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Journal of Clinical Oncology, Vol 23, No 21 (July 20), 2005: pp. 4802-4803 © 2005 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.01.3490
Systemic Treatment of Bone Metastases From Breast Cancer: Is It All That It’s Cracked Up to Be?Division of Medical Oncology, Sunnybrook and Women's College Health Sciences Center, Toronto, Ontario, Canada To the Editor: We commend Hamaoka et al for their excellent review of bone imaging in metastatic breast cancer, in which they review the role of various imaging techniques for detecting bone metastases and assessing response to treatment.1 With respect to the use of bisphosphonates for the treatment of skeletal metastases secondary to breast cancer, this review may prove pertinent, particularly in evaluating the correct duration of treatment. Despite the rapid integration of bisphosphonates into standard clinical practice, many uncertainties remain regarding their use, such as the most beneficial scheduling of treatment, which patients to treat, and the optimal duration of therapy.2 Of these uncertainties, the impact of not knowing the optimal duration of therapy is particularly important, as these agents are often continued indefinitely.3,4 This practice not only has important financial implications,4 but having terminally ill patients return to their treatment center on a monthly basis for intravenous treatment could create additional strain on the patient and family. To address these gaps in the data, improved methods of evaluating the effect of bisphosphonates on bone metastases are needed. Additionally, clinicians require tools that can accurately identify patients who are not responding to treatment so that appropriate modifications can be made. Assessing treatment response in bone metastases is currently hampered by the lack of an effective means of measuring disease response in a clinically desirable time frame. The review by Hamaoka et al has highlighted many of the inadequacies of radiologic follow-up and reaffirmed the need for more sensitive, time-efficient, and practical methods of monitoring treatment response.
Markers of bone turnover seem to hold the most promise in identifying patients likely to respond to and benefit from bisphosphonate treatment. These markers could also be an indicator for discontinuing therapy to avoid prolonged therapy. Of the markers under investigation, telopeptide (NTx; N terminal type 1 collagen degradation product) seems to be the most promising as an early indicator of effect. In a study of 121 patients with metastatic bone disease by Brown et al, patients with a baseline NTx It is possible that a combination of imaging techniques and bone markers will prove to be a useful method of monitoring the effectiveness of treatment for bone metastases. Clearly however, we need to improve on our current methods of assessing treatment response to ensure that these agents are being used in a manner that will optimize patient outcomes. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest. REFERENCES
1. Hamaoka T, Madewell JE, Podoloff DA, et al: Bone imaging in metastatic breast cancer. J Clin Oncol 22:2942-2953, 2004 2. Clemons M, Rea D: Perspectives on the future of bisphosphonate use in breast cancer patients. Semin Oncol 31:87-91, 2004 (suppl 10) 3. Verma S, Kerr-Cresswell D, Dranitsaris G, et al: Bisphosphonate use for the management of breast cancer patients with bone metastases: A survey of Canadian Medical Oncologists. Support Care Cancer 12:852-858, 2004[CrossRef][Medline] 4. Clemons M, Enright K, Cesta A, et al: Do physicians follow systemic treatment and funding policy guidelines? Can J Clin Pharmacol 11:e168-e178, 2004[Medline] 5. Brown J, Thompson C, Ellis S, et al: Bone resorption predicts for skeletal complications in metastatic bone disease. Br J Cancer 89:2031-2037, 2003[CrossRef][Medline] 6. Clamp A, Danson S, Nguyen H, et al: Assessment of therapeutic response in patients with metastatic bone disease. Lancet Oncol 5:607-616, 2004[CrossRef][Medline] Related Reply
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Copyright © 2005 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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100 nmol mmol–1 creatinine were approximately 20-fold more likely (odds ratio = 19.5; P < .001) to experience a complication defined as spinal cord or nerve root compression, symptomatic radiographically confirmed pathological fractures, orthopaedic surgery to bone, hospital admissions for control of bone pain, and/or death due to metastatic bone disease over the subsequent 3 months than patients with normal baseline NTx values.
