UROLOGIC NURSING
UROLOGIC NURSING / November-December 2019 / Volume 39 / Number 6 293
Rikka Burroughs, DNP, BA, ARNP, AGPCNP-C, CUNP, is a Nurse Practitioner, Physicians’ Clinic of Iowa, Cedar Rapids, IA and University of Iowa College of Nursing, Iowa City, IA.
Bone Health Assessment in Men On Androgen Deprivation Therapy For Prostate Cancer: A Nurse Practitioner-Led Quality Improvement Protocol Rikka Burroughs
P rostate cancer is the most common solid organ cancer and is the second leading cause of cancer mortality for men in the United States (American Cancer Society [ACS], 2018; American Uro – logical Association [AUA], 2018). An d rogen dep rivation therapy (ADT) is a common ther- apy for locally advanced prostate cancer, and is the mainstay of treatment for metastatic and bio- chemically recurrent prostate cancer (Loblaw et al., 2007; National Comprehensive Cancer Network [NCCN], 2017). Al – though an effective treatment for prostate cancer, ADT causes accelerated loss of bone mass, leading to increased risk for frac- ture (Chahin, Gualamhusein, Breunis, & Alibhai, 2016; Damji, Bies, Alibhai, & Jones, 2015).
Approximately 1 in 2 men (44.8%) diagnosed with prostate cancer and on Medicare will receive ADT, many for 2 years or longer (Gilbert, Kuo, & Shahinian, 2011; Meng et al., 2002); the actu- al incidence of prostate cancer in the full U.S. population of men is unknown. ADT can cause mor- bidities that are often inadequate- ly addressed (NCCN, 2017). Two such sequelae are osteopenia and secondary osteoporosis (Chahin et al., 2016; NCCN, 2017). Substantial bone loss can occur within the first 6 months of ADT therapy (Datta & Schwartz, 2012). In fact, 1 in 10 men treated with ADT will sustain a new fracture
within 24 months of treatment initiation (Datta & Schwartz, 2012). About 6 in 10 men diag- nosed with prostate cancer are over age 65 years, and when screened, as many as half of these men are noted to have low bone mass prior to initiation of ADT (ACS, 2018; Panju et al., 2009). Therefore, ADT treatment places them at even further risk of frac- ture (Panju et al., 2009).
Significance of the Problem
Osteoporosis-related frac- tures are associated with in – creased morbidity and mortality (Walsh & Eastell, 2013). Low bone
© 2019 Society of Urologic Nurses and Associates
Burroughs, R. (2019). Bone health assessment in men on androgen deprivation therapy for prostate cancer: A nurse practitioner-led quality improvement protocol. Urologic Nursing, 39(6), 293-301 doi:10.7257/1053816X.2019. – 39.6.293
Androgen deprivation therapy (ADT) causes bone loss. Despite this, there is sub- stantial variability in clinical practice related to bone health prevention and treat- ment for men with prostate cancer receiving ADT. This quality improvement proj- ect facilitated consistency in providing evidence-based care for bone health in men with prostate cancer on ADT at a private urology clinic.
Key Words: Bone health, osteoporosis, Plan-Do-Study-Act, men’s health, bone density, nurse practitioner utilization.
SERIES/RESEARCH
Instructions for CNE Contact Hours
UNJ 1914 Continuing nursing education (CNE)
contact hours can be earned for completing the learning activity
associated with this article. Instructions are available at suna.org/library
Deadline for submission: December 31, 2021 1.3 contact hour(s)
294 UROLOGIC NURSING / November-December 2019 / Volume 39 / Number 6
mass and fracture can cause increased anxiety and depres- sion, decreased self-esteem, de – creased socialization, increased isolation, strained relationships with social support persons, increased pain, overall higher health care costs, decreased sur- vival, and decreased quality of life for patients and their care- givers (Chahin et al., 2016; Damji et al., 2015; National Osteo – porosis Foundation [NOF], 2019; Turner et al., 2016a).
Men are often under-diag- nosed, under-educated, and under-treated for low bone mass (Chahin et al., 2016; Shahinian, Kuo, Freeman, & Goodwin, 2005). Men receiving ADT have a 50% increased risk of fracture; however, men receiving ADT are not routinely screened and treat- ed for osteopenia or osteoporosis (Chahin et. al, 2016; Damji et al., 2015; Shahinian et al., 2005). Bone health practices not con- forming to current guidelines for men on ADT are observed across the spectrum of care from pri-
mary care to urology and radia- tion and medical oncology (Alibhai et al., 2006; Al-Shamsi et al., 2012; Tanvetyanon, 2005).
The NCCN (2017) guideline for prostate cancer recommends use of supplemental calcium and vitamin D for all men on ADT. The NCCN (2017) also recom- mends obtaining a baseline dual- energy X-ray absorptiometry (DXA) to measure bone mineral density (BMD) in men with increased risk for fracture prior to or within 90 days of initiation of ADT. DXA is a radiologic test that quantifies BMD, a determin- ing factor of bone strength (Lewiecki et al., 2016). The NCCN (2017) also recommends additional treatment if DXA shows high fracture risk using a fracture risk tool, such as the Fracture Risk Assessment Tool (FRAX). FRAX is completed by the health care provider and assesses select risk factors, such as glucocorticoid and smoking history, personal and familial fracture history, alcohol use, and
height and weight (Kanis et al., 2011; University of Sheffield, n.d.). FRAX determines a 10-year probability of fracture of the hip or other major fracture, such as wrist, shoulder, or spine that is responsive to treatment (Kanis et al., 2011; University of Sheffield, n.d.).
Despite NCCN guideline rec- ommendations, there is substan- tial variability in provider prac- tice, knowledge, prevention, and treatment of low bone density for men on ADT (Al-Shamsi et al., 2012; Damji et al., 2015; NCCN, 2017; Panju, et al., 2009; Pradhan et al., 2012; Tanvetyanon, 2004). Risks of fracture within this pop- ulation, coupled with co-mor- bidities and lifestyle choices, fur- ther place this population at risk (Chahin et al., 2016). Damji and colleagues (2015) found that only about 32% of the 83 urologists and 73 radiation oncologists they surveyed tested BMD routinely (≥ 80% of patients) prior to start- ing ADT. Low self-reported com- petency levels regarding calcium
SERIES
Research Summary Introduction
Androgen deprivation therapy (ADT) is a common ther- apy for locally advanced prostate cancer, as well as for bio- chemically recurrent and metastatic prostate cancer. An effective treatment for men with prostate cancer, ADT can cause morbidities which are often not fully or adequately addressed in urology.
Purpose The purpose of this quality improvement (QI) project
was to facilitate consistency in providing evidence-based care related to bone health screening, education, and treat- ment for men with prostate cancer on ADT by decreasing barriers to assessment and creating a pathway from urolo- gists to the nurse practitioner who also specializes in bone health and prostate cancer.
Methods An office-based protocol for an internal referral process
was developed to facilitate transition from urologist to nurse practitioner in a urology clinic. The protocol included the referral order, lab order, and appropriate time interval, and was implemented upon the initiation of ADT. A survey assessed urologist knowledge and perceived treatment bar- riers prior to and after education and implementation of the protocol.
Results The number of patients seen by the nurse practitioner
within 90 days of ADT treatment initiation increased from 36% (Q4 2017) to 53% (Q4 2018) (p > 0.05). The proportion of patients who completed the lab set after implementation of the referral process increased from 16% (Q4 2017) to 73% (Q4 2018) (p < 0.01). The urologist survey demonstrat- ed an increase in urologist perception of the importance of bone health assessment, overall knowledge of bone health for men on ADT, and a reduction in barriers to bone health care.
Conclusion Implementation of a protocolized internal referral
process facilitated consistency in providing timely, evidence- based care related to bone health for men with prostate can- cer on ADT. This QI project enhanced urologist knowledge of bone health in men on ADT and reduced barriers to bone health care.
Level of Evidence: V-B Source: Johns Hopkins Hospital/Johns Hopkins University, 2016.
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(64%) and vitamin D supplemen- tation (62%), providing educa- tion regarding healthy bone behaviors (40.5%), and managing osteopenia and osteoporosis (41.2%) among survey partici- pants were also found (Damji et al., 2015). Furthermore, less than 20% of survey participants received at least some type of specialized training and educa- tion regarding bone health risk and measurement (Damji et al., 2015).
Reasons for low rates of bone health screening include pro – viders’ lack of understanding of bone health, poor clarity of guidelines, and insufficient knowledge of potential conse- quences of low bone density (Damji et al., 2015). Jain, Bilori, Gupta, Spanos, and Singh (2016) identified additional reasons for low screening rates, including low priority for providers to screen for low bone density and that the electronic medical record (EMR) lacks reminders to support clinical decision-mak- ing. Pradhan and colleagues (2012) noted the unavailability of the DXA scan within the practice area as a contributing factor for lack of screening. Provider time constraints, discomfort with pa – tient counseling regarding low bone density, and risk of overbur- dening the patient with informa- tion are other reasons cited for not following the guidelines (Jain et al., 2016; Turner et al., 2016b).
Literature Review
A literature search was con- ducted to examine the evidence on improving bone health prac- tice in the care of men treated with ADT for prostate cancer. PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) data- bases were reviewed. Key search terms included implementation, protocol, osteoporosis, prostate cancer, nurse…
