Executive Summary There is a gap in the literature regarding the key areas that measure the success of navigation programs—patient experience (PE), clinical outcomes (CO), and business performance or return [ Read More ]
February 2017 VOL 8, NO 2
Prevention Is the Key to Bone Health in Patients with Prostate Cancer
An interview with The Urology Group, Cincinnati, OH
Pamela Skurkay, BSN, RN, CPAN, CURN, has been a certified perianesthesia nurse since 1986 and a certified urology nurse since 2009, Clinical Manager for Physician Office, Bladder Control Center, CyberKnife Suite, and Outpatient Pharmacy; Angela K. Hunter, BSN, Advanced Prostate Cancer Coordinator; and Diana Shafer, BSN, CURN, CPC-I, Manager of Compliance and Electronic Medical Records.
In this interview, members of The Urology Group discussed the importance of bone health in patients with prostate cancer, including details about the guidelines they use, the impact of prevention, as well as the different therapies they use in their practice.
JONS How common are skeletal-related events (SREs) in patients with prostate cancer undergoing hormonal ablation therapy?
Ms Shafer In our practice, and since we started the Bone Health Program, we have seen <5% of SREs. The norm in skeletal-related issues among patients on androgen deprivation therapy (ADT) for 4 years is approximately ≤20%.
We know that too often bone health is ignored in urologic practices. We like to be on the forefront of technological and pharmaceutical treatments for our patients. We think bone health is extremely important. It goes hand in hand with treating prostate cancer, so we like to be proactive in preventing SREs, and, hopefully, lead the way for our colleagues across the nation to take bone health more seriously in their practices.
Ms Hunter When we do encounter SREs in our practice, it is usually after the patient has already sustained and been treated for one, and they are just letting us know about it at their next visit.
JONS Have you noticed any difference in the occurrence of SREs before and after you instituted monitoring treatment with prophylaxis?
Ms Hunter We started performing dual-energy x-ray absorptiometry (DXA) scans in patients with prostate cancer more than 10 years ago. We have been on the forefront of this for quite a while. I think that is why the SRE percentages that we see are low compared with the national norm. Although we do not have the statistics from 10 years ago, our numbers gradually started coming down from when we started that protocol back then.
JONS How do SREs impact quality of life and survival of your patients?
Ms Skurkay Pain in particular is a significant issue for our patients, and we try to be proactive in preventing any kind of incidents associated with skeletal fractures. Studies have shown that when patients have a major fracture in their hip or spine, their life expectancies decrease significantly. By preventing those fractures, we can keep our patients active, and, hopefully, increase their life spans.
Ms Shafer It is very important for patients to continue their active lifestyle; they want to continue playing tennis or golf. I had a patient who was concerned because he could no longer empty a 30-lb bag of salt into his water softener—he needed his son-in-law to come to his house to do it for him. These issues are important to patients and impact their self-image.
Ms Hunter We try to make sure that we keep their bones as healthy as possible so that they can continue their daily living activities. They don’t feel the same if they have to rely on somebody else to do something that they are used to doing themselves.
JONS How and when do you screen for bone health in these patients?
Ms Shafer We monitor patients as soon as they start ADT. We look at their chart and make sure that they have had a DXA scan in the past 2 years.
If a DXA scan has not been done, we order it, and if results are low (T-score, <2.5), then we give patients denosumab (Prolia) to begin protecting their bones. We also make it a point to educate our patients on the dental issues associated with Prolia when they start treatment, and make sure they are seeing a dentist regularly.
Patients whose disease has metastasized are given Xgeva (denosumab) instead of Prolia. The nuance in treatment here is that Prolia is given to patients without bone metastases to increase bone mass in men at high risk for fracture who are receiving ADT for nonmetastatic prostate cancer, whereas Xgeva is given to patients who have bone metastases to prevent SREs.
Ms Hunter In patients whose disease has metastasized, bone scans are usually conducted twice a year. We would conduct DXA scans more often, but Medicare only allows us to do a DXA scan once every 2 years on these patients.
We also make sure that patients are taking calcium and vitamin D supplements and that their calcium levels don’t get low. We check calcium levels on a regular basis if they are taking Prolia to make sure that their calcium is staying at a good, normal level. We also urge patients to stop smoking—it is always a good thing to do, no matter what.
We provide patients with educational packets when they first start ADT, which include information on bone health, the link to a website where they can sign up and get more information and talk to other people who may have questions that they had not thought of.
Ms Skurkay The educational packet also includes suggestions for light, weight-bearing exercises to help improve their bone mass. It also recommends getting enough sleep and offers other general advice on things that would be helpful for bone therapy.
Ms Shafer It also addresses weight management. If the patients are overweight, we recommend that they try to lose some weight because that will decrease their risk for a fracture.
JONS How often should bone health screenings occur?
Ms Skurkay We perform DXA scans in patients with prostate cancer undergoing hormone ablation every 2 years, according to Medicare guidelines. Patients undergoing hormone suppression therapy receive annual bone scans, whereas patients with metastatic cancer of the bones get scans every 6 months.
Ms Hunter X-rays and magnetic resonance imaging are performed sooner (ie, between regularly scheduled scans) if the patient develops bone pain, becomes symptomatic, or if something else changes.
JONS What guidelines do you follow to treat and prevent SREs or fractures in patients with prostate cancer?
Ms Hunter We follow the American Urological Association’s guidelines, as well as those of the National Comprehensive Cancer Network. Our physicians usually form a committee where they discuss those guidelines, and then, as a group, come up with a practice that they think best fits the patient population here in the Cincinnati, OH, area.
New healthcare providers and nurses are educated about these guidelines when they start with The Urology Group, so that all of our patients receive the same standard of care.
Ms Skurkay When patients come in for their first visit, they will receive a packet that includes supplements such as calcium and vitamin D; educational literature, such as mild and light weight-bearing exercises; and weight management information if they are overweight. Most of our treatment relies on preventive therapy.
JONS What treatment approach do you take in patients with prostate cancer who have a history of low-trauma fracture?
Ms Skurkay The physician may choose to use bisphosphonate infusions or Xgeva injections in patients with a history of low-trauma fracture.
Patients taking bisphosphonates come to the office once a month for an intravenous (IV) infusion of Zometa (zoledronic acid). They will usually have blood drawn 2 weeks prior to the infusion to check creatinine levels. Bisphosphonate dosage is adjusted if creatinine levels are too high (>1.5 mg), or if the level rises by >0.5 mg within 1 month following their latest infusion.
Patients taking Xgeva also come to the office once a month for a subcutaneous injection to the abdomen or thigh. During the first visit, patients stay a half hour so that they can be monitored for side effects after the injection; if they tolerated the injection, we will proceed with treatment. The office visits, which last 15 minutes or less, entail talking to the patient, getting their vital signs (while the medication is warming to room temperature), administering the shot, and then they are out the door.
Patients seem to prefer getting the subcutaneous injection rather than the IV infusion. One of the reasons is that patients can sometimes experience nausea if the bisphosphonate infusion runs too fast; therefore, they usually have to stay for 20 to 30 minutes
JONS What side effects have you observed following an Xgeva injection?
Ms Skurkay The side effects patients experience with bisphosphonate infusions and Xgeva injections are similar. Patients have reported mild, flulike symptoms, fatigue, low-grade temperature, and occasionally chills, for 24 to 48 hours after treatment. Patients may be switched to a different category of medications if they report more extensive side effects, such as those lasting longer than 48 hours, or if they have severe symptoms (eg, severe pain). We advise patients to contact us right away if these side effects occur.
JONS How are antiresorptive agents used in patients with prostate cancer?
Ms Skurkay Antiresorptive agents are usually initiated as soon as any bone metastases are identified. They are given regularly (once a month), and whether patients are prescribed bisphosphonate infusions or Xgeva subcutaneous injection depends on the patients’ condition and their insurance.
JONS Do most of your patients with prostate cancer have Medicare insurance?
Ms Skurkay At The Urology Group, we have a lot of patients with prostate cancer who are not of Medicare age; they may be younger. We have patients who are in their 40s or 50s.
It is really important for these patients to be able to maintain a normal lifestyle; it really affects their self-image a lot when they can’t perform their normal daily activities. I’m not just talking about waking up and getting dressed in the morning—they like to golf, or have an active lifestyle, play with their grandchildren, lift things that they could normally lift without worrying about getting a fracture. It is more important to the younger men than it is to the older men.
As Diana mentioned earlier, we had a patient who said that he could no longer lift 30-lb bags of salt to fill his water softener and had to have his son-in-law come over and do it for him—it was embarrassing for him that he couldn’t even do that normal activity, which he used to do so easily.
Ms Hunter It’s not just about a 30-lb bag of salt—it’s also about their kids, and their grandkids. They can’t pick them up, love them, and hold them like they want.
JONS Have there been any issues with patients not being able to afford their therapy?
Ms Skurkay With the private payers, there have sometimes been issues with extremely large copays for patients, but there are foundations available that offer assistance to patients so that they can get the medications they prefer.
Ms Shafer The foundations also help Medicare patients with their copays, or their 20%, depending on whether they have health maintenance organization Medicare or traditional Medicare.
JONS Is there a difference in patient adherence to therapy among antiresorptive agents?
Ms Skurkay I feel that there is a difference in patient adherence. Most of our patients prefer to get a subcutaneous injection in their abdomen or thigh because they can be in and out of the office in 15 minutes, whereas getting an IV infusion takes 20 to 30 minutes, or more.
In addition, patients getting IV therapy also have to get a blood test within 2 weeks of their infusion versus the injection, which doesn’t require follow-up blood work.
Ms Shafer I, too, have seen that a lot of patients prefer the subcutaneous injection versus the infusion, just because it’s only 1 shot and it’s less invasive.
JONS Do your patients share their views on the advantages of one medication over another?
Ms Skurkay We find that a lot of our patients have researched their medication or treatments on the Internet. They actually come in to us fairly well-educated and ask us some pretty good questions. My patients much prefer the subcutaneous injection versus IV infusion.
We have also had several patients who were needle- phobic. A little shot in the belly is easier for them to tolerate than going through an IV infusion.
Ms Hunter It seems like, in today’s modern world, everybody wants convenience, and for things to be quick and easy. The quicker it is for the patient, the happier the patient.
Ms Shafer A lot of offices don’t have the setup to administer IV bisphosphonates, so they would have to come here to have that done. That would be an inconvenience to a lot of them, when they could go right down the street from their house and get both their shots at 1 time, during 1 visit.
JONS Do you allow patients taking Xgeva to self-administer the injections at home?
Ms Skurkay We do not allow patients to self-administer Xgeva; all the injections are administered by a nurse in the office. Some patients, however, administer their own testosterone injections at home, and we do teach them how to do that. We also have patients who have erectile dysfunction who are taught how to administer their own penile injections with medication.
JONS Does your practice allow the nurse navigator to help patients with prostate cancer with their medication choices and financial issues, or do you do that?
Ms Shafer Angela Hunter, BSN, is our advanced prostate cancer coordinator. It’s her job to watch our prostate cancer population and move them to physicians who will get them the appropriate treatment as soon as they possibly can.
We have a team of precertified specialists who precertify these types of medications, and apply to the foundations to help patients with their financial copays.
Ms Hunter I’m still getting my feet wet. I’ve been on the clinical side, and now I work on the backside, and to be honest, I like both. I like the patient care, but I also like what I’m doing now, too. I really miss the staff I used to work with, as well as my patients. You really get attached to them. I worked specifically with one of our advanced prostate cancer physicians, so I got to see their patients on a monthly basis. You really get to know the patients, and they get to know you. It’s a comfortable feeling for both parties because the patient feels comfortable enough to tell you something that they may not tell somebody else.
JONS How do you envision the future evolution of management of bone health in patients with advanced prostate cancer?
Ms Shafer I think with technology and all the different medications that are being researched now, the bone health of our future patients can only get better from this point forward.
Ms Skurkay It’s all about preventive therapy.
Ms Hunter With everybody having access to the Internet, not only can we provide them with information, but patients have the opportunity to go online and research even more information. Knowledge is power, and I think that the more knowledge we have, the more powerful the person. Chances of preventing bone health issues in the future can only get better.