Preventing, identifying, and managing medication-related osteonecrosis of the jaw: a practical guide for nurses and other allied healthcare professionals.

BACKGROUND: Medication-related osteonecrosis of the jaw (MRONJ) is an infrequent, but potentially serious, adverse event that can occur after exposure to bone-modifying agents (BMAs; e.g., bisphosphonates, denosumab, and antiangiogenic therapies). BMAs are typically used at higher doses to prevent skeletal-related events in cancer patients and at lower doses for osteoporosis/bone loss. MRONJ can cause significant pain, reduce quality of life, and can be difficult to treat, requiring a multiprofessional approach to care. METHODS: We reviewed the literature and guidelines to summarize a practical guide on MRONJ for nurses and other allied healthcare professionals. RESULTS: While there is a risk of MRONJ with BMAs, this should be considered in relation to the benefits of treatment. Nurses and other allied healthcare professionals can play a key role alongside physicians and dentists in assessing MRONJ risk, identifying MRONJ, counseling the patient on the benefit-risk of BMA treatment, preventing MRONJ, and managing the care pathway of these patients. Assessing patients for MRONJ risk factors before starting BMA treatment can guide preventative measures to reduce the risk of MRONJ. Nurses can play a pivotal role in facilitating multiprofessional management of MRONJ by communicating with patients to ensure compliance with preventative measures, and with patients' physicians and dentists to ensure early detection and referral for prompt treatment of MRONJ. CONCLUSIONS: This review summarizes current evidence on MRONJ and provides practical guidance for nurses, from before BMA treatment is started through to approaches that can be taken to prevent and manage MRONJ in patients receiving BMAs.

Management of bone health in patients with cancer: a survey of specialist nurses.

BACKGROUND: Patients with cancer can experience bone metastases and/or cancer treatment-induced bone loss (CTIBL), and the resulting bone complications place burdens on patients and healthcare provision. Management of bone complications is becoming increasingly important as cancer survival rates improve. Advances in specialist oncology nursing practice benefit patients through better management of their bone health, which may improve quality of life and survival. METHODS: An anonymised online quantitative survey asked specialist oncology nurses about factors affecting their provision of support in the management of bone metastases and CTIBL. RESULTS: Of 283 participants, most stated that they worked in Europe, and 69.3% had at least 8 years of experience in oncology. The most common areas of specialisation were medical oncology, breast cancer and/or palliative care (20.8-50.9%). Awareness of bone loss prevention measures varied (from 34.3% for alcohol intake to 77.4% for adequate calcium intake), and awareness of hip fracture risk factors varied (from 28.6% for rheumatoid arthritis to 74.6% for age > 65 years). Approximately one-third reported a high level of confidence in managing bone metastases (39.9%) and CTIBL (33.2%). International or institution guidelines were used by approximately 50% of participants. Common barriers to better specialist care and treatment were reported to be lack of training, funding, knowledge or professional development. CONCLUSION: This work is the first quantitative analysis of reports from specialist oncology nurses about the management of bone metastases and CTIBL. It indicates the need for new nursing education initiatives with a focus on bone health management.

Skeletal Health Part 2: Development of a Nurse Practitioner Bone Support Clinic for Urologic Patients.

Part 1 of this article highlighted the potential negative effects of cancer on the skeleton and provided an overview of available treatment options. Part 2 presents a nurse practitioner-led Bone Support Clinic, which was developed for patients with cancer-induced bone disease and cancer therapy-induced bone loss. This clinic, started in 2011 in a university medical center urology/oncology outpatient center in London, England, United Kingdom, has been a collaborative effort among a multidisciplinary team of doctors, nurse practitioners and nurses. Patients have responded positively to the improved continuity of care, and we have been able to assess and treat impending skeletal-related events in a more timely manner The needs of our patient population and problems with the existing service are reviewed, and the importance of a multidisciplinary approach to these problems is discussed. Initiation of a nurse practitioner-led Bone Support Clinic and the impact of timely response to the effects of cancer and cancer therapies on the skeletal system are outlined and offered as a model.

Skeletal Health Part 1: Overview Of Bone Health and Management In the Cancer Setting.

Cancer-induced bone disease and cancer therapy-induced bone loss are significant skeletal problems related to the treatment for urological and other cancers. Our team of specialists and nurse practitioners developed a nurse practitioner-led Bone Support Clinic for urologic cancer patients at a university hospital in London, England, United Kingdom, to address this issue. The clinic has been well-accepted, has made a positive impact on the patient journey, helps to ensure continuity of care, and highlights patients who require assessment or treatment for impending skeletal-related events in a timely fashion. This article has been divided into two parts for improved readability.

Osteonecrosis of the Jaw in Patients Receiving Bone-Targeted Therapies: An Overview--Part I.

Urologic patients receiving bone-targeted therapies are at risk of developing osteonecrosis of the jaw (ONJ). ONJ has historically been associated with bisphosphonate therapy. More recently, RANK-Ligand inhibitors (denosumab) have also been used to reduce the risk of skeletal-related events in patients who have advanced cancers with bone metastases. More than 65% of men with metastatic prostate cancer and nearly 75% of women with metastatic breast cancer are affected by bone metastases. The literature has described ONJ associated with bisphosphonate therapy as bisphosphonate-related osteonecrosis of the jaw (BRONJ). However, with evidence also linking the use of RANK-Ligand inhibitors with osteonecrosis of the jaw, we advocate use of the term "anti-bone resorption therapy-related osteonecrosis of the jaw" (ABRT-ONJ). The term "medication-related osteonecrosis of the jaw" (MRONJ) is now becoming more widespread. There is not a universally accepted definition of ABRT-ONJ, which may have hindered recognition and reporting of the condition. In Part I of this article, a review of current knowledge around the etiology of ABRT-ONJ and incidence data are provided. In Part II, we provide an audit of ONJ in a nurse consultant-led bone support clinic. In the article, we refer to zoledronic acid because this is the bisphosphonate of choice for use in men with prostate cancer in the United Kingdom.

Schistosomiasis-an endemic parasitic waterborne disease.

Schistosomiasis (or bilharzia) is a chronic waterborne disease caused by parasitic worms or schistosoma in the tropics and sub tropics. Five main species exist, and common to all is its transmission to humans as a result of exposure to infested fresh water, into which the cercariae of the parasite are released by freshwater snails. With the rise of tourism and travel, more people are travelling to countries where schistosomiasis is a risk. Schistosoma haematobium is responsible for urogenital schistosomiasis, in which manifestations range from acute hypersensitivity reactions to bladder disease in the detection of which the nurse cystoscopist can have a significant role. Treatment is highly effective, and the diagnosis should be considered in individuals with possible clinical illness who have travelled to or lived in endemic areas.

Cancer-induced bone disease.

A diagnosis of bone metastases may be devastating for patients with cancer because it suggests that the cancer is incurable and that patients are at increased risk of developing skeletal-related events. The optimal goal for these patients should be to maintain quality of life. Nurses have an important role in the care of patients with cancer-induced bone disease and need to have a good understanding of the effects of bone metastases to ensure prompt management of this condition.

Penile cancer: diagnosis, clinical features and management.

This article aims to provide the reader with an overview of penile cancer. The focus is on clinical and medical aspects to help nurses understand incidence, aetiology, diagnosis and treatment, to enable them educate and support patients affected by this disease. Psychological support of patients and their partners is also emphasised as the effects of penile cancer can be significant.

Prostate cancer overview. Part 2: metastatic prostate cancer.

Advances in diagnosis mean that prostate cancer can be detected in the early stages, when options such as surgery and radiotherapy offer curative approaches and active surveillance is appropriate. However, advanced or metastatic disease continues to challenge medical management, which offers only palliative approaches. With such a prognosis, effective treatment of metastatic and metastatic castrate-resistant prostate cancer (mCRPC) is an important element of the management of these patients. The second article of this two-part series focuses on the main management approaches, emerging therapies and nursing roles.

Prostate cancer overview. Part 1: non-metastatic disease.

Prostate cancer is now recognised as one of the most important medical problems facing the male population, with additional factors such as age, race and familial history amplifying the risk of disease. Part 1 of this two-part article, discusses and provides an overview of the key risk factors, through to diagnosis and management of non-metastatic disease. With the current changing dynamics in healthcare provision both in hospitals and the community setting, the articles aims to inform the wider nursing arena of the key issues that may be raised by men seeking advice and intervention both before and following treatment.

Management of patients with metastatic prostate cancer.

Prostate cancer is the most common cancer in men and is recognised as a significant health problem. Treatment of advanced or metastatic prostate cancer is challenging, and support and care should be tailored to meet the individual's needs. This article focuses on the pharmacological management of metastatic prostate cancer and the nurse's role in providing patients with information about the disease. It is hoped that this article will be used as a resource to improve patient care.

The Managing Advanced Cancer Pain Together (MACPT) conversation tool: an evaluation of use in clinical practice.

Aim: To investigate use of the 'Managing Advanced Cancer Pain Together' conversation tool between individuals with advanced cancer and healthcare professionals (HCPs) during routine consultations. Methods: Twenty-one patients and six HCPs completed questionnaires before and after use of the tool (at their routine consultation 1 and consecutive consultation 2, respectively). Results: Patients and HCPs were satisfied with communication during both consultations. When using the tool, patients most frequently selected physical pain descriptors (95.2%), followed by emotional (81.0%), social (28.6%) and spiritual (28.6%) descriptors. Patients found the tool useful, stating that it helped them describe their pain. HCPs considered the tool difficult to incorporate into consultations. Conclusion: The study highlighted the need to consider the various aspects of cancer pain.

The Managing Advanced Cancer Pain Together conversation tool was designed to help patients with advanced cancer and their healthcare professionals (HCPs) discuss various aspects of pain (physical, emotional, social and spiritual pain) during their consultations. The tool comprises 41 words to describe pain, and patients are asked to select three words that best describe their experience. For this study, patients with advanced cancer and their HCPs completed two consultations, one without the tool and one with the tool. Overall, patients found the tool helpful and used words relating to physical (95.2%), emotional (81.0%), social (28.6%) and spiritual (28.6%) pain to describe their recent experience. HCPs reported that the tool may be difficult to use during consultation due to limited time.

Metastatic Prostate Cancer: An Update on Treatments and a Review of Patient Symptom Management.

BACKGROUND: Available treatment options have improved overall survival and contributed to delayed progression, but metastatic prostate cancer remains incurable. Treatment strategies are based on disease progression assessed by a combination of biochemical, radiographic, and symptomatic changes. OBJECTIVES: The aim of this article is to review metastatic prostate cancer, symptoms representing disease progression, disease treatments, and symptom management. METHODS: A PubMed® search restricted to English-language articles published since 1990 was conducted in August 2018 with combinations of the keywords "metastatic prostate cancer," "symptom assessment," and "treatment." Review articles were excluded, but their reference lists were reviewed to identify additional articles. Information from relevant articles published after August 2018 was added as appropriate based on author consensus. FINDINGS: Nursing professionals play vital roles in symptom recognition and reporting, identification of disease progression, patient education, and implementation of individualized treatment strategies.

Guidance for the assessment and management of prostate cancer treatment-induced bone loss. A consensus position statement from an expert group.

CONTEXT AND OBJECTIVE: Incidence of prostate cancer (PC) is increasing, but androgen deprivation therapy (ADT) and other therapies are substantially improving survival. In this context, careful consideration of skeletal health is required to reduce the risk of treatment-related fragility fractures and their associated morbidity and mortality. This risk is currently not well-managed. ADT causes significant loss of bone mineral density (BMD). In the metastatic setting, systemic treatments (e.g. chemotherapy, abiraterone, enzalutamide) are used alongside ADT and may require concomitant glucocorticoids. Both ADT and glucocorticoids pose significant challenges to skeletal health in a population of patients already likely to have ongoing age-related bone loss and/or comorbid conditions. Current PC guidelines lack specific recommendations for optimising bone health. This guidance presents evidence for assessment and management of bone health in this population, with specific recommendations for clinical practitioners in day-to-day PC management. METHODS: Structured meetings of key opinion leaders were integrated with a systematic literature review. Input and endorsement was sought from patients, nursing representatives and specialist societies. SUMMARY OF GUIDANCE: All men starting or continuing long-term ADT should receive lifestyle advice regarding bone health. Calcium/vitamin D supplementation should be offered if required. Fracture risk should be calculated (using the FRAX® tool), with BMD assessment included where feasible. BMD should always be assessed where fracture risk calculated using FRAX® alone is close to the intervention threshold. Intervention should be provided if indicated by local or national guidelines e.g. UK National Osteoporosis Guideline Group (NOGG) thresholds. Men requiring bone protection therapy should be further assessed (e.g. renal function), with referral to specialist centres if available and offered appropriate treatment to reduce fracture risk. Those near to, but below an intervention threshold, and patients going on to additional systemic therapies (particularly those requiring glucocorticoids), should have FRAX® (including BMD) repeated after 12-18 months. PATIENT SUMMARY: Modern treatments for prostate cancer have led to significant improvements in survival and quality of life. However, some of these treatments may lead to weakening of patient's bones with risk of fracture and it is therefore important to monitor patients' bone health and provide bone protection where needed. This paper provides specific guidance to clinical teams, based on the most recent research evidence, to ensure optimal bone health in their patients.

A nurse practitioner model for the assessment of suspected prostate cancer referrals is safe, cost and time efficient.

PURPOSE: To evaluate the outcomes from a Urology Nurse Practitioner (UNP)-led service for the initial assessment and diagnostic decision making and for suspected prostate cancer referrals. METHODS: Using a modified Delphi analysis approach, a panel of Urological Prostate Cancer specialists were asked to review the UNP management plans of a convenience sample of 60 randomly selected patient cases - between June 2012 and June 2015. The panel was required to establish consensus or identify divergence of clinical practice, based on five key statements. In addition, cost analysis, waiting time and patient satisfaction evaluation were made regarding the nurse-led service. RESULTS: In 87% (52/60 cases), consensus was reached by the panel that the UNP management plan was entirely appropriate and in only two cases was there discordance, where the panel felt that the management plan by the UNP was inappropriate with errors potentially and significantly affecting the patient. Over the 3 years, a modest cost saving of £11,500.38 was realised, which due to increased referrals has now realised in 1 year (2017/18) a saving of £11,335.50. Compared to the previous physician-led service, waiting times for patient appointment fell by 52% over the 3-year period; 57/63 (90%) patients reported being satisfied with seeing a UNP instead of a doctor for their first appointment; 60/63 (95%) reported that, following the initial hospital visit with the UNP, they had a clear understanding of what the next steps were in their assessment. Overall, 54/63 (86%) were 'very satisfied' with the UNP-led service. CONCLUSION: Our study demonstrates that a UNP approach to the assessment and management of suspected prostate cancer referrals provides an effective approach to care in an ever-demanding healthcare arena.Through a supported training programme, urology nurses can deliver a high standard of service.

Medication-related osteonecrosis of the jaw: definition and best practice for prevention, diagnosis, and treatment.

Skeletal complications caused by osteoporosis or bone metastases are associated with considerable pain, increased mortality, and reduced quality of life. Furthermore, such events place a burden on health care resources. Agents that prevent bone resorption, such as bisphosphonates or denosumab, can reduce the risk of skeletal-related events and are widely used in patients with osteoporosis or bone metastases of cancer. Medication-related osteonecrosis of the jaw (MRONJ) is a rare, but potentially serious, adverse event associated with high cumulative doses of bisphosphonates or denosumab. However, MRONJ can be treated, and the likelihood of the development of this condition can be reduced through prophylactic dental care and the maintenance of good oral hygiene. Dentists, as part of a multiprofessional team, have a critical role in preventing MRONJ. This review describes the incidence and pathophysiology of MRONJ and provides guidance for dental practitioners with regard to the screening, prophylactic treatment, diagnosis, and management of patients with this condition.

Diagnosis and management of malignant spinal cord compression: part 2.

Malignant spinal cord compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multidisciplinary care and rehabilitation are paramount in optimising quality of life for the affected individual. The effects of MSCC can range from minor sensory, motor and autonomic changes to severe pain, and complete paralysis that significantly affects the remainder of a patient's quality of life. When caught early, the symptoms of MSCC can be prevented, minimised or possibly reversed. However, failure to recognise the condition and its serious nature, together with limited awareness of the importance of early referral for treatment, can result in irreversible paralysis. Therefore, it is essential that nurses providing clinical care for these at-risk patients are able to identify early symptoms, and undertake a thorough patient history and examination; educating the patient and their family about the signs and symptoms of MSCC that need to be reported as soon as they occur.

Diagnosis and management of malignant spinal cord compression: part 1.

Malignant spinal cord compression (MSCC) is a particularly challenging area of cancer care where early diagnosis and expert multidisciplinary care and rehabilitation are paramount in optimising quality of life for the affected individual. The effects of MSCC can range from minor sensory, motor and autonomic changes to severe pain and complete paralysis that significantly affects the remainder of a patient's quality of life. When caught early, the symptoms of MSCC can be prevented, minimised or possibly reversed. However, failure to recognise the condition and its serious nature, together with limited awareness of the importance of early referral for treatment, can result in irreversible paralysis. Therefore, it is essential that nurses providing clinical care for these at-risk patients are able to identify early symptoms, and undertake a thorough patient history and examination, educating the patient and their family about the signs and symptoms, which should be reported as soon as they occur.

Recognizing Symptom Burden in Advanced Prostate Cancer: A Global Patient and Caregiver Survey.

BACKGROUND: Bone metastases in men with prostate cancer are often initially asymptomatic, resulting in delayed identification, diagnosis, and appropriate treatment. To assess how patients with advanced prostate cancer (aPC) communicate symptoms to health care providers, an international patient survey was conducted. METHODS: An online and phone survey was conducted by Harris Poll in 11 countries (Brazil, France, Germany, Japan, Italy, Netherlands, Singapore, Spain, Taiwan, United Kingdom, United States) from February 12 to October 27, 2015, in men with aPC (ie, those who reported as having PC beyond the prostate [metastatic]) and their caregivers. Cell weighting was used to ensure equal weight of data across countries. Percentages are based on weighted n values. RESULTS: A total of 927 men with aPC (weighted n = 664) and 400 caregivers completed the survey. Most commonly reported symptoms were fatigue (73%), urinary symptoms (63%), sexual function symptoms (62%), and bone pain (52%). Of 568 patients with bone metastases (weighted n = 421), most (73%) noticed pain before receiving a diagnosis of metastatic PC. Most patients with aPC (56%) were uncertain if their pain was cancer related, 55% felt they had to live with daily pain, 45% sometimes ignored pain, and 39% had difficulty talking about pain. Patients who had a caregiver were more likely than those without to discuss pain at every visit (45% vs. 32%, P < .05). CONCLUSIONS: Disease symptoms in aPC are often underrecognized. Tools encouraging effective communication among patients, caregivers, and health care providers on early symptom reporting may lead to enhanced symptom and disease management.

Skeletal complications and the use of bisphosphonates in metastatic prostate cancer.

Metastatic prostate cancer represents an incurable progression of the disease that accounts for the vast majority of disease related mortality and is associated with significant skeletal morbidity with events including bone pain, fractures and spinal cord compression. This article provides an overview of the bone disease in this patient group, with a specific focus on the role of bisphosphonate use, in addressing quality of life issues. Key clinical trial data relating to bisphosphonates is presented and discussed, culminating in key management guidelines.