Update on Identifying and Managing Osteoporosis in Women With Breast Cancer

With Deanna Yamamoto, RN, MS, CS, ANP, AOCNP® and Pamela Viale, RN, MS, CS, ANP, AOCNP®

2010-05-22 13:03:02 SJardine@ONS Welcome to the ONS Virtual Journal Club!
2010-05-22 13:04:18 deanna and pam Thanks for joining the chat. We are happy to answer any questions you all have on the osteoporosis article!
2010-05-22 13:04:50 SJardine@ONS Welcome!! Today we will be discussing Update on Identifying and Managing Osteoporosis in Women With Breast Cancer with Deanna Yamamoto, RN, MS, CS, ANP, AOCNP® and Pamela Viale, RN, MS, CS, ANP, AOCNP®
2010-05-22 13:06:49 huffh@musc.edu Thank you for doing this. I unfortunately had signed up but I am working today and have not properly reviewed the article. I will try to review now unless I am interrupted by my pager. I will also stay logged in during the time period to see if any questions / answers trigger thoughts.
2010-05-22 13:07:24 SJardine@ONS What is the clinical problem that is addressed in the article?
2010-05-22 13:08:21 deanna and pam Osteoporosis and bone health in women with breast cancer. Breast cancer is the number one cancer occurring in women with approximately 192,000 cases last year. Many of these women are on AIs and at risk for osteoporosis.
2010-05-22 13:08:55 SJardine@ONS Why is this problem important for nurses?
2010-05-22 13:09:47 deanna and pam Because this disease is so common and so many women are on aromatase inhibitors; 20% of women will die the first year after they develop a hip fracture....
2010-05-22 13:10:55 deanna and pam Also the nurses have a big role in education of women with breast cancer regarding their increased risk for fracture. Nurses are sometimes the best communicators of this information and can certainly reinforce it...
2010-05-22 13:11:13 SJardine@ONS What is the article type: case study, literature review or synthesis of the evidence?
2010-05-22 13:12:14 deanna and pam This article is a literature review. We became interested in the subject when the providers in our practice began ordering intravenous bisphosphonate twice a year (off label) for this group of patients...
2010-05-22 13:13:56 SJardine@ONS What sources of evidence and search strategies did you use to collect the evidence?
2010-05-22 13:15:39 deanna and pam We searched all available literature bases for evidence-based articles to review for our paper as well as national guidelines for osteoporosis such as the National Osteoporosis Foundation and NCCN…once we reviewed these we looked at our clinical practice and tried to address this problem.....also used information from the World Health Organization....
2010-05-22 13:17:08 SJardine@ONS What were the different resources that were needed to collect , evaluate and synthesize the evidence?
2010-05-22 13:18:26 deanna and pam Journal articles, internet resources and journals, poster presentations from national meetings, library as resource, and materials obtained from the National Osteoporosis Foundation
2010-05-22 13:19:21 deanna and pam We were also fortunate that several authors of excellent papers in the literature gave us specific permission to reprint some of the tables and algorithms used in our paper; we appreciate the generosity of our peers very much!
2010-05-22 13:20:08 SJardine@ONS Was a rating scale used to evaluate the evidence? Which one?
2010-05-22 13:21:36 deanna and pam We did not use a specific rating scale to evaluate the evidence but we noted each reference for type of study (ie retrospective or prospective) and how many patients were involved in each study (specifically looking for larger studies) and p values to determine the significance of studies reviewed for the paper.
2010-05-22 13:23:49 SJardine@ONS What were the outcomes or recommendations for practice, education, administration, and/or research based on the evidence presented?
2010-05-22 13:32:14 deanna and pam The first recommentation would be awareness that the problem exist in this patient population, and test the patients at risk with bone density testing . Most are aware that postmenapausal women are at risk but there are a number of other risk factors i.e. having Type I diabetes, and the use of certain drug such as steroids .
2010-05-22 13:38:41 deanna and pam In addition to DEXA and drug therapy for osteoporosis nurses can educate patients regarding diet, exercise, fall prevention and lifestyle modifications (such limiting alcohol use and stop smoking). Of upmost imporance is assuring that patients are adherent with the medications. Studies have shown at patients are not always adherent. One large trial reported in 2006 looked at 35,000 women and found that 43% were refill compliant and 20% persisted with bisphosphonate therapy during the two month study.....adherence made a big difference because there were signficantly fewer fractures if patietns were adherent to bisphonate therapy
2010-05-22 13:39:00 SJardine@ONS Does osteoporosis of the jaw occur in patients receiving aromatase inhibitor treatments?
2010-05-22 13:42:14 deanna and pam Osteoporosis of the jaw (ONJ) can occur with both intravenous and oral bisphosphonates although it is much more common with intravenous agents. In one study of frequency of ONJ in IV bisphosphonates (getting the agent for bone mets) the incidence in patients with breast cancer was 1.2%.. However a more recent study pointed to a prevalence of 5.3% in breast cancer patietns. When looking at the incidence with oral bisphosphonates, the incidence is much lower and has been stated as possibly one in 2200 cases. Regardless, the risk is there and patients should be cautioned to have good oral hygeine, avoid invasive dental procedures while on therapy, and report any sensations in their jaw such as pain or numbness.
2010-05-22 13:43:14 deanna and pam Additionally, althugh there are no standardized guidelines to determine how safe it is to have a procedure done while on bisphosphonates, the literature currently states to hold bisphosphonate therapy for two or three months before having a necessary invasive procedure completed.
2010-05-22 13:43:52 SJardine@ONS Any new information since this article was published?
2010-05-22 13:47:32 deanna and pam Since the publication of this paper, Zoledronic Acid ( Reclast 5mg) was approved by the FDA for the treatment of osteopenia one infusion every two years.
2010-05-22 13:51:21 deanna and pam Additionally, a new therapy (a monoclonal antibody) called denosumab, which is manufactured by Amgen is pursuing approval by the FDA for treatment of osteoporosis and has been studied in women with breast cancer and men with prostate cancer. It is anticipated that this agent will be approved within a few months (the FDA required more safety data when originally filing for approval last year) and this agent seems to be very effective (and perhaps more effective than other bisphosphonates we currently have). We must wait for the final data and decision by the FDA. Denosumab would be given as a subcutaneous injection versus an infusion, so theoretically would be easier to give, although it is every six months. The side effect profile seems fairly benign in that there have been cases of ONJ and patients have described fewer symptoms related to adminstration. However, a higher risk of infection was seen as a trend in some of the trials, so we will have to see if this bears out.
2010-05-22 13:54:59 deanna and pam Denosumab is kind of interesting in that it targets the RANK receptor for RANKL a receptor activator nuclear factor kappa beta ligand; RANKL seems to be very important in bone health and is invovled in cell signaling. Future studies will probably continue to focus on RANKL....zoledronic acid is somewhat different because it specifically targets the osteoclasts and interrupts the cycle of cytokines involved in recruitment of osteoclasts (which break down bone) and other growth factors stimulating cell growth.
2010-05-22 13:55:51 SJardine@ONS What closing thoughts would you have for us on this topic?
2010-05-22 13:58:14 deanna and pam We would like nurses reading our paper to understand the risk of osteoporosis with AI therapy (which is such an improtant component of therapy) for women with breast cancer; how profound the estrogen loss is with these therapies, and what they can do to educate patients that are in this high risk group. Hopefully the tables of available therapies will help them understand treatment options and be better prepared to discuss them with their patients. Thanks for joining in the chat today!
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