How Well do Nurses Understand and Manage Cancer Pain from Bone Metastases - Term Paper Example

Heading: Bone Metastases Pain Your name: Course name: Professors’ name: Date Introduction In this paper, the main question on the quality use if medicine concerns the way in which nurses properly understand and manage cancer pain resulting from bone metastases, and effectively boost the patients’ life quality. Some of the terms that may need to be defined include metastases, and cancer. This paper will involve the introduction of cancer pain and bone metastases. It also explores some of the evidenced-based literature on the nurses’ understanding and management of cancer pain caused metastases. During the choice of the above question, two principles of quality medicine usage including selection of management options; drugs and non-drug treatment, and use of medicine safely and effectively. Moreover, the paper will involve appraisal of studies used to determine their strengths and weaknesses; to highlight the agreement and disagreement areas; gaps in the studies; and the significance and implications of the evidence to practice. Search for available literature In the selection of literature to be used in this paper, some databases were used including the Cochrane databases, and American Cancer Society. The choice of these literature sources was influenced by the relevance of the information provided in the articles used. Secondly, the literature was chosen because they contain evidenced-based information regarding the question at hand. The information in these databases are up-to-date, and thus making them more appropriate for the study. Background of cancer pain and metastases Pain entails a major problem in cancer patients. To enhance the pain relief and quality of care, it is imperative to understand the cause, cancer pain types, thoroughly evaluate pain, as well as employ of individualized strategies for managing pain. On the other hand, cancer results when cells in the body begin to grow out-of-control. Despite the numerous types of cancer, they all occur due to out-of-control growth and spread of abnormal cells. Metastatic cancer involves a cancer that spreads from one part where it originated (primary site) to other body parts. Upon creaking away from cancerous tumors, cells travel via lymph vessels and bloodstream (American Cancer Society, 2012). Cancerous cells traveling from via lymph or blood vessels may spread to other tissues or organs in distant body parts. Most of the cancer cells breaking off from initial tumor often die without imposing any problems to an individual. Nevertheless, some of them may settle in new areas; hence starting to develop and create new tumors. This spread of cancer from an original part to a new body part entails metastasis. When cancer spreads to the new body party, it is said to have metastasized. In case of a single tumor, it is known as a metastatic or metastasis tumor. American Cancer Society (2012) says that advanced cancer has a widespread complication, which is an excruciating bone metastasis. The most usual metastatic area for prostate, breast, and lung cancers is the bones, and this accounts for 73% bone metastases. Concerning 200,000 new bone metastases cases are detected in the US every year. The high vascularisation of the bone environment makes and offers a favorable medium for metastatic tumors may develop. The occurrence of metastasis differs by cancer type, as well as by pathophysiology. For instance, breast tumors produce parathyroid hormone-related protein, which is responsible for activating osteoclasts. According to the recent research by Quinn and Miller (2008), bone metastases are characterized by 83% of patients experiencing pain; a typical background pain worsened by movement; 50% of patients experience breakthrough pain lasting for less than 30 minutes, with 25% reports that it lasts for less than 15 minutes; and 52% of patients say that breakthrough pain was unforeseeable. Furthermore, Quinn and Miller (2008) realized that bone pathology that causes pain has exceptional feature that integrates both neuropathic and inflammatory characteristics. This result can lead to modern treatment mechanism. Sensory nerves innervate all bone parts, while the invasion of tumor, weakening of the bones, and remodeling of bone may cause nerve injuries. Osteoclasts secrete a highly acidic setting that can cause pain. Immune cell and tumor cells are responsible for the release of numerous proteins and pain-inducing cytokines. Since cancer pain is overwhelming, it is critical for nurses to understand and manage the patients effectively in order to promote their quality of life. Use of Calcitonin According to the study by Martinez-Zapata (2006), retrieved from the Cochrane database, bone metastasis entails a situation in which malignant bone tumors in basic lung, breast, kidney, and prostate is usual. 80%-85% of patients with malignant lung, breast, and prostate grow a bone metastasis. Some of the therapeutic approaches for painful bone metastases are founded on various mechanisms including treatments or base treatments directed to oncological illnesses; radiotherapy for restricted bone metastases; conventional analgesics; specific drugs for pain, such, calcitonin, bisphosphonates, and estronium-89. According to Martinez-Zapata (2006), calcitonin is a hormone released in the thyroid glands of certain organisms. It contains a hypocalcaemic action caused by reserve of osteoclastic bone resorption, and by kidney actions resulting from enlarged urinary phosphorus and calcium excretion. Naturally, existing synthetic salmon calcitonin, porcine calcitonin, and artificial human calcitonin are used clinically. In terms of its objectives, the study aimed at determining the effectiveness of calcitonin in the reduction of metastatic bone pain among patients with painful bone metastases. Other objectives included assessment of the advantages of calcitonin in the reduction of bone complications, and improvement of patient survival, as well as reporting to any negative effects of the intervention. Some of the techniques of conducting a study are randomized double blind trials (Martinez-Zapata, 2006). Regarding the participants, the study involved 90 adults above 18 years, women, and men, experiencing pain from bone metastasis resulting from primary tumor. With respect to the intervention types used in the study, there was an inclusion and exclusion criteria. In case of inclusion criteria, there was a calcitonin and a rescue medication against placebo and a rescue medication; analgesic or steroids radiotherapy usage; and comparison between various intervention doses and models (Martinez-Zapata, 2006). On contrast, Martinez-Zapata (2006) notes that exclusion criteria excluded researches in which bisphosphonates were given to participants were randomized to distinct treatment groups from the research. It also excluded studies where calcitonin efficacy in pain treatment of bone metastases was tested within a short time, while considering only researches with a minimal follow-up. In relation to the types research measures, Martinez-Zapata (2006) maintains that the study gathered data regarding the evaluation of pain at baseline, four, six, nine, and 12 months; quality of life; pain relief; adverse effects; improvement period; hospitalization; rescue medication at post intervention and baseline ; and bone metastases problems. Notably, the study did not gather assessments of pain ranked by nurses, physicians, carers, or nurses, but the ones ranked by patients. The review was performed to evaluate the efficacy of calcitonin in controlling pain due to bone complications and bone metastases. The participants were treated for the condition with 100 placebo and subcutaneous calcitonin. The study had no evidence for management of bone complications. In fact, the researches demonstrated that calcitonin offered a higher number of negative effects as compared to placebo (Martinez-Zapata, 2006). In terms of applicability and completeness of the evidence, all relevant studies assessing calcitonin in the treatment of bone pain were included. However, the conclusions may not be reliable and are prone to change in future upon publications of other reports with extra information. The use of few participants caused lack of ability to sense small, but vital intervention changes. Since men with painful bone metastasis and breast cancer, the study lacks evidence from men; hence, it is incomplete and unreliable. Regarding the evidence quality, the total bias risk in included studies was inexplicit. The studies lacked allocation concealment and explanation of randomization generation. Another study failed to describe participants’ blinding adequately (Martinez-Zapata, 2006). In terms of agreement and disagreements with other reviews and studies, Martinez-Zapata (2006) says that the study shows that relief should be first objective in the management of bone metastases to enhance the patients’ life quality. Various treatment levels for attaining relief pain usually start with an analgesic or a non-steroidal anti-inflammatory drug, and maintain the low-potency opioids with another strong opioid. Regularly, this drug series fails for various reasons and usually since the drugs are unprescribed at the greatest therapeutic doses. When pain is uncontrolled with these alternatives, there are optional treatments, such as, radiocucleotides, radiotherapy, calcitonin, and bisphosphonates. Imperatively, Martinez-Zapata (2006) indicates that radiotherapy is usually used to offer pain relief for localized for painful bone metastases. Almost 75% of patients get pain relief and half the figure becomes pain-free. Nevertheless, when there are numerous bone metastases, systematic treatment like radionucleotides, bisphosphonates, and calcitonin with various evidence degrees for efficacy may be essential. The study contains a contribution to the accessible scientific evidence on the utilization of calcitonin in the area, as it does not recognized any methodical review that evaluates calcitonin for metastatic bone pain. The absence of primary studies, it is hard to draw powerful conclusions on calcitonin efficacy. In terms of gaps, the review lacks primary studies; hence, the need to consider various therapeutic strategies in deciding on the appropriate management of painful bone metastases by nurses. Concerning the implications for practice, the limited accessible evidence fails to aid the utilization of calcitonin in the control of metastases bone pain. Modern studies situated during the informing of the study in 2011, and thus the conclusions are the same. While current researchers provide extra information on this management, other therapeutic strategies must be considered (Martinez-Zapata, 2006). This information is critical in guiding nurses in the effective understanding and management of patients suffering from bone metastasis pain; hence, improving their life quality. Use of bisphosphonates Another study is by Wong and Wiffen (2009) investigates the use of bisphosphonates in relieving metastases pain. Bisphosphonates refer to structural pyrophosphates’ analogues, a typically occurring constituent of bone crystal evidence. Distinct side chain change of primary pyrophosphate structure results in various bisphosphonates generations, with distinct activity levels. Mostly, via powerful affinity to bone, these chemicals offer physico-chemical defense through the absorption of calcium phosphate, suppression of mature osteoclasts’ normal operation, and prevention of osteoclast precursors growing. Bisphosphonates remains effective in the management of hypercalcemic patients, protecting their place as a normal treatment for the condition. The study aimed at determining the bisphosphonates effectiveness in relieving pain among bony metastatic patients. The methods used in the study included the use of randomized design distributed in whole were included, with exclusion of abstracts. All studies were included whereby the bisphosphonates effect on cancer pain was evaluated. Moreover, only those studies with patient reported bone metastatic pain were included, as well as those with source unspecified pain sources (Wong and Wiffen, 2009). In addition, the study used clinical trials that involved patients with bone metastases from basic were qualified for inclusion. Regarding the intervention types, reports on bisphosphonates usage were included. The control arm may constituent open or placebo controls. It studies where diverse bisphosphonates doses were compared, included, but were examined independently. In terms of outcome measures, the study has primary and secondary outcomes (Wong & Wiffen, 2009). One of the methodological limitations is that in spite of the 50 randomized researches in the area of study, the information is unlimited that it is hard to reach strong conclusions. The study used many trials, lacks consensus on the inclusion of pain endpoints. There are also problems with the bisphosphonate trials; hence, the need for researchers and clinicians to seek for advice during planning from pain trials experts. Despite the limitations, there is evidence suggesting vital advantage of using bisphosphonates (Wong & Wiffen, 2009). Analgesics remain significant in the treatment of bone metastases pain. Besides, radiotherapy helps nurses to understand and manage the condition. For patients with painful, using bisphosphonates for pain lessening is reasonable. With the above conclusions, there is inadequate evidence to suggest bisphosphonates for the treatment of bone metastases pain as a first line treatment (Wong & Wiffen, 2009). Regarding the implications of the study for practice, Wong & Wiffen (2009) show that the review offers an approximation of one patient advantaged with pain relief for every six patients being managed. There is inadequate information to suggest its utilization to offer immediate effect, and the most reaction is probable to be seen within four weeks. Difficult drug responses were harsh to discontinue therapy in one out of 11 patients under treatment. Bisphosphonates must alongside analgesics and radiotherapy when the modalities alone are insufficient for treatment of bone metastases pain. Besides, there is inadequate evidence to suggest the patients’ selection for this therapy approach based on basic histologies. Consequently, the above information is beneficial in improving the nurses’ ability to understand and manage patients of bone metastasis pain effectively, and enhance their life quality. Use of radioisotopes The third study reviewed in this paper is by Figuls et.al (2011). The study explores effectiveness of using Radioisotopes in the management of bone metastases pain. The study indicates that the bony metastases results in serious pain, pathological fractures, spinal cord compression, and hypercalcaemia. It also shows that the present available management approaches used in relieving this pain include radiotherapy, surgery, hormone therapy, chemotherapy, bisphosphonates, and radioisotopes. In terms of objectives, the study aims at determining the safety and efficacy of radioisotopes among patients with bone metastases to reduce the pain; minimize the number of problems to the condition; as well as to enhance the patients’ survival. Regarding the methods, the study used Randomized Controlled Trials, and the PaPas Trials Register. when selecting the criteria to use, the review selected studies that had bone metastases pain as a main result after management with a radioisotope, in comparison with a another radioisotope and placebo (Figuls et.al, 2011). Regarding the collection and analysis of data, Figuls et.al, (2011) maintain that the study evaluated the risk bias on all included researches by order of generation, blinded study patients, allocation concealment, outcome assessors and researchers, as well as incomplete data outcome. The review also conducted statistical analysis as an accessible case examination, and computed global estimates of influence with random-effects model. It also conducted an Intention-To-Treat sensitivity examination. As per the results, there were 15 studies, and 1146 examined participants; four or 325 participants were included, as well as 11 new or 821 participants. Of these studies, only three of them had a low risk bias. The researchers observed a slight advantage of radioisotopes in achieving full relief and partial relief within both short and medium terms of eight studies involving 499 participants (Figuls et.al, 2011). As per the research findings, there was no conclusive proof that radioisotopes actually change the analgesia use relating to placebo. Thrombocytopenia and lucocytopenia are secondary impacts importantly related to the use of radioisotopes. Besides, there were no higher pain flares in radioisotopes group. In fact, the study has scarce information to moderate quality during the comparison of Strontium -89 with Rhenium-186, Samarium-153, and phosphorus-32. The researchers also observed that there were significant variations between therapies. Likewise, they observed no changes when they compared various doses of Samarium-153 (Figuls et.al, 2011). As per the authors’ conclusions, the review added new proof on the efficacy of placebo and radioisotopes, Strontium -89 in comparison with other radioisotopes, as well as comparisons of Rhenium-186, and Samarium-153 doses. The study indicated some proof that radioisotopes can offer complete minimization of pain between one and six months without any increase in the use of analgesic, but there are frequent, man serious effects. In terms of the study’s agreements and disagreements with other reviews and studies, Figuls et.al (2011) indicate that whereas other studies view existing proof to favor radioisotopes strongly, the study indicates that the present evidence should be moderated due to studies’ risk bias, results’ heterogeneity, and restricted number of participants and studies conducted. Moreover, most of the studies considered by the study indicated that use of radioisotopes help in the reduction of pain caused by bone metastases. Furthermore, Figuls et.al (2011) demonstrates that the study’s implications for practice show that the study contributed new proof on radioisotopes efficacy against placebo. The study successfully assessed its objectives relating to placebo comparison, in relation to safety and pain regulation. There is also reasonable quality confirmation to aid a beneficial influence of radioisotopes over regulation of pain within short and long term, with no changes in the use of analgesia. There was an observation of high severe secondary impacts including thrombocytopenia, and leucocytopenia. The study also demonstrates that radioisotopes have no effect on the modification of mortality or spinal cord compression. Moreover, there is proof that for the impact of radioisotopes on neutropenia, hypercalcaemia, and life quality, or fractures. It also has little or poor quality proof concerning the safety and efficacy of certain radiopharmaceuticals. Presently, radioisotopes are still a secondary alternative for patients experiencing multifocal pain caused by bone metastases, upon the failure of bisphosphonates, radiotherapy, and hormone therapy (Figuls et.al, 2011). Notably, the results are helpful in promoting the nurses’ capacity to understand and manage patients of bone metastasis pain effectively and enhance their quality of life. Single fraction and multifraction radiotherapy The fourth study used in this paper involves a review by Sze, Shelley, Held, and Mason (2002). Latest randomized studies showed that using single fraction radiotherapy was as successful as multifraction radiotherapy to relief pain caused by bone metastases. Nevertheless, there are issues concerning the higher management rates and efficacy in the prevention of the future problems, such as, spinal cord compression, and pathological fracture using single fraction radiotherapy. The objective of the study was to conduct a methodological meta-analysis and review of the single fraction radiotherapy against multifraction radiotherapy for the minimization of pain resulting from bone metastases, as well as the prevention of bone problems. Regarding the techniques used in the study, trials via EMBASE, MEDLINE, and Cancerlit among others were necessary. Here, the study extracted relevant studies for review. The criteria used in the selection of the study sample, randomized studies were suitable for comparing multifraction and single fraction radiotherapy of pain caused by bone metastases. In the gathering and analysis of data, the study used the Intention-To-Treat standard. The outcomes were assembled through meta-analysis in order to approximate the impact of therapy on pain reaction, pathological fracture, rate of re-treatment, as well as rate of spinal cord compression (Sze, Shelley, Held, & Mason, 2002). As per the results, 11 trials involved 3435 participants were used. Out of these, 52 participants were randomized many times for various bone metastases pain locations; hence, 3487 randomized painful locations. These trials involved patients suffering pain from bone metastases of any basic sites, though mostly breast, prostate, and lung. Total pain reaction rate for multifraction and single fraction radiotherapy were 59% and 60% respectively, demonstrating no change in the two radiotherapy programs (Sze, Shelley, Held, & Mason, 2002). Besides, Sze, Shelley, Held, Mason (2002) indicate that patients managed by single fraction therapy had greater re-treatment rates, with 21.5% needing re-treatment in comparison with 7.4% of patients in multifraction radiotherapy arm. Moreover, there was a high pathological fracture rate among single fraction radiotherapy patients. There were also similar rates for both arm patients regarding spinal cord compression. Regarding the implications of the evidence for practice, the authors concluded that single fraction radiotherapy and multifraction radiotherapy are equally effective in the relief of pain resulting from bone metastases pain. Nevertheless, the rates of retreatment and pathological fracture were greater upon single fraction radiotherapy. Researches with health economic endpoints and life quality are acceptable to determine the best management alternative (Sze, Shelley, Held, & Mason, 2002). Relevance and implication for nursing practice and research in the future The information from the above reviews are relevant to the nursing practice, as they inform nurses and guide them in the appropriate management and understanding of patients experiencing bone metastasis pain. These findings help in enhancing the ability of the nurses to administer the above drugs in the management patients of bone metastasis pain, and boost their quality of life. Therefore, nurses ought to understand the above information to enhance their quality of care delivery and improvement of life quality of these patients. Future research should also focus on more strategies of helping nurses to improve the patients’ life quality through effective management and administration of drugs. Conclusion It is imperative for nurses to understand and manage cancer pain caused by bone metastases effectively. Various studies indicate that pain is a common phenomenon among patients suffering from cancer, such as, prostate, breast, and lung cancer. When cancer spreads from its primary site to other body parts, especially the bones, patients experience metastases bone pain. Consequently, it is crucial to ensure that therapeutic measures are administered to relieve them of the pain, while selecting appropriate medicine, and using them safety and effectively. The above studies, further, indicate that patients suffering from bone metastasis pain can be managed using bisphosphonates, calcitonin, radioisotopes, as well as single fraction, and multifraction radiotherapies. Therefore, the above information helps nurses in better understanding and management of patients with bone metastasis pain. References American Cancer Society (2012). Bone Metastasis. Pp. 1-30. http://www.cancer.org/acs/groups/cid/documents/webcontent/003087-pdf.pdf Figuls M., et al. (2011). Radioisotopes for metastatic bone pain. Cochrane Database of Systematic Reviews, 2(7), 1-4. DOI: 10.1002/14651858.CD003347.pub2. Martinez-Zapata, M.J. et al. (2006). Calcitonin for metastatic bone pain. Cochrane Database of Systematic Reviews, 2(3), 1-3. DOI: 10.1002/14651858.CD003223.pub2. Quinn, T.E., Miller, K. (2008). Bone Metastases and Pain. Yale Cancer Center, 2 (5), 1-3. http://medicine.yale.edu/cancer/research/education/YaleCares_May2008.pdf Sze W.M., Shelley, M., Held, I., Mason, M. (2002). Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy. Cochrane Database of Systematic Reviews, 2 (1), 1-2. DOI: 10.1002/14651858.CD004721 Wong, R.K.S., &Wiffen, P.J. (2002). Bisphosphonates for the relief of pain secondary to bone metastases. Cochrane Database of Systematic Reviews, 3(2), 1-2. DOI: 10.1002/14651858.CD002068. Read More