bone health in cancer - dr. sandy sehdev

Bone Health in Cancer Dr. Sandy Sehdev

Medical Oncologist

William Osler Health Centre

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What will we discuss

● About our bones

● About bone metastases

● The complications of bone metastases

● Treatment options for bone complications

● The impact of cancer treatment on bone health

● What else can you do to keep your bones strong?

● Ask the expert

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Our bones

● Bone is living tissue, which is

constantly being broken down

and rebuilt, a process called

remodeling

● The loss of living bone tissue

makes bones fragile and more

likely to fracture

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Bone function

● The major functions of bones

are to:

● Provide structural support for the

body

● Provide protection of vital organs

● Provide an environment for

marrow (where blood cells are

produced)

● Act as a storage area for minerals

(such as calcium)

“Facts about bones” accessed at http://www.iofbonehealth.org/patients-public/about-osteoporosis/facts-about-bones.html on August 9, 2010

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About bone metastases

● One of the most common places for prostate or breast cancer to

spread is to the bone

● Approximately 65 to 75 per cent of people with advanced prostate or

breast cancer experience bone metastases

● Growing cancer cells weaken and destroy bone around the

tumour

● Can lead to debilitating complications

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Cycle of bone destruction

● Cancer cells travel from original

site to bone where they stimulate

bone cells called osteoclasts

● Osteoclasts increase bone

destruction making room for the

tumour to grow in the bone

● As bone is destroyed, proteins

are released that can cause

cancer cells to grow…

…and the cycle of bone destruction continues

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Warning signs

● No warning signs in some

patients

● Bone pain

● One of the first signs that cancer

has spread to the bone

− Up to two-thirds of people with

bone metastases experience

debilitating pain

● May require pain medication

(may develop tolerance)

● Can severely impact quality of life

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Warning signs

● Fractures (broken bones)

● Hypercalcemia (a result of

excess calcium released into

blood stream)

● Symptoms may include:

− Constipation or diarrhea

− Confusion

− Dehydration

− Nausea or vomiting

− Memory loss and depression

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Diagnosing bone metastases

● To determine if the cancer has spread to the bones, a doctor may

order several tests, including:

● Imaging tests (X-rays and radionuclide bone scans, CT scans, MRI

scans and PET scans)

● Blood tests

● Urine tests

● Biopsies

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Bisphosphonates reduce the risk of SREs in

breast cancer patients

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Study Schema

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Primary End Point: Time to First On-Study SRE

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Secondary End Point: Time to First and

Subsequent SREs

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Pain Progression: Denosumab vs. ZA

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Quality of Life – Denosumab vs. ZA

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ZOOM: A Prospective, Randomized Trial of ZA for Long-Term

Treatment of Bone-metastatic BrCa after 1 Year of ZA Treatment

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ZOOM: Primary Efficacy Analysis: SMR

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Select AEs with ZA and Denosumab During the 2-

Year Open-Label Treatment Phase

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Risk Factors for ONJ in Cancer Patients

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Treatment options for complications of bone

metastases

● Several treatment options are

available

● Your doctor will determine which

is right for you based on your

health needs and lifestyle

Bisphosphonates

RANK-Ligand inhibitor

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Treatment options for complications of bone

metastases

Medication can be administered in different ways

• By mouth (tablets/liquids)

• By intravenous/IV infusion (into the vein)

• By subcutaneous injection (under the skin)

Many people may go untreated, remaining at risk of

developing serious bone complications

Speak to your doctor about treatment options that are

right for you

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Current approved bone-targeted

therapies in Canada

Breast Cancer

● Denosumab (Xgeva®)

● Administered as subcutaneous

injection every 4 weeks

● Zoledronic acid (Zometa™)

● Administered every 3 or 4 weeks

via a 15-minute infusion

● Pamidronate (Aredia™)

● Administered every 3 or 4 weeks

as a 2 hour intravenous/IV infusion

● Clodronate (Ostac™)

● Administered as oral tablets daily

Prostate Cancer

● Denosumab (Xgeva®)

● Administered as subcutaneous

injection every 4 weeks

● Zoledronic acid (Zometa™)

● Administered every 3 or 4 weeks

via a 15-minute infusion

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Possible side effects

RANK-Ligand Inhibitor

● The most common are fatigue

and asthenia;

hypophosphatemia; and nausea

● It can cause hypocalcemia

● Osteonecrosis of the jaw has

been reported in patients with

denosumab

Bisphosphonates

● Fever, flu-like symptoms, fatigue,

nausea, asthenia, severe

hypophosphatemia

● Osteonecrosis of the jaw

● Worsening of kidney function

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The impact of cancer treatment on bone health

● In addition to bone metastases, some cancer treatments can also

cause bone loss

● Androgen deprivation therapy (prostate)

● Aromatase inhibitors (breast)

● Bone loss can increase risk of fractures

● Fractures can lead to hospitalization, nursing home admissions, and

home care support services

● Currently no drug therapies are specifically approved for cancer

treatment-induced bone loss in Canada

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Tips for maintaining strong bones

● Speak to your doctor before starting a new exercise regimen

● Participate in weight-bearing exercise and strength training

● Brisk walking

● Dancing

● Make your diet count, and include calcium

● Eat low-fat and nonfat dairy products,

leafy greens, and calcium-fortified foods

● Fruits and vegetables provide other

bone-building nutrients

● Avoid falls or injuries

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Tips for maintaining strong bones

● Intake at least 500 mg calcium daily and at least 400 IU vitamin D

daily (except patients with hypercalcemia)

● Limit caffeine to 2-3 cups per day

● Do not smoke

● Take care to avoid falls which can

lead to fracture

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Summary

● Bone is the most common site for cancer to spread in people with

advanced prostate or breast cancer

● Bone pain is often the first sign the cancer has spread

● Bone metastases can be detected with bone scans and other

diagnostic tools

● Bone metastases can lead to serious complications which are

associated with disability, hospitalization and death

● Talk to your doctor about available treatments to reduce the risk of

serious complications

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What else can you do?

● Talk to your doctor about bone

health

● Tell your doctor right away if you

have unexplained pain in your

bones

● Keep active and eat a good diet,

supplement with calcium and

vitamin D

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Ask the expert

Questions?

Bone Health Awareness Program

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Bone health awareness program objectives

● Raise awareness about the

importance of bone health in

advanced breast and prostate cancer

● Inspire patients to educate others and

take action

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Program overview

Ambassadors Original artwork

Media Events

Website Awareness with government

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Program elements

● Men and women who have had

bone metastases OR have an

interest in bone health

● Willing to take action to help

raise awareness and help others

access the treatments they need

Bone health ambassadors

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Program elements

● Local artists engaged in

Vancouver, Calgary & Toronto

● Visual representation of survivor

stories

Original artwork

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Program elements

● Events held in Toronto,

Vancouver, Calgary

● Sunday, June 2: National

Cancer Survivor Day

● Artwork unveiled for

survivors, supporters, groups

Local events

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Program elements

Media

● Generating media coverage of

ambassador stories

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Website: bonehealthincancer.ca

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Program elements

Awareness with government

● Call to action to make bone-targeted

treatment options available to all who

need them

● Awareness that bone metastases as a

concern for cancer survivors

● Advocates creating awareness with

elected and government officials

through letters and meeting

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Public access to bone-targeted treatment

denosumab zoledronic acid

British Columbia Covered (palliative only) Covered (palliative only)

Saskatchewan Covered Covered

Alberta Not covered Not covered

Manitoba Covered

Covered

Ontario Covered Covered

Quebec Covered Not covered

Newfoundland and

Labrador

Not covered Covered

New Brunswick Covered Covered

Nova Scotia Covered Covered

Prince Edward

Island

Not covered Not covered

Prostate cancer

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Public access to bone-targeted treatment

Breast cancer denosumab zoledronic acid pamidrondate clodronate

British Columbia Covered

(palliative only)

Not covered Covered (palliative

or specific criteria)

Covered

(palliative or

specific criteria)

Saskatchewan Not covered Not covered Covered Covered

Alberta Not covered

Not covered Covered Covered

Manitoba Not covered Not covered Covered Covered

Ontario Not covered Covered Covered Covered

Quebec Covered Covered Covered Covered

Newfoundland

and Labrador

Not covered

Not covered Covered Covered

New Brunswick Not covered Not covered Covered Covered

Nova Scotia Not covered

Not covered Covered Covered

Prince Edward

Island

Not covered

Not covered Not covered

Not covered

Will you join us?

Contact:

Jackie Manthorne, President and CEO, CCSN

Phone: 613-898-1871

Email address: jmanthorne@survivornet.ca

Questions?

Thank you!