Karen Roesser:

I think it depends on the patient's diagnosis. If a patient has early stage breast cancer, I would not discuss this upfront with them. If they have aggressive disease and have positive lymph nodes, I would alert them to the possibility that this disease could go elsewhere and that they need to call if they have any complaints of pain, such as bone pain. They also need to be aware that this pain may be better at times (this could be related to positioning), but if it's present, they should call. In addition, I would ensure that they knew of other symptoms to be aware of related to bone metastases, including an achy feeling, shooting pains down the legs, any complaints of lower back pain, a "pulled muscle", or complaints of tingling or numbness.

Karen:

We know that multiple myeloma likes to go to the bones in up to 95% of cases. We know this is a disease that very frequently may involve the bone. So, if a patient presents with little or no bone involvement, it still needs to be discussed with the patient that we will be watching them closely for further areas of bone involvement. We also tell the patient that they need to alert the practitioner to anything that may mean further sites of disease.

Karen:

You want to alert a patient about the possibility of bone metastasis, but not make them so anxious about this possibility. I may say something like this: "Unfortunately we know that this is a type of cancer that doesn't always like to stay 'home.' This means it has the possibility of going to other sites. The bones are one of those sites. The good news is, we can give you treatment to help reduce the risk of further problems if it does spread to the bones. The important thing is, however, that you have to let us know if this happens. This means calling the office and letting us know if you are having any new pains, such as bone pain, which may be a sign of this. Sometimes, this may just feel like an 'ache,' but the important thing to remember is that an 'ache' is a pain and you need to let us know if you have an 'ache'."

Pam:

If a patient comes to me and says, "I have discomfort somewhere," I say, "We're going to do an X-ray." If it turns up bone lesions, I tell the patient, "You have to start on therapy (ZOMETA) and here's why: Once bone metastases develop, you can suffer a skeletal-related event (SRE)." Letting patients know that there is something we can do to impact or lessen the risk of an SRE is important.

Karen:

If it's in this one site, can it go to other sites? How will I know if it has gone to other sites? What should I expect in terms of pain? Does this mean it is now more likely to go to other sites in the body (other than bone)?
I try to answer each question honestly and as straightforward as possible, without causing them to have a high level of anxiety related to this. They do need to understand that bony disease can be painful, but that we will work to try to control that pain. If it has metastasized to the bone, yes, I am concerned about the possibility of it going to other sites. However, it could be years before this may happen.

Karen:

I tell patients that multiple myeloma is a disease that is typically very sensitive to treatment with many types of drugs that kill cancer cells. Response to treatment can be expected. In some patients, high dose chemotherapy and stem cell transplant may be an option.

Cathy:

It is important to keep your bones healthy to avoid injury.

Karen:

The importance of taking their vitamin D and calcium supplementation, the importance of staying hydrated and drinking fluids, the importance of maintaining good oral hygiene, and the importance of staying on schedule with their ZOMETA treatments. I also advise patients to go to the dentist to have an oral exam if they have not been recently.

Karen:

The goals of care in a patient with advanced disease would be different than with a patient for whom you are anticipating long-term survival. In the patient with advanced disease, you may be hoping for symptom control along with some prolongation of survival. If the patient has advanced disease that has relapsed after initial therapy, I would let them know that there are still several options for them.

Pam:

It's essential for patients to report early signs and symptoms of disease progression.

Karen:

I think simple terms work best: ZOMETA works in the bone to try to stop bone breakdown from occurring. When a tumor is in the bones, the number of osteoclasts (a type of bone cell that breaks down bone) may be stimulated. ZOMETA works to reduce the ability of these osteoclasts to do this.

Karen:

I use patient education sheets on ZOMETA, including the patient brochure . The brochure is easy to give to a patient, especially when you're getting together information about chemotherapy the patient is receiving.

Karen:

Potential benefits are reduction in occurrences and complications of damage to your bones, reduction in pain associated with metastasis, and reduction in fractures.

Karen:

If we can reduce the activity of these osteoclasts, then we can reduce their ability to break down bone. It is this breakdown of bone that can lead to fractures and an unstable spine.

Karen:

Side effects are mostly flu-like symptoms, which is easily treatable with NSAIDS. If these side effects occur, they get better after the first few treatments. I also review other side effects, including bone pain, nausea, and fatigue. I want to make sure patients understand these are side effects that may occur. In addition, I review the fever, myalgias, and arthralgias that could occur.

Karen:

I give patients information on possible side effects and how to treat them. I do inquire about their side effects when they come in for their next treatment.

Cathy:

We make sure they know it is not chemo, but a very important component of their cancer therapy.

Cathy:

Before the infusion, you assess patients. Are they dehydrated? Having side effects? Taking vitamin D and calcium? How's their dental health? New patients are asked why they think they are getting ZOMETA and they're given more information about it. At subsequent infusions, patients are questioned about side effects from the last infusion.

Karen:

Any change in their level of pain, whether they are able to drink adequately to maintain hydration status, and whether they have any dental concerns or appointments scheduled with the dentist.

Karen:

Patients need to be diligent about their mouth care–they should get an evaluation from a dentist before starting ZOMETA, continue to see their dentist every 6 months, and discuss with their oncologist and dentist if any invasive oral procedures need to occur. If they have any oral pain, heaviness, swelling, open areas or infection in their gums, they need to let their oncologist know.

Karen:

Yes, definitely, this makes it easier for the patient to get all their treatment at the same time and keeps them on schedule, too, so they are less apt to miss their appointment.

Karen:

I'll try to get the patient in as soon as possible if they missed the appointment so as to try to keep them on schedule. I would discuss with the physician that the q3-4 week schedule has resulted in the greatest efficacy in reducing the incidence in skeletal related events and time to first skeletal related event.

Karen:

I talk to the patient about the precautions that we will take in regard to their kidneys––monitoring their kidney function and holding the dose until their kidney function returns to close to their baseline function before restarting treatment. Also, what they can do to help: drinking 8—10 glasses of fluids a day and limiting caffeinated beverages to 2 servings per day.

Karen:

I think if a nurse sits down at the patient's level with them, it lets the patient know that you are really interested in how they are doing, to tell you what side effects they may be experiencing, and that you really want to know so you can help them. Sometimes, if symptoms are occurring related to an infusion of ZOMETA, just as a patient may keep logs related to symptoms from chemotherapy, they could also keep a log regarding any symptoms they might have related to ZOMETA.

Cathy:

Make sure you are comfortable discussing bone metastases and why they are getting ZOMETA. Also, understand the interactions for possible side effects and proper monitoring and infusion of ZOMETA.

Karen:

I think it makes you more conscious of the "whole picture" of the patient and the treatments they are receiving. The adjunctive treatments (such as IV bisphosphonate treatment with ZOMETA) associated with a patient's drug regimen are also a very important piece of the patient's well being.

Karen:

By nurses being more aware of signs/symptoms of bone metastases as well as patients who may be at increased risk, they are identifying patients earlier who may be at risk, speaking to them about signs/symptoms of bone metastasis and getting them started on a program to maintain the integrity of their bones. This in turn impacts healthcare, as we may have fewer patients who need surgical interventions or radiation therapy as treatment for their fracture or spinal cord compression.

Karen:

It gives nurses the tools to be better equipped to know what to say to patients when they ask questions about bone metastases, what can be done to treat it, and how to administer and care for patients who are receiving ZOMETA.