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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
- 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.
- Janjan N A. Radiation for bone metastasis. Cancer Supplement.
1629-1645, 1997.
- 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.
- 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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