Improving management of patients with advanced cancer

Figures & data

Figure 1 Overall risk of skeletal-related events in patients with bone metastases from breast cancer treated with bisphosphonates.^12–19 Hypercalcemia was not included as a skeletal-related event (SRE) in this analysis.

Copyright © 2005. Reproduced with permission of Cochrane Collaboration. Pavlakis N, Schmidt R, Stockler M. Bisphosphonates for breast cancer. Cochrane Database Syst Rev. 2005(3):CD003474.¹⁰

Abbreviations: ZOL, zoledronic acid; PAM, pamidronate; IBN, ibandronate; CLO, clodronate; IV, intravenous; SREs, skeletal-related events.

Table 1 Guidelines for administering bisphosphonate therapy

Assessment information checklist^Citation25 Height and posture Weight Serum creatinine and corrected serum creatininea (0.6–1.3 mg/dL or 70–120 μmol/L) Hydration status – Signs and symptoms of dehydration – Adequate fluid intake (2–3 L/day)b – Diarrhea or vomiting in previous 24 hr Pain and analgesic assessment – Severity – Site – Type of pain Concomitant medications – Dose and schedule – Calcium and vitamin D supplementation Concomitant treatments (eg, radiotherapy, chemotherapy) Mobility and activity Oral condition Discussion of any adverse events since last visit Determination of whether the patient has experienced any new skeletal-related events – Effectiveness of treatment from patient’s viewpoint

Observations for a patient diary^Citation25 During the first 5 days after each infusion – Urinary frequency – Fever/malaise – Other symptoms Ongoing symptoms – Pain level (VAS or BPI) – Locations of any bone pain – Analgesic use or other medications – Physical activity or ability to move

Patient education – side effects^Citation25 Possible adverse events – Flu-like symptoms (after initial infusion) and skeletal pain (acetaminophen [paracetamol] can be administered prophylactically) – Renal function deterioration (serum creatinine and creatinine clearance) – Osteonecrosis of the jaw (spontaneously or after dental procedure) – uncommon What to do when side effects occur – Ensure availability of therapy for common adverse events – Advise patients of adverse events for which they should contact the healthcare team – Ensure patient’s accessibility to the hospital – Reassure patients who experience flu-like symptoms that the symptoms will be less severe after each subsequent infusion and will not likely occur after the second or third infusion

Supportive care measures^Citation26 Acute-phase reaction: Assess dehydration and electrolyte levels – Nausea/vomiting: Administer antiemetics (eg, thiethylperazine or prochlorperazine) and/or mild analgesics (eg, acetaminophen) as necessary – Fever: Monitor vital signs and nutritional status; administer antipyretics (eg, acetaminophen) prophylactically for the first 24 hours after the first and second infusions and then as needed; admit patient for persistent fever – Diarrhea: Monitor vital signs and nutritional status; administer antidiarrheals (eg, loperamide) – Acute-phase reaction tends to occur after the first bisphosphonate infusion and typically does not occur or is less severe with subsequent doses Anemia: Red blood cell transfusion and/or erythropoietin Myalgia/arthralgia: Administer analgesics (eg, acetaminophen) or nonsteroidal anti-inflammatory agents (eg, ibuprofen), unless contraindicated Constipation: Administer stool softeners; maintain adequate fluid intake; modify diet; increase fiber intake Headache: Administer analgesics (eg, acetaminophen) Anorexia: Nutritional supplements, appetite stimulants Edema lower limb: Maintain elevation of extremities; use compression stockings, if needed Practical assistance: Patients may benefit from arrangements for assistance with their mobility at home, housekeeping, transportation, etc Psychosocial distress: Patients may experience emotional distress related to their situation and should be referred for professional evaluation if distress levels are found to be too high

Notes:

a Corrected for age, weight, and sex;

b Unless patient is on restricted fluid intake.

Copyright © 2009. Reproduced with permission from Oncology Nursing Society. Fitch M, Maxwell C, Ryan C, Lothman H, Drudge-Coates L, Costa L. Bone metastases from advanced cancers: clinical implications and treatment options. Clin J Oncol Nurs. 2009;13(6):701–710.²

Table 2 Issues included in the Bone Metastases Quality of Life Questionnaire (EORTC QLQ-BM22)

Symptom scales

Painful sites

1. Back

2. Leg(s) or hip(s)

3. Arm(s) or shoulder(s)

4. Chest or ribs

5. Buttocks

Pain characteristics

6. Constant pain

7. Intermittent pain

8. Pain not relieved by medications

Functional scales

Functional interference

9. Pain while lying down

10. Pain while sitting

11. Pain when trying to stand up

12. Pain while walking

13. Pain with activities such as bending or climbing stairs

14. Pain with strenuous activity

15. Pain interfered with your sleeping

16. Modify your daily activities

Psychosocial aspects

17. Felt isolated from those close to you

18. Worried about loss of mobility

19. Worried about becoming dependent on others

20. Worried about your health in the future

21. Felt hopeful your pain will get better

22. Felt positive about your health

Copyright © 2009. Reproduced with permission from Elsevier. Chow E, Hird A, Velikova G, et al. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for patients with bone metastases: the EORTC QLQ-BM22. Eur J Cancer. 2009;45(7):1146–1152.³⁸

Abbreviation: EORTC, European Organisation for Research and Treatment of Cancer.

Figure 2 A) Effect of monthly infusion of zoledronic acid on pain. *P < 0.05; ^†P < 0.005 versus baseline. B) Effect of monthly infusion of zoledronic acid on quality of life. *P < 0.05 versus baseline.

Abbreviations: BPI, Brief Pain Inventory; EORTC, European Organisation for Research and Treatment of Cancer. Copyright © 2005. Reproduced with permission from Nature Publishing Group. Wardley A, Davidson N, Barrett-Lee P, et al. Zoledronic acid significantly improves pain scores and quality of life in breast cancer patients with bone metastases: a randomised, crossover study of community vs hospital bisphosphonate administration. Br J Cancer. 2005;92(10): 1869–1876.⁴⁰

Table 3 Effect of zoledronic acid on skeletal morbidity rate in patients with solid tumors and bone metastases

ZOL schedule (patients, n)	Skeletal morbiditya, SREs/mo	Follow-up durationb, mo
None (3038)	0.43	8.68
Any (1508)	0.29	12.2
On-label	0.16	17.11
Off-label	0.31	9.93

Notes:

a P ≤ 0.05 for each comparison;

b P < 0.001 for each comparison.

Copyright© 2008. Adapted with permission from John Wiley and Sons. Hatoum HT, Lin SJ, Smith MR, Barghout V, Lipton A. Zoledronic acid and skeletal complications in patients with solid tumors and bone metastases: analysis of a national medical claims database. Cancer. 2008;113(6):1438–1445.⁴⁷

Abbreviations: SRE, skeletal-related event; ZOL, zoledronic acid.

KohnoNAogiKMinamiHZoledronic acid significantly reduces skeletal complications compared with placebo in Japanese women with bone metastases from breast cancer: a randomized, placebo-controlled trialJ Clin Oncol200523153314332115738536

 PubMed Web of Science ®Google Scholar

Tubiana-HulinMBeuzebocPMauriacL[Double-blinded controlled study comparing clodronate versus placebo in patients with breast cancer bone metastases]Bull Cancer200188770170711495824

 PubMed Web of Science ®Google Scholar

PavlakisNSchmidtRStocklerMBisphosphonates for breast cancerCochrane Database Syst Rev20053CD00347416034900

 PubMed Web of Science ®Google Scholar

MaxwellCRole of the nurse in preserving patients’ independenceEur J Oncol Nurs200711Suppl 2S38S4117768093

 PubMed Web of Science ®Google Scholar

MaxwellCSwiftRGoodeMDoaneLRogersMAdvances in supportive care of patients with cancer and bone metastases: nursing implications of zoledronic acidClin J Oncol Nurs20037440340812929273

 PubMedGoogle Scholar

FitchMMaxwellCRyanCLothmanHDrudge-CoatesLCostaLBone metastases from advanced cancers: clinical implications and treatment optionsClin J Oncol Nurs200913670171019948468

 PubMed Web of Science ®Google Scholar

ChowEHirdAVelikovaGThe European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for patients with bone metastases: the EORTC QLQ-BM22Eur J Cancer20094571146115219097882

 PubMed Web of Science ®Google Scholar

WardleyADavidsonNBarrett-LeePZoledronic acid significantly improves pain scores and quality of life in breast cancer patients with bone metastases: a randomised, crossover study of community vs hospital bisphosphonate administrationBr J Cancer200592101869187615870721

 PubMed Web of Science ®Google Scholar

HatoumHTLinSJSmithMRBarghoutVLiptonAZoledronic acid and skeletal complications in patients with solid tumors and bone metastases: analysis of a national medical claims databaseCancer200811361438144518720527

 PubMed Web of Science ®Google Scholar