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News Archive: Michigan Oncology Journal Fall 99

Bone Metastasis: Approaching an Old Problem in a New Way

-J. Sybil Biermann, M.D.

Assistant Professor, Section of Orthopedics
Department of Surgery
Director, Bone Metastasis Clinic

The Scope of Bone Metastasis
With improvements in cancer treatment and survival, there is an increasing population of cancer patients who are living with bone metastasis. There are an estimated 170,000 new cases of bone metastasis diagnosed annually in the United States, and as cancer longevity continues to improve, these patients often survive months or years with symptomatic bone disease. In fact, patients with bone metastasis from cancers of the breast or prostate often live for years after the diagnosis of bone metastasis. Indeed, there are estimated to be more than 500,000 Americans living with bone metastasis.

Serious sequellae of bony metastatic disease include the potential for cord compression or pathologic fracture. Additionally, the patient with metastatic bone disease frequently experiences significant pain that may be difficult to treat. The patient often faces not only these potential issues and their own mortality, but also challenges with ambulation and other daily activities.

Standard Treatment for Bone Metastasis
Because bone metastasis is part of a systemic disease involving a primary cancer and other sites of metastasis, treatment is often systemic with either cytotoxic drugs or hormones or both. However, because the local manifestations of bone metastasis can be severe, local therapies are important and play a major role as well. Classic modes of local bone treatment include fractionated external beam radiation delivered over a period of two to three weeks; surgical intervention for pathologic fractures and their prevention with prophylactic nailing (1); and radiopharmaceutical therapy with isotopes such as Strontium (2). Pain can be controlled with oral narcotics. While these measures are effective for many patients with bone metastasis, more recent research has focused on improving interventions to prevent the structural complications of bone failure and to maximize pain control.

New Therapies for Bone Metastasis
The last decade has seen significant growth in effective ways of controlling symptoms and improving quality of life. New treatment modalities include: altered fractions of radiation therapy to shorten therapy; new surgical techniques and increased consideration of prophylactic treatment; modern analgesics and improved delivery systems; bisphosphonates (3); newer radioisotopes with better side effect profiles (4); regional blocks; and emphasis on environmental modifications to maximize independence. While the advent of so many options and possibilities is encouraging for the future, it can also be confusing. Studies have focused on the effectiveness of each of these modalities; however, there are few investigations into the effects or benefits of combining two or more modes of treatment simultaneously. Since most cancer investigations focus on the ability to prolong life, detailed studies on the contribution of bone-specific therapies to improvements in quality of life, limb function, ambulation and ability to function independently are relatively lacking.

Currently, the patient with unrelieved metastatic bone pain or the physician managing such a patient can be overcome with the obstacles of seeking advice from several different clinics and attempting to assimilate recommendations to maximize the best overall treatment or combinations of treatments. Patients are often in pain and relatively immobile, relying on family members for transportation, so the task of seeking care from multiple specialists is nearly impossible.

Rationale for a Multidisciplinary Clinic
The University of Michigan Comprehensive Cancer Center has formed a multidisciplinary clinic to generate concise yet comprehensive treatment plans and recommendations for the patient with symptomatic bony metastasis, with the goal of returning the patient to as full a function and pain-free existence as achievable.

The clinic is held biweekly and attended by faculty physicians from orthopedic surgery, diagnostic radiology, radiation therapy, pain service, physical medicine and rehabilitation, nuclear medicine and medical oncology. Other representatives may be recruited as appropriate from physical therapy, psychiatry, endocrinology, spine surgery, neurosurgery and other disciplines.

Patients referred to the clinic are evaluated thoroughly with respect to their medical history and previous treatment. Cathy Flavin, R.N., C.N.S, patient coordinator for the clinic, works with each patient to make sure that all information is available to the Bone Metastasis Clinic members. Histories are taken in advance of the clinic and relevant imaging studies are forwarded for pre-screening by the Musculoskeletal Diagnostic working group. Information from referring physicians, especially specific questions relevant to the patient's care, is also gathered. At the visit, each patient undergoes a thorough history, physical and review of presenting symptoms by one of the clinicians.

A needs assessment also is performed for each patient to determine if they have additional issues involving diet, disease education or social services. Arrangements are then made for patients to consult with Cancer Center dietitians, patient educators and oncology social workers as appropriate.

A working conference is held during each clinic, attended by specialists in the different areas of bone metastasis treatment. Recommendations are then discussed with patients and their families. Letters are sent to referring physicians advising them of the group's recommendations and providing contact information should there be any questions or additional follow up needed.

Opportunity for Clinical Investigation
With tremendous advances made in the treatment and survival rates of cancer and the central focus of research in these areas, there have been relatively few investigations into the management of patients with bone metastasis. With new agents now available for treatment, some initial studies have been performed, but very little is known about the quality of life of the patient with bone metastasis, their physical functioning, psychosocial and physical needs, and the effects that treatment may have on these.

The Bone Metastasis Clinic provides many new opportunities for clinical trials and other research, as well as opportunities to increase our understanding of the basic mechanisms of bone metastasis. Such clinical trials would be difficult or unmanageable in other patient settings. The clinic is also an ideal setting for collaboration with pharmaceutical companies, increasing opportunities to offer investigational agents to our patients. Comprehensive studies involving quality of life assessment and health services outcomes are possible as well.

Finally, educational materials on this topic are scant. Working in collaboration with the U-M School of Public Health, materials are currently being developed for patients on the symptoms and management of bone metastasis.

Referrals to the Bone Metastasis Clinic
Patients may be scheduled for the Bone Metastasis Clinic by calling 800-865-1125. Patients will be put in touch with the Patient Care Coordinator, who will explain the multidisciplinary evaluation process and arrange for relevant information to be forwarded to the clinic. Patients may be seen in the clinic at their request or that of their physician. Because this clinic addresses the local issues associated with bone metastasis and not the treatment of systemic disease, we request that all patients remain under the care of their primary oncologist and consultations requested for other cancer management issues be directed to appropriate areas in the Cancer Center. Following clinic visits, the referring primary care physician, medical oncologists and other concurrent care physicians identified will receive letters outlining the panel's recommendations for care.

References

  1. Redmond BJ, Biermann JS, Blasier RB. Interlocking intramedullary nailing of pathological fractures of the shaft of the humerus. J Bone Joint Surg. 78A:891-896, 1996.
  2. Janjan N A. Radiation for bone metastasis. Cancer Supplement. 1629-1645, 1997.
  3. Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in reducing skeletal events in patients with advanced multiple myeloma. N Eng J Med. 334: 488-493, 1996.
  4. Serafini AN, Houston SJ, Resche I., et.al. Palliation of pain associated with metastatic bone cancer using samarium-153 lexidronam: a double-blind placebo-controlled clinical trial. J of Clin Onc. 16(4):1574-81, 1998.

 

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Please note: The articles listed in the Cancer Center's News Archive are here for historical purposes. The information and links may no longer be up-to-date.