Cancer Related Issues: Bone Metastases

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1 Cancer Related Issues: Bone Metastases Bronwyn Long, RN, DNP, ACHPN, AOCNS Updated from Hawkins, R. Cancer Related Issues: Bone Metastasis. Pittsburgh, PA: Hospice and Palliative Nurses Association; 2010: e-learning course. Disclosures Bronwyn Long has no real or perceived conflicts of interest that relate to this presentation. Objectives 1. Review bone physiology 2. Describe the pathophysiology of bone metastasis 3. Discuss assessment for patients with bone metastasis 4. Examine management of patients with bone metastasis 1

Disclosures Bronwyn Long has no real or perceived conflicts of interest that relate to this presentation. Objectives 1.

2 Bone Basics Adult human skeleton: 206 bones Functions Structure Mobility Protection Hematopoiesis Storage Acid-base balance Detoxification Endocrine Cortical or Compact Bone Hard outer shell of bone Composed of mineralized collagen 80% of total body Found in the appendicular skeleton Source: Southard, 2010 Trabecular or Spongy Bone Internal Load bearing, shock absorbing Spongy, mesh-like 20% of total body Bone core with bone marrow contact Found in the axial skeleton Source: FAB 2

of total body Found in the appendicular skeleton Source: Southard, 2010 Trabecular or Spongy Bone Internal Load bearing,

3 Bone Physiology Remodeling: normal balance between resorption and replacement Osteoblasts Osteoclasts Renew/repair bone and maintain metabolic balance Bone Metastases Source: Loyola University Chicago, Stritch School of Medicine Bone Metastasis Physiology Tumor cells travel to metastatic sites through blood vessels and lymphatic system Ideal environment for tumor cells: easily accessible blood supply, abundance of growth factors, porous nature 3

School of Medicine Bone Metastasis Physiology Tumor cells travel to metastatic sites through blood vessels and

4 Bone Metastases Physiology Once tumor cells have invaded the bone matrix they produce growth factors that can directly or indirectly stimulate osteoclasts to degrade bone Growth factors that can stimulate tumor cell growth are released from bone, thus establishing a vicious cycle of bone destruction and local tumor growth Types of Bone Metastases Osteolytic Lesions Tumor produces substances that activate resorption Increased bone destruction Breast, lung, thyroid, renal, melanoma, GI Multiple myeloma Plain film Osteoblastic Lesions Tumor produces cytokines that activate osteoblasts Increased bone formation Unbalanced osteolytic activity and marked bone turnover Prostate, breast, lung, carcinoid Bone scan Most Common Site of Metastasis Axial skeletal sites have the greatest risk for developing bone metastasis Spine 69% Skull 14% Ribs and lumbar spine most common area Source: About Cancer Upper Limbs 10-15% Rib Cage 58% Pelvis 41% Femur 25% 4

that activate resorption Increased bone destruction Breast, lung, thyroid, renal, melanoma, GI Multiple myeloma Plain film Osteoblastic Lesions Tumor produces cytokines that activate osteoblasts

5 Clinical Consequences Skeletal-related events (SREs) Pathological fractures Spinal cord compression Hypercalcemia Shortened survival Bone pain Anemia Reduced mobility Decreased quality of life Symptoms of Bone Metastasis Bone pain Intermittent to constant Dull, aching or boring Worsens throughout day and into night; with bed rest Percussion tenderness Back pain may be due to spinal cord compression or vertebral collapse Acute pain may represent fracture Symptoms of Bone Metastasis Not all bone metastases cause pain Hypercalcemia Constipation, nausea, anorexia, extreme thirst, polyuria, fatigue, muscle weakness, confusion Neurological impairment Spinal cord compression Numbness, tingling, muscle weakness in extremities Back pain Difficulty with urination or bowel movements 5

$cord compression or vertebral collapse Acute pain may represent fracture Symptoms of Bone Metastasis Not all bone metastases cause pain Hypercalcemia Constipation, nausea, anorexia, extreme$

6 Physical Exam Identify areas of discomfort Tenderness to palpation Acute or chronic pain locations Back pain Radiates around to front Numbness Tingling Loss of sensation below compression site Change in bowel and bladder function Muscle/motor weakness Diagnostic Work-Up Plain film x-rays Bone Scan CT Scan MRI Treatment Strategies Goals of treatment Relieve pain Preserve function Maintain skeletal integrity Prevent skeletal-related events (SREs) Improve quality of life Modalities Radiation, surgery, hormonal therapy, chemotherapy, and bisphosphonate therapy Other medications 6

Bone Scan CT Scan MRI Treatment Strategies Goals of treatment Relieve pain Preserve function Maintain skeletal integrity Prevent skeletal-related

7 Radiation Therapy Standard of care for bone metastasis External beam is local treatment to treat pain and stabilize bone Single fraction of 8 Gy Multiple fractions Stereotactic body radiation therapy (SBRT) Surgical Treatment Goal is to promote mobility and reduce pain Stabilization of the bone that is fractured or has impending fracture Fixation of the femur, humerus, pelvis and vertebrae are indicated Radioisotopes for Bone Metastasis Radioisotopes have an affinity for bone Strontium-89 is a high-energy beta particle emitting radioisotope Has been effective in decreasing pain Samarium-153 is also effective in alleviating pain in bone metastasis Both have bone marrow toxicity Osteoblastic lesions Multiple lesions 7

humerus, pelvis and vertebrae are indicated Radioisotopes for Bone Metastasis Radioisotopes have an affinity for bone Strontium-89 is a high-energy beta particle emitting

8 Chemotherapy Aimed at controlling the primary tumor Used to stabilize disease progression May not help with bone integrity Diet and Exercise Diet Exercise Calcium Vitamin D Limit alcohol intake Regular exercise program Moderate to intense weight bearing exercise Strength/resistance training Medication Management Pain Medications NSAIDs Corticosteroids Opioids Adjuvant IV Bisphosphonates RANKL Inhibitor Hormones 8

exercise program Moderate to intense weight bearing exercise Strength/resistance training Medication

9 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) Reduce inflammation and pain Aspirin Ibuprofen Naproxen Ketorolac IV loading dose Risk of GI bleed, ulcer Monitor renal function Corticosteroids Reduce inflammation and pain Rapid pain control Dexamethasone Risk of insomnia, psychosis Opioids Long-acting analgesia Breakthrough pain relief Bowel regimen Monitor for urinary retention 9

Corticosteroids Reduce inflammation and pain Rapid pain control Dexamethasone Risk of insomnia,

10 Adjuvants Opioid-sparing regimen Acetaminophen Monitor total daily dose Topical analgesia Lidocaine 5% patch Anxiolytics Benzodiazepines for anxiety, muscle relaxation Muscle relaxers Bisphosphonates Potent inhibitors of osteoclast-mediated bone resorption Main goal is to stabilize bone and decrease pain Prevent SREs Pain control is not immediate Also effective in hypercalcemia IV more effective than PO Zoledronic acid Pamidronate Bisphosphonate Therapy: Side Effects Skeletal/bony pain Nausea Fever Anemia Hypocalcemia/hypokalemia Renal insufficiency Osteonecrosis of the jaw (ONJ) 10

and decrease pain Prevent SREs Pain control is not immediate Also effective in hypercalcemia IV more effective than PO Zoledronic acid Pamidronate

11 RANK Signaling and Bone Homeostasis The binding of RANKL to its receptor, RANK, induces a cascade of signaling events that drives differentiation, function, and survival of osteoclasts Essential for osteoclastogenesis Osteoclast-induced resorption Critical for remodeling Denosumab Hormonal Therapy Used in hormonally sensitive tumors such as prostate and breast Can improve pain but not the integrity of bone caused by destructive lesions Calcitonin Nurses Play a Pivotal Role Identify patients at risk Evaluate patient s complaints Identify symptoms of bone metastasis Help patients understand test results Discuss recommended treatment options Support, comfort, and palliative care 11

as prostate and breast Can improve pain but not the integrity of bone caused by destructive lesions Calcitonin Nurses Play a Pivotal Role Identify patients at risk

12 References The Bone and Cancer Foundation. Managing pain related to cancer and bone Available at: Accessed: May 25, Bonneau, A. Management of bone metastases. Canadian Family Physician. 2008; April (54): Fitch, M., Maxwell, C., Ryan, C., Lothman, H., Drudge-Coates, L., & Costa, L. Bone metastases from advanced cancers: Clinical implications and treatment options. Clinical Journal of Oncology Nursing. 2009; (13) Kachnic, L. A., DiBiase, S. J., Kavanaugh, B., & Ross, M. E. Radiation therapy for the management of painful bone metastases. UpToDate Available at: Accessed: May 25, References Loyola University Chicago. Bone metastasis (secondary bone tumors). Stritch School of Medicine. Available at: y/met_bone_list1.htm. Accessed: May 25, Southard, W. Long bone orthopedics Available at: Accessed: May 26, Weinstein, E. & Arnold, R. Fast Facts and Concepts #113 Bisphosponates for Bone Pain Available at: Accessed: May 26, Weinstein, E. & Arnold, R. Fast Facts and Concepts #129 Steroids in the Treatment of Bone Pain Available at: Accessed: May 26,

Bone metastases from advanced cancers: Clinical implications and treatment options. Clinical Journal of Oncology Nursing. 2009; (13) 701-710. Kachnic, L. A., DiBiase, S. J., Kavanaugh, B., & Ross, M.

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