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Survivorship Care Plan: Bone Health

Sandra Kurtin, RN, MSN, AOCN, ANP-C Assistant Professor of Clinical Medicine, University of Arizona College of Medicine; Adjunct Assistant Professor of Nursing, University of Arizona College of Nursing, Tucson, AZ, discusses survivorship care plans to help maintain bone health in patients with multiple myeloma.

Tip Sheet about this topic

Hello. I’m Sandra Kurtin, and welcome to the Multiple Myeloma Center for Nurses Video: Survivorship Care Plan: Bone Health. In this video, we’ll discuss recommendations from the International Myeloma Working Group (or IMWG) and the National Comprehensive Cancer Network (or NCCN) to help patients living with multiple myeloma maintain adequate bone health. For additional resources, visit the Multiple Myeloma Center for Nurses website.

Bone lesions, including one or more osteolytic lesions as shown on skeletal radiography, computed tomography (or CT) scan, or positron emission tomography and CT combined scan, is one of the CRAB diagnostic features of multiple myeloma.1

The acronym CRAB stands for Calcium elevation, Renal dysfunction, Anemia, and Bone disease.1

Eighty percent to 90% of patients with multiple myeloma have osteolytic lesions during the course of their disease.2,3

Osteolytic lesions may result in bone pain, fractures, hypercalcemia, spinal cord compression, renal dysfunction, decreased mobility, reduced activities of daily living, and neurologic defects.2,4

As a nurse, you play a key role in helping your patients manage bone disease and maintain bone health throughout the course of their disease.

Let’s take a look at the bone remodeling process and how it can be disrupted in people with multiple myeloma.

Normal bone remodeling is ongoing and comprises old bone resorption or removal (known as osteoclastic activity) and new bone formation (known as osteoblastic activity).2

In normal bones, this process is balanced or “coupled” and keeps bones healthy. Myeloma bone disease, on the other hand, is the result of a disruption or “uncoupling” of the normal osteoclast-osteoblast interaction.2

This can result in increased osteolytic activity and reduced osteoblast activity, which suppresses the process of new bone formation.2,5

This disrupted process makes multiple myeloma unique compared with other cancers with bone metastases, where both bone resorption and formation continue to occur, and helps explain why bone scans are often negative in patients with extensive bone disease.2,5

In people with multiple myeloma, bone lesions occur because of increased osteoclastogenesis with decreased osteoblastic activity, which disrupts the bone remodeling process.2,3,6

Osteoclastogenesis results in greater bone resorption, while decreased osteoblastic activity means that new bone is not formed.2,3

While this process is not fully understood, a few specific areas of dysfunction have been identified.2,3

Myeloma cells produce a protein resembling a normally functioning immunoglobulin G antibody in structure called M protein. M protein is inactive, but its accumulation is responsible for tissue and organ damage at distant sites.2

Additionally, interactions between multiple myeloma cells and bone marrow stromal cells lead to an overproduction of cytokines and cause osteoclast activation.6

Finally, multiple myeloma cells can produce molecules that can inhibit osteoblast differentiation and function, which can worsen the osteoclast/osteoblast imbalance.6

Now let’s look at ways to address bone health in our patient care.

Bone health survivorship care plans should focus on:

• Screening and interventions for bone disease and

• Practices that reduce and manage bone complications in patients with multiple myeloma.4

Bone disease related to multiple myeloma requires a multidisciplinary approach and may include supportive care such as bisphosphonates, radiotherapy, pain control, vertebroplasty or kyphoplasty, and surgery in appropriate patients.2

The NCCN guidelines and the IMWG recommend the use of bisphosphonates in all patients diagnosed with multiple myeloma and receiving primary therapy.7,8

Additionally, the NCCN guidelines recommend that patients taking bisphosphonates be monitored for renal dysfunction and osteonecrosis of the jaw (or ONJ).7

ONJ is a condition in which a patient has exposed bone in the mouth that does not heal after 6 to 8 weeks of therapy.8

Ideally, patients should have a complete dental exam and undergo any invasive dental procedures 90 days prior to initiating bisphosphonate therapy. Bisphosphonates should be withheld for 90 days before and 90 days after any invasive dental procedures that occur after the start of bisphosphonate therapy.7

NCCN guidelines and the IMWG recommend low-dose radiation therapy as palliative care for uncontrolled pain, impending pathological fracture, or impending spinal cord compression.7,8

The most common indication for radiation therapy in multiple myeloma is pain control.3,4

NCCN guidelines recommend consideration of vertebroplasty or kyphoplasty for symptomatic vertebral compression fractures.7

Vertebroplasty or kyphoplasty are minimally invasive procedures that may improve movement and reduce pain in patients who have suffered compression fractures.3

Vertebroplasty is a minimally invasive procedure whereby bone cement is injected into the vertebral body to provide stability and relieve pain.3

Kyphoplasty, also called balloon kyphoplasty, is a similar procedure during which a balloon is placed into the vertebral body to expand it.3,8 The bone cement is then injected.3

Not all patients are candidates for these procedures.

NCCN guidelines and the IMWG recommend orthopedic consultation for impending or actual long-bone fractures, bony compression of the spinal cord, or vertebral column instability.7,8

Intractable pain that has not resolved with nonsurgical measures may be another reason for orthopedic consultation.3

This concludes the Multiple Myeloma Center for Nurses video: Survivorship Care Plan: Bone Health. To find out more on this and other topics related to multiple myeloma, please see additional videos and resources on this site. Here you will find a number of educational tools, including tip sheets to help you discuss these topics with your patients, answers to common questions, and other downloadable materials. Thank you.

 

References:

1. Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet. 2014;15:e538-e548.

2. Durie BGM. Concise review of the disease and treatment options: multiple myeloma cancer of the bone marrow. 2011/2012 ed. International Myeloma Foundation website. http://www.myeloma.org/pdfs/CR2011-Eng_b1.pdf. Accessed December 3, 2014.

3. Hameed A, Brady JJ, Dowling P, Clynes M, O’Gorman P. Bone disease in multiple myeloma: pathophysiology and management. Cancer Growth Metastasis. 2014;7:33-42.

4. Leigh BR, Kurtts TA, Mack CF, Matzner MB, Shimm DS. Radiation therapy for the palliation of multiple myeloma. Int J Radiat Oncol Biol Phys. 1993;25(5):801-804.

5. Roodman GD. Pathogenesis of myeloma bone disease. Blood Cells Mol Dis. 2004;32(2):290-292.

6. Terpos E, Cibeira T, Blade J, Ludwig H. Management of complications in multiple myeloma. Semin Hematol. 2009;46(2):176-189.

7. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Multiple Myeloma. V1.2015. http://www.nccn.org.

8. Terpos E, Morgan G, Dimopoulos MA, et al. International Myeloma Working Group recommendations for the treatment of multiple myeloma–related bone disease. J Clin Oncol. 2013;31(18):2347-2357.