Managing Bone Pain in Metastatic Disease Rachel Schacht PA-C Medical Oncology and Hematology Associates Presented on 11/2/2018
None Disclosures
Managing Bone Pain in Metastatic Disease This lecture will cover therapeutic options for management of adult patients with bone pain from metastases disease originating from solid tumors
Bone Metastasis Cancers that typically spread to bone: Prostate Breast Kidney Thyroid Lung
Bone Metastasis Presentation on physical exam: Dull aching pain No pain Sharp pain when force or vibration is applied to the fracture site Diagnostic imaging: x-ray is the preferred imaging study when bone metastasis is suspected PET scan or CT can also assist with diagnosis
Common Sites of Bone Metastasis In order of frequency: Spine Pelvis Femur Ribs Proximal humerus Skull
Managing Bone Metastasis Treatment Goals: Maximizing pain control Minimizing risk for skeletal-related events (SREs) Preserving and restoring function to the patient Enhancing local tumor control
Managing Bone Metastasis Treatment must be individualized to the patient s specific symptoms, clinical presentation, histologic tumor type, performance status, and goals/preferences. For example, someone with asymptomatic bone metastasis and limited life expectancy may prefer observation vs. aggressive intervention.
Maximizing Pain Control Analgesias First line treatment: Acetaminophen or NSAIDs if no contraindications Second line treatment: Addition of opioids, caution advised as several opioids have acetaminophen component Refer to anesthesia pain specialist Nerve block, spinal cord stimulator, epidural port-acath, or implanted pain pump Glucocorticoids may reduce somatic pain from bone metastasis
Skeletal Related Events Skeletal related events associated with bone metastasis include: PAIN Pathologic Fractures (Pathologic fractures are fractures caused by disease vs. traumatic fractures which are caused by external damage) Hypercalcemia Spinal cord compression
Skeletal Related Events Compression fracture Is a loss of vertebral body height usually resulting in a wedge deformity Could result in nerve compression Postural changes which result in decreased lung capacity or propensity for additional fractures
Treatment of Compression Fractures Vertebroplasty Percutaneous injection of bone cement under fluoroscopy into the collapsed vertebral body Kyphoplasty Involves an inflatable bone tamp, or balloon expander, that once inflated creates a cavity that can be filled with bone cement. The choice between kyphoplasty and vertebroplasty is best dictated by the expertise of the practitioner preforming the procedure. For nonsurgical candidates consider back brace, walker, wheelchair and other devices to assist with ADL.
Treating Pathologic Fractures Fractures to long bones, such as the femur or humerus may require stabilization with an intramedullary rod. These patients should be referred to an orthopedist for evaluation. As a general rule, fixation with intramedullary rod is recommended if >50% of the cortical bone thickness is destroyed. Radiation therapy post operatively is recommended for most patients as this promotes remineralization and bone healing, alleviates pain, and reduces the risk for subsequent fracture or loss of fixation by treating metastatic disease
Bone Remodeling Osteoblasts and osteoclasts are responsible for bone growth, also referred to as bone turnover.
Reducing Skeletal Related Events Bisphosphonates Inhibit osteoclast-mediated bone resorption They have been shown to provide minimal relief of bone pain as well as reduce the number of fractures Risks of bisphosphonates include: Renal damage ONJ GI upset Hypocalcemia, especially in vitamin-d deficient patients Denosumab Monoclonal antibody against RANKL Blocks osteoclast activation
Reducing Skeletal Related Events Abiraterone Androgen biosynthesis inhibitor acting through selective CYP-450 inhibition Improves survival and bone pain in castrationresistant prostate cancer Given in combination with prednisone
Enhance Local Tumor Control Radiation Therapy Goals of palliative treatment of bone metastases are pain relief, preservation of function, and maintenance of skeletal integrity
Radiation Therapy External Beam Radiation Therapy (EBRT): Appropriate if there is one or a limited number of painful bone metastasis Sometimes a pain flare, which is a worsening of pain 1-2 days after RT initiation can occur, but typically pain relief associated with RT occurs rapidly.
Radiation Therapy Stereotactic Body RT (SBRT): Targeted radiation to a tumor while minimizing radiation to adjacent normal tissue, allowing treatment of small- or moderate-sized tumors in either a single or limited number of dose fractions. May provide useful palliative alternative for patient with ongoing bone pain after EBRT Although it is a safe and effect treatment for painful spine mets it may be associated with increased risk of vertebral fractures.
Radiation Therapy Treatment of patients with widespread bone pain that can not be treated with focal RT can be treated with: 1. Bone-targeted radioisotopes Beta or alpha emitting radioisotopes which localize to areas of osteoblastic activity and can be used in tumors with osteoblastic metastasis. It s given systemically and can be provided same time as EBRT. Efficacy data is mainly on prostate cancer with bone metastasis w/o visceral mets. 2. Hemibody Irradiation The use of hemibody irradiation has largely been replaced by the administration of radiopharmaceuticals More toxic than focal RT Can be used when radiopharmaceuticals are not avaiable
Treatment Goals: Summary Maximizing pain control Analgesias, glucocorticoids, bisphosphonates and appropriate referrals to anesthesia pain management. Minimizing risk for skeletal-related events (SREs) Start osteoclast inhibitors in appropriate patients. Preserving and restoring function to the patient Prescribe assistive devices for ADLs, palliative referrals, and orthopedic referrals for surgical candidates. Enhancing local tumor control Appropriate referrals to radiation oncology
Citations 1. Nielsen. Palliative Radiotherapy of Bone Metastases: there is now evidence for the use of single fractions. Radiother Oncol. 1999;52(2):95 2. Govindan R & Morgensztern D. (Eds.). (2015). The Washington Manual of Oncology. Philadelphia, PA: Wolters Kluwer.