| 2010-05-27 11:49:09 |
mohammad |
hello |
| 2010-05-27 11:54:04 |
Chemo nurse |
Hi |
| 2010-05-27 11:59:41 |
Chemo nurse |
hello |
| 2010-05-27 12:59:58 |
cindy |
Hi! I am looking to sit in on the virtual journal club chat at 1pm on "Update to Identifying and Managing Osteoporosis in Women With Breast Cancer" am I in the right place?? |
| 2010-05-27 13:03:37 |
Stephanie@ons |
Welcome to the ONS Virtual Journal Club!!! |
| 2010-05-27 13:04:01 |
deanna and pam |
Hi! We welcome questions regarding our article! |
| 2010-05-27 13:04:42 |
Stephanie@ons |
Today we will be talking about 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® |
| 2010-05-27 13:05:26 |
Stephanie@ons |
What questions do you have for Deanna and Pam? |
| 2010-05-27 13:07:33 |
cindy |
Great! I am in the right place! I am a brand new breast cancer navigator, just starting my job and I am enrolled in the site specific breast cancer webcourse. I just got the info regarding this chat and have not participated in an ONS "chat" before. I was hoping there would be more people involved in this chat so I could "observe"and learn from the discussion. |
| 2010-05-27 13:08:06 |
WHNP |
I have a very hard time convincing a women to consider IV tx for osteoporosis with or without a Dx of breast cancer? Any tips? |
| 2010-05-27 13:08:10 |
deanna and pam |
No problem, welcome to the chat. You can ask anything you like. |
| 2010-05-27 13:08:37 |
deanna and pam |
Why has your patient failed oral therapies? Is that no longer an option for her? |
| 2010-05-27 13:10:20 |
WHNP |
Since bone loss are more predictive of fracture risks, the IV tx is a better tx with someone who already has osteoporosis. My understanding is that the oral therapies are being questioned at how long someone can remain on them? |
| 2010-05-27 13:10:48 |
WHNP |
The hip is more predictive than the spine |
| 2010-05-27 13:11:02 |
deanna and pam |
If the issue is compliance with therapy, then IV is preferred. It's so patient specific. One of our patients was started on Zometa and had terrible arthralgias...would never take the IV again. |
| 2010-05-27 13:12:17 |
deanna and pam |
Intravenous bisphosphonates are very effective. Patients have stayed on the oral for years but can get side effects. There was also some interesting data that came out recently on risk of fracture in the head of the femur with alendronate....final data is not out yet, but interesting..... |
| 2010-05-27 13:12:27 |
WHNP |
The concern is that the biphosphates only replace one type of bone but there are 2 types in bone. I think it is unclear what happens when only 1 type of bone remains??? |
| 2010-05-27 13:13:45 |
deanna and pam |
True....you can't force a patient to take IV instead of orals, but if this is a patient with breast cancer I am inclined to want to use IV bisphosphonate particularly with the new data from Gnant on reduction of breast cancer risk with use of zoledronic acid |
| 2010-05-27 13:14:27 |
cindy |
Do you think due to the recent media reports regarding the risk of fractures in the femur that patients are reluctant to try zometa? |
| 2010-05-27 13:14:57 |
Stephanie@ons |
What is the clinical problem that is addressed in the article? |
| 2010-05-27 13:15:23 |
Stephanie@ons |
Welcome to the chat BGregoire1. |
| 2010-05-27 13:15:30 |
deanna and pam |
I would say that is true; also the ONJ risk is also there! |
| 2010-05-27 13:15:45 |
Stephanie@ons |
We are 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® Please feel free to ask your questions. |
| 2010-05-27 13:16:11 |
WHNP |
Is there any predictive pattern for those at risk for the jaw bone problem? |
| 2010-05-27 13:16:18 |
deanna and pam |
Although the risk of ONJ is much higher with the use of bisphosphonates in bone mets, reports of ONJ have been published with orals as well |
| 2010-05-27 13:17:03 |
deanna and pam |
No predictive pattern, but risk factors include poor dentition, invasive dental procedure performed |
| 2010-05-27 13:17:15 |
WHNP |
How soon after starting treatment can ONJ be identified early? |
| 2010-05-27 13:18:14 |
deanna and pam |
There is no particular pattern from the series I have reviewed; but the longer you are on therapy, the higher your risk; also it is higher with Zometa than pamidronate since it is a more potent bisphosphonate........ |
| 2010-05-27 13:18:43 |
WHNP |
Are the vitamin D and calcium recommendations the same with those on biphoshponates? more critical? Need good Vit. D absorption? |
| 2010-05-27 13:18:50 |
deanna and pam |
Additionally, dentists are unclear how long to stop (or even to stop) a bisphosphonate in order to have a dental procedure done...... |
| 2010-05-27 13:20:03 |
deanna and pam |
1000-1500 mg is recommended along with 400 IU of vitamin D. Patients need to read the label on the calcium to make sure they are getting the right amount of elemental calcium.........we are also checking vitamin D levels |
| 2010-05-27 13:20:25 |
WHNP |
800 iu to 1000iu? |
| 2010-05-27 13:20:25 |
Stephanie@ons |
What were the outcomes or recommendations for practice, education, administration or research based on the evidence presented? |
| 2010-05-27 13:21:35 |
deanna and pam |
Some patietns who are low in vitamin D get treated with 50,000 units weekly for twelve weeks and then levels rechecked...you can get 800 IU units with two MVIs |
| 2010-05-27 13:23:15 |
deanna and pam |
Our recommendations for practice are to identify those patietns at risk and increase nurses awareness of the problem. Appropriate screening should be done with dexa and vitamin D level......education, particularly because adherence to bisphosphonates is such an issue. One trial showed that patients compliance dropped off by 40% the first year of therapy! |
| 2010-05-27 13:24:19 |
WHNP |
After hormonal therapy tx for breast cancer does the bone loss risk continue at an accelerated rate or can return to that women's normal risk? |
| 2010-05-27 13:25:44 |
deanna and pam |
We don't have data to definitively state the answer to that question....but once the profound estrogen depletion is over, it would seem likely. I can't state for sure... |
| 2010-05-27 13:26:20 |
WHNP |
any thoughts when to repeat DEXA after tx |
| 2010-05-27 13:27:35 |
deanna and pam |
Every two years, unless you feel the patient is at higher risk, you can recheck every year. Bone markers can be checked as well, but the dexa scan give you more information. Not likely it would be covered by Medicare, however |
| 2010-05-27 13:29:02 |
cindy |
What patient ed materials are available on this topic? |
| 2010-05-27 13:29:31 |
deanna and pam |
New things on the horizon in this area.....Novartis is seeking FDA approval for zoledronic acid in breast cancer based on the Gnant trial....that will be interesting. And Amgen's denosumab looks very promising, so stay tuned because that will be subcutaneous versus IV or oral.....and different side effect profile.... |
| 2010-05-27 13:30:02 |
WHNP |
can you address the DEXA and greater than 300 lb pt? Granted her risk in general might be less due to being heavy but if she is on an AI we are now increasing it. Are you still using her DEXA for tx what would you use if not? |
| 2010-05-27 13:30:25 |
deanna and pam |
Patient ed materials are available on osteoporosis from the NOF (National Osteoporosis Foundation) and you can print them off their website....the National Arthritis Foundation also has some nice materials. |
| 2010-05-27 13:31:38 |
deanna and pam |
It is a problem when the patient is overweight. testing of the radius is another test you can use for this type of patient |
| 2010-05-27 13:33:09 |
WHNP |
I always wonder if overweight women and non asian or caucasian women develop osteoporosis early without obvious risk factors are they really a much higher risk pt to monitor? |
| 2010-05-27 13:35:07 |
deanna and pam |
We don't have a reference to support this, but we think the overweight woman is at lower risk. Family history is also an important indicator, and co-morbidities (such as diabetes) and other medicaitons can certainly increase risk. So it's important to get a truly comprehensive assessment and history |
| 2010-05-27 13:35:35 |
deanna and pam |
If the women have additional risk factors, you can get insurance to pay for a dexa scan earlier than one would normally start |
| 2010-05-27 13:36:35 |
Stephanie@ons |
BGregoire1, do you have any questions for Deanna and Pam? |
| 2010-05-27 13:37:54 |
BGregoire1 |
My only question was the educational material and they already addressed that issue, thanks |
| 2010-05-27 13:38:21 |
Stephanie@ons |
What is the incidience of osteonecrosis of the jaw in patients who are taking AI's? |
| 2010-05-27 13:38:54 |
WHNP |
Should calcium/D be taken at different times than AI? |
| 2010-05-27 13:39:30 |
Stephanie@ons |
Welcome mandi10 to the ONS Virtual Journal CLub chat!! |
| 2010-05-27 13:39:42 |
mandi10 |
good afternoon |
| 2010-05-27 13:39:52 |
Stephanie@ons |
We are 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® Please feel free to ask you questions at anytime. |
| 2010-05-27 13:40:25 |
Stephanie@ons |
The transcript for this chat and the past chats are posted on the ONS website under Publications/VIrtual Journal Club. |
| 2010-05-27 13:40:56 |
deanna and pam |
The incidence of ONJ in breast cancer patients on AIs is not yet available, but we have some data from several series including bone mets and patients taking bisphosphonates for osteoporosis....Several of these trials described a risk of 1.2% or lower in breast cancer and as high as 2.4% in multiple myeloma. Most recently, a paper published last year in 2009 on breast cancer showed a rate of 5.3%........it's definitely something to monitor. In one of the trials, ONJ resolved in a quarter of the patients with just conservative therapy and no debridement |
| 2010-05-27 13:41:50 |
deanna and pam |
The signs and symptoms of ONJ could be a feeling of heaviness in the jaw, pain, numbness and of course, the diagnosis is made when exposed bone in the jaw is visible. |
| 2010-05-27 13:45:36 |
WHNP |
can you answer the question whether Calcium/D should be taken at different times than AI? Doesn't matter? before bed? |
| 2010-05-27 13:46:47 |
Stephanie@ons |
working on that one now. |
| 2010-05-27 13:47:22 |
cindy |
Has anyone in this chat seen ONJ in the clinical setting? First hand? |
| 2010-05-27 13:48:07 |
WHNP |
I have not seen it but I mostly work with oral tx which is less risk than IV |
| 2010-05-27 13:48:30 |
deanna and pam |
In regards to the timing of when to take calcium/D and AI. You don't want to take the calcium with other medications that could affect the absorbtion of calcium. It is always better to limit the calcium to 500mg at a time of more than that may not be absorbed. Patient who need to take two tablets should not take them together. Calcium can be taken any time of the day but not with blood pressure medications or antibotics. |
| 2010-05-27 13:50:24 |
deanna and pam |
Yes, have definitely seen it. In fact, we published the first case in our institution in CJON in 2005......it is rare, but if you take care of patients on bisphosphonates for a long time you will see it......it first appeared in 2003 in the medical literature, and the physicians writing up the case attributed it to taxol since they had never seen it with bisphosphonates, but now we know it is indeed a risk with these agents |
| 2010-05-27 13:52:48 |
deanna and pam |
Didn't know if the participants were aware of the hip fracture risk is with additional drugs, but proton pump inhibitors have also been associated with fracture....these patients should take some form of calcium supplementation since their dietary calcium absorption may be decreased... |
| 2010-05-27 13:53:01 |
cindy |
ONJ is untreatable and irreversible correct? |
| 2010-05-27 13:55:04 |
deanna and pam |
No, ONJ can heal in many cases. Although some patietns have experience very delayed healing or non-healing, in one of the series we reviewed, a quarter of the patients resolved without any intervention. There are dental guidelines now that talk about the stages of ONJ and how to treat this side effect, basically calling for antibiotic rinses, oral antibiotics in some cases, and debridement in specific cases. In the guidelines, they basically state that the issue of whether or not to interrupt the therapy of bisphosphonate is up to the provider, but with mild forms state the drug can be continued... |
| 2010-05-27 13:55:36 |
Stephanie@ons |
As our time is coming to a close does anyone have and last questions for Deanna and Pam? |
| 2010-05-27 13:57:41 |
deanna and pam |
If you are interested in the latest paper on ONJ and treatment, the American Association of Oral and Maxillofacial Surgeons published a position paper in 2009 in the J of Oral Maxiloofacial Surgery.......it's very helpful |
| 2010-05-27 13:57:58 |
Stephanie@ons |
I would like to thank Deanna and Pam for their expertise. Thank you all for joining us today. Watch your email and the ONS website for upcoming Virtual Journal Club chats and Hot Topic Chats. |
| 2010-05-27 13:58:25 |
deanna and pam |
Thank you! |
| 2010-05-27 13:58:30 |
WHNP |
thanks |
| 2010-05-27 13:59:00 |
cindy |
Thank you...very interesting and educational! |