients at a large academic center and whose hospital enrolled the first patient on talquetamab monotherapy in the pivotal MonumenTAL-1 trial, describes two ideal candidates: patients needing a bridge to CAR-T therapy, and patients like Meredith who relapse while on a B cell maturation antigen, or BCMA, directed therapy such as a CAR-T product or a BCMA-targeting bispecific. In this heavily pre-treated population, she reports, complete remissions with durable responses have been observed, something rarely seen before in patients with so many prior therapies.

The drug’s side effect profile is distinctive because GPRC5D is also expressed in normal tissues. In MonumenTAL-1, cytokine release syndrome occurred in 75 to 79 percent of patients, but most events were low grade, occurred at or before the first full dose, and resolved, which is why step-up dosing and mandatory hospitalization during the initial doses are built into the treatment protocol. More than 70 percent of patients experience taste changes, and dry mouth, weight loss, rash, skin disorders, and nail changes are common. Skin and taste problems tend to appear within three to four weeks, while weight and nail changes develop more slowly. Rashes generally resolve within weeks, but taste, nail, and weight changes often persist, with modest improvement over time in most patients.

Meredith experienced this profile firsthand. She spent two weeks hospitalized at the start of treatment and had cytokine release syndrome, from which she recovered before discharge. Severe itching and red blotches on her face and body emerged first, managed with daily baths with bathing salts, allergy medications, and alcohol-free medical creams, resolving after five to six weeks. Nail discoloration and transient blurred vision followed. She lost 45 pounds during treatment, and the most burdensome effects were taste changes and dry mouth, which she managed by experimenting with cold liquids such as popsicles, ice cream, and smoothies, and soft foods including applesauce, mashed potatoes, pasta, and fish. After three to four months the side effects decreased substantially, and she is now in month 19 of treatment, feeling better emotionally and physically than she did after CAR-T.

The clinical machinery behind these outcomes is elaborate. Catamero’s team educates patients and care partners about cytokine release syndrome symptoms, including fever and hypotension, monitors vital signs every four to six hours during step-up dosing, and deploys intravenous fluids, oxygen, antipyretics, and, when needed, the interleukin-6 inhibitor tocilizumab or steroids. The US label advises that doses may be delayed to manage oral toxicity, and reducing dose frequency after a response is achieved has proven helpful and is supported by trial evidence. Dietitian Isabelle Wlodkowski provides mandatory nutrition consultations during the hospital stay, counseling patients on high-calorie, high-protein strategies, eight to ten cups of fluid daily for dry mouth, sugar-free gum, small frequent meals, and home weight tracking. A phase 2 study called TALISMAN is now using an objective instrument, the Waterless Empirical Taste Test, which preliminary results suggest can detect taste changes earlier than patient self-report and capture improvement as early as three months after treatment begins.

The transition from inpatient to outpatient care is where the multidisciplinary model earns its keep. Catamero emphasizes laboratory monitoring for infections and cytopenias, prophylaxis strategies, rapid pathways for evaluating fever, and proactive screening for skin and oral toxicities that patients often under-report until advanced. A safe handoff between a specialist center and a community oncologist depends on an explicit shared care plan covering dose schedules, prior cytokine release syndrome or neurotoxicity grades, 24/7 triage phone numbers, and shared toxicity algorithms. Patient advocate Becky Bosley of the International Myeloma Foundation stresses preparation for the hospitalization required during step-up doses, including delegating family and work responsibilities and planning financially for copays, and points to the foundation’s more than 150 myeloma-specific support groups and its AI-powered chatbot, Myelo, which answers questions using only information from myeloma.org.

Meredith’s care now spans a myeloma specialist, a local hematologist-oncologist, cancer nurses, a nutritionist, and an in-house patient advocate, with nursing staff having arranged treatment at a facility closer to home to ease the burden of traveling every other week. Her husband attends nearly every appointment, and she belongs to local and Mayo Clinic-affiliated support groups while following educational programming from the International Myeloma Foundation, the Multiple Myeloma Research Foundation, the Leukemia & Lymphoma Society, and the American Cancer Society. Her light chain lab values have been stable at every visit, her advice to new patients is to give the treatment six to eight weeks before judging it, and she teaches voice lessons, gardens, and exercises again. Her story illustrates a central message of the perspective: in relapsed myeloma, the drug is only half the treatment, and the coordinated team around it is what keeps patients on therapy and living well.

Subject of Research: Patient and clinician perspectives on living with relapsed/refractory multiple myeloma and multidisciplinary management of talquetamab therapy

Article Title: Perspectives on Living with Relapsed/Refractory Multiple Myeloma and Multidisciplinary Care from a Patient, Nurse Practitioner, Dietitian, and a Patient Advocate

Article References: Bosley, B., Wlodkowski, I., Catamero, D., & Meredith, S. (2026). Perspectives on Living with Relapsed/Refractory Multiple Myeloma and Multidisciplinary Care from a Patient, Nurse Practitioner, Dietitian, and a Patient Advocate. Advances in Therapy. https://doi.org/10.1007/s12325-026-03801-2

Image Credits: AI Generated

DOI: 10.1007/s12325-026-03801-2

Keywords: multiple myeloma, relapsed/refractory myeloma, talquetamab, bispecific antibodies, CAR-T therapy, cytokine release syndrome, GPRC5D, dysgeusia, supportive care, oncology nutrition, patient advocacy, multidisciplinary care

The scale of the problem the framework addresses is sobering. According to the ESPEN clinical nutrition guidelines cited in the review, tumor-induced metabolic disturbances and treatment-related toxicities contribute to malnutrition in a large proportion of patients, and an estimated 10 to 20 percent of people with cancer die from malnutrition rather than from the tumor itself. Recent meta-analyses report that severe malnutrition affects roughly 20 percent of cancer patients, with prevalence climbing to 46 percent among hospitalized patients assessed using the GLIM criteria. The consequences ripple across every dimension of care: a global multicenter study found that one third of patients undergoing gastrointestinal cancer surgery were severely malnourished, a condition linked to significantly higher 30-day postoperative mortality, while a separate meta-analysis showed that GLIM-defined malnutrition nearly triples the risk of death within one year compared with well-nourished patients.

The authors contend that the reason conventional nutritional support often falls short is structural rather than conceptual. Standard practice includes individualized dietary counseling, oral nutritional supplements, enteral nutrition, and parenteral nutrition, with the oral and enteral routes preferred whenever the gastrointestinal tract is functional. These interventions can improve intake, weight, and some patient-reported outcomes, but their effects vary widely depending on tumor type, baseline nutritional status, inflammatory burden, and treatment phase. Perioperative immunonutrition containing arginine, omega-3 fatty acids, and nucleotides has shown benefit in selected surgical populations, yet most existing strategies remain single-component or non-targeted. Cancer-associated wasting, by contrast, is a tangled web of metabolic reprogramming, systemic inflammation, immune dysfunction, gut-barrier injury, microbiota disturbance, and treatment toxicity, and no single nutrient can plausibly address all of these dimensions at once.

Enter the traditional Chinese medicine concept of prescription compatibility. In classical Chinese formularies, Jun herbs target the primary pathological mechanism, Chen herbs provide supportive and synergistic effects, Zuo herbs mitigate toxicity or moderate adverse effects, and Shi herbs guide the actions of the principal components and harmonize the whole formulation. The authors are careful to frame this as a translational metaphor rather than proof of pharmacological equivalence between herbs and nutrients. Still, they argue, the compatibility logic is unusually well suited to oncology nutrition because malnourished cancer patients often simultaneously face insufficient intake, inflammation, insulin resistance, skeletal muscle loss, mucosal injury, diarrhea, micronutrient deficiency, anxiety, and fatigue. A hierarchical structure helps clinicians distinguish non-negotiable foundations from optional adjuncts and prevents the substitution of essential energy and protein support with poorly evidenced supplements.

In the proposed model, Jun nutrients constitute the foundational substrate layer: proteins, carbohydrates, and fats. Protein is the centerpiece, with guidelines recommending at least 1.0 gram per kilogram of body weight per day in cancer patients, ideally raised to 1.2 to 1.5 grams per kilogram. Review evidence suggests that daily intake above 1.4 grams per kilogram during treatment helps preserve muscle mass, while intake below 1.2 grams is commonly associated with muscle loss. The PRIMe trial in colorectal cancer explored a high-protein intake of 2.0 grams per kilogram during chemotherapy, with preliminary findings suggesting that roughly half of the patients maintained or improved muscle mass. Carbohydrates serve as an efficient energy source that spares protein from oxidation, with complex carbohydrates and dietary fiber from whole grains, fruits, and vegetables improving insulin sensitivity and reducing inflammatory mediators, whereas refined sugars and high glycemic loads warrant caution given the Warburg effect and the possible association of hyperglycemia with tumor growth and invasion. Fats supply concentrated energy and essential fatty acids, with priority given to monounsaturated and polyunsaturated sources such as olive oil, nuts, and deep-sea fish oil. A randomized controlled trial showed that daily supplementation with six grams of medium-chain triglycerides improved muscle strength and daily functioning in frail older adults within three months, suggesting a potential role against cancer-related wasting, and Mediterranean-style, olive-oil-rich dietary patterns have been linked to substantially reduced breast cancer incidence.

Chen nutrients are the reinforcing layer, selected when a patient shows inflammation, muscle wasting, or impaired anabolic response. The prototype is the omega-3 polyunsaturated fatty acids EPA and DHA, which suppress pro-inflammatory eicosanoids and cytokines, inhibit nuclear factor-kappa B activation, and enhance insulin sensitivity. Clinical studies report that fish oil supplementation improves appetite, increases skeletal muscle mass, and stabilizes body weight in advanced cancer, and a meta-analysis found that oral supplements containing omega-3 fatty acids increased body weight in patients with cancer cachexia by an average of approximately 1.22 kilograms alongside significant improvements in quality-of-life scores. Branched-chain amino acids, particularly leucine, and its metabolite beta-hydroxy-beta-methylbutyrate, activate the mTOR pathway and suppress muscle protein breakdown, respectively. A meta-analysis in hepatocellular carcinoma showed that perioperative supplementation reduced postoperative infections and ascites and produced average weight gains of nearly two kilograms. L-carnitine completes this tier by transporting long-chain fatty acids into mitochondria, suppressing proteolysis through AKT and FOXO3a signaling, and, in early clinical work, improving fatigue, body composition, and quality of life in patients with advanced cancer.

Zuo nutrients act as coordinating adjuncts that protect the gut and buffer treatment toxicity. Probiotics such as Lactobacillus and Bifidobacterium species, together with prebiotics like inulin, support intestinal barrier function and short-chain fatty acid production. Systematic reviews indicate that probiotic use among patients receiving chemotherapy or radiotherapy reduces the risk of diarrhea of any grade by approximately 65 percent and severe diarrhea by about 57 percent, while another meta-analysis reported a roughly 30 percent reduction in chemotherapy-induced diarrhea and a halving of severe cases, alongside markedly lower rates of oral mucositis. Glutamine, a conditionally essential amino acid during physiological stress, fuels intestinal epithelial cells, promotes mucosal repair, and reduces permeability and bacterial translocation. Meta-analyses show that glutamine nearly halves the risk of grade III to IV oral mucositis from chemotherapy or radiotherapy, prompting MASCC to list oral glutamine as an optional prophylactic measure, and supplementation has also reduced chemotherapy-induced diarrhea in colorectal cancer patients by roughly 35 percent.

Shi nutrients, the guiding cofactors, include vitamins, trace elements, and coenzymes that make the entire system work. B vitamins drive energy metabolism and hematopoiesis, vitamins A, C, and E support epithelial integrity and antioxidant defense, and vitamin D carries endocrine and immunomodulatory functions, with higher serum levels associated with longer survival in patients receiving immune checkpoint inhibitors. Trace elements matter enormously: in a retrospective study of gynecological malignancies, serum zinc declined significantly after surgery and chemoradiotherapy, and zinc deficiency was 4.8 times more likely in patients whose tumors recurred, with levels below 61 micrograms per deciliter independently predicting recurrence. Iron, folate, and vitamin B12 are essential for erythropoiesis, though excessive iron must be avoided for its possible tumor-promoting effects. Coenzyme Q10, a mitochondrial electron carrier, has shown in breast cancer trials that 100 milligrams daily for six to twelve weeks significantly reduced circulating VEGF and IL-8 and suppressed matrix metalloproteinase activity, suggesting a possible role in easing fatigue and inflammation.

The framework’s greatest practical promise may lie in its adaptability to specific cancers and complications. In breast cancer, vitamin D and calcium anchor skeletal health during endocrine therapy while glutamine and probiotics buffer chemotherapy toxicity; in lung cancer, anti-inflammatory omega-3 fatty acids and branched-chain amino acids counter the cachexia that affects so many patients at diagnosis; in esophageal cancer, tube-fed enteral nutrition and perioperative immunonutrition with arginine and fish oil reduce postoperative infections; in hepatocellular carcinoma, branched-chain amino acid-enriched formulas meet protein needs while limiting ammonia-related metabolic burden. The authors stress that traditional Chinese medicine formulas, including Huangqi Sijunzi, Liujunzi, and Buzhong Yiqi decoctions, should complement rather than replace standard oncologic nutrition care, and they acknowledge that randomized controlled trials of structured nutrition-TCM integrative strategies remain limited. Looking ahead, they propose that patient stratification using metabolomics, inflammatory markers, and microbiome profiles, combined with nutritional informatics and systems modeling, could transform this ancient hierarchy into testable combination hypotheses and dosing rules, moving supportive oncology from experience-based practice toward genuinely data-driven, precision nutritional medicine.

Subject of Research: Application of the traditional Chinese medicine principle of Jun-Chen-Zuo-Shi to individualized nutritional therapy for cancer-associated malnutrition and cachexia.

Article Title: “Jun-Chen-Zuo-Shi” – the Chinese medical perspective on clinical oncology nutritional therapy

Article References: Lin, S., Li, B., & Yao, Q. (2026). “Jun-Chen-Zuo-Shi” – the Chinese medical perspective on clinical oncology nutritional therapy. Holistic Integrative Oncology, 5(1), Article 62. https://doi.org/10.1007/s44178-026-00282-9

Image Credits: AI Generated

DOI: 10.1007/s44178-026-00282-9

Keywords: cancer cachexia, malnutrition, Jun-Chen-Zuo-Shi, traditional Chinese medicine, oncology nutrition, omega-3 fatty acids, branched-chain amino acids, glutamine, probiotics, micronutrients, nutritional therapy, lean body mass