Palliative pamidronate treatment in patients with bone metastases from breast cancer

Clodronate improves bone mineral density in post-menopausal breast cancer patients treated with adjuvant antioestrogens

The effect of clodronate on bone mineral density (BMD) was studied in 121 post-menopausal breast cancer women without skeletal metastases. In addition, two antioestrogens, tamoxifen and toremifene, were compared in their action on bone mineral density. Patients were randomized to have an adjuvant antioestrogen treatment either 20 mg of tamoxifen or 60 mg of toremifene daily for 3 years. In addition all patients were randomized to have 1600 mg of oral clodronate daily or to act as control subjects. BMD of the lumbar spine and femoral neck were measured by dual-energy radiographic absorptiometry before therapy and at 1 and 2 years. At 2 years, clodronate with antioestrogens markedly increased BMD in the lumbar spine and femoral neck by 2.9% and 3.7% (P = 0.001 and 0.006 respectively). There were no significant changes in BMD in the patients given antioestrogens only. No significant differences were found between tamoxifen and toremifene on bone mineral density. Clodronate with antioestrogens significantly increased bone mass in the lumbar spine and femoral neck. Both antioestrogens, tamoxifen and toremifene, similarly prevented bone loss in the lumbar spine and femoral neck.

Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. Protocol 19 Aredia Breast Cancer Study Group

BACKGROUND

Bisphosphonates such as pamidronate disodium inhibit osteoclast-induced bone resorption associated with cancer that has metastasized to bone.

METHODS

Women with stage IV breast cancer who were receiving cytotoxic chemotherapy and had at least one lytic bone lesion were given either placebo or pamidronate (90 mg) as a two-hour intravenous infusion monthly for 12 cycles. Skeletal complications, including pathologic fractures, the need for radiation to bone or bone surgery, spinal cord compression, and hypercalcemia (a serum calcium concentration above 12 mg per deciliter [3.0 mmol per liter] or elevated to any degree and requiring treatment), were assessed monthly. Bone pain, use of analgesic drugs, performance status, and quality of life were assessed throughout the trial.

RESULTS

The efficacy of treatment was evaluated in 380 of 382 randomized patients, 185 receiving pamidronate and 195 receiving placebo. The median time to the occurrence of the first skeletal complication was greater in the pamidronate group than in the placebo group (13.1 vs. 7.0 months, P=0.005), and the proportion of patients in whom any skeletal complication occurred was lower (43 percent vs. 56 percent, P = 0.008). There was significantly less increase in bone pain (P=0.046) and deterioration of performance status (P=0.027) in the pamidronate group than in the placebo group. Pamidronate was well tolerated.

CONCLUSIONS

Monthly infusions of pamidronate as a supplement to chemotherapy can protect against skeletal complications in women with stage IV breast cancer who have osteolytic bone metastases.

Utility of bisphosphonates in treating bone metastases

Bone is the most common site of metastases from breast and prostate cancer, and bone destruction is characteristic of multiple myeloma. Increased osteoclast activity plays a key role in cancer-induced bone destruction. Bisphosphonates reduce osteoclastic bone resorption through various mechanisms as yet not fully elucidated. Bisphosphonates have proven to be effective in the treatment of tumor-induced hypercalcaemia. Several clinical trials indicated that these compounds can positively influence many aspects of neoplastic bone disease, however, many questions regarding their long-term efficacy and optimal therapeutic schedule await clarification from well-designed clinical trials.

Clodronate decreases the frequency of skeletal metastases in women with breast cancer

The aims of this study were to determine the effects of the bisphosphonate, clodronate, on the incidence of skeletal metastases and associated morbidity in women with advanced breast cancer. 133 women with recurrent breast cancer, but no evidence of skeletal metastases, were randomly allocated to receive clodronate 1600 mg daily by mouth or an identical placebo for 3 years under double-blind conditions at two clinical oncology centers in the UK and Canada. Main outcome measures included the occurrence of skeletal metastases, as judged by sequential bone scans and radiographs, and the morbidity associated with skeletal metastases comprising the incidence of hypercalcemia, vertebral, and nonvertebral fractures, and bone pain assessed by the requirements for skeletal radiotherapy. The number of patients developing skeletal metastases was lower in clodronate-treated patients than with placebo (15 vs. 19), but was not significantly different. The number of skeletal metastases was significantly lower with clodronate treatment than with placebo (32 vs. 63; p < 0.005). The complications of skeletal disease were fewer by 26% in clodronate-treated patients compared to controls (p < 0.01). Compared to placebo, significant effects in favor of clodronate were observed for vertebral deformities (29%) and nonvertebral fractures (75%), but the event frequency of each was low. There was a small (22%) but nonsignificant treatment effect on the requirements for radiotherapy and hypercalcemia (39%). There was no effect of clodronate on survival. We conclude that clodronate by mouth significantly decreases the number and complications of skeletal metastases in women with advanced breast cancer.

Bisphosphonates inhibit the adhesion of breast cancer cells to bone matrices in vitro

Bisphosphonates are used with increasing frequency in the management of skeletal complications in patients with breast cancer. In this paper, we have investigated whether bisphosphonates, besides their known beneficial effects on tumor-associated osteoclastic resorption, are capable of inhibiting breast cancer cell adhesion to bone matrix. For that we used two in vitro models for bone matrix (cortical bone slices and cryostat sections of trabecular bone from neonatal mouse tails). Four bone matrix-bound nitrogen-containing bisphosphonates (pamidronate, olpadronate, alendronate, and ibandronate) inhibited adhesion and spreading of breast cancer cells to bone dose-dependently, whereas etidronate and clodronate had little or no effect. Strikingly, the relative order of potency of the bisphosphonates in inhibiting the adhesion of cancer cells to cortical and trabecular bone corresponded to their relative antiresorptive potencies in vivo as well as their ranking in in vitro bone resorption assays with predictive value for their clinical efficacy. It appears that nitrogen-containing bisphosphonates alter selectively the adhesive properties of the extracellular bone matrix preventing the attachment of breast cancer cells to it. Besides the beneficial effects of bisphosphonates on tumor-induced osteoclastic resorption, the previously unrecognized effect presented in this paper makes these agents suitable for earlier pharmacologic intervention in patients with breast cancer at risk of developing bone metastases.

Effects of oral clodronate on bone mineral density in patients with relapsing breast cancer

The high prevalence of bone metastases in breast cancer and the risk that spinal and femoral osteoporosis may add further morbidity provide a rationale for bisphosphonate therapy in patients with skeletal metastases from mammary carcinoma. We investigated the effects of oral clodronate given during 9 months, with a 24-month follow-up, on bone mineral density (BMD), on biochemical markers of bone remodeling, and on osseous complications in 67 women with documented relapsing breast cancer, aged 58.7 +/- 1.5 years (x +/- SEM). Patients with active cancer disease were randomly allocated to two groups, with or without clodronate treatment (1600 mg/day, orally). Twenty-six women considered in complete remission (52.4 +/- 2.4 years) were also studied. Expressed in deviation from gender- and age-matched normals (z score), base-line BMD at the levels of lumbar spine (LS), femoral neck (FN), and midfemoral shaft (FS) was +0.10 +/- 0.22 vs. -0.12 +/- 0.25, +0.03 +/- 0.19 vs. -0.54 +/- 0.24, and +0.08 +/- 0.14 vs. -0.02 +/- 0.22, in patients with active breast cancer and in subjects in remission, respectively. After 9 months of treatment, fasting urinary calcium to creatinine ratio was lower (0.26 +/- 0.04 vs. 0.40 +/- 0.04 mmol/mmol creatinine, p < 0.02) and serum osteocalcin was stabilized (-2.1 +/- 1.1 vs. +7.0 +/- 3.3 micrograms/L, as compared with pretreatment values, p < 0.02), in the clodronate-treated group. The rate of osseous complications (pathological fracture, hypercalcemic episode, scintigraphic or radiological evidence of metastasis development, chemo- or radiotherapy for bone disease progression) was 28.8 events per 100 patient-year in the clodronate-treated group vs. 39.0 in controls, and 31.5 vs. 40.5, after 9 and 15 months of follow-up, respectively. In 15 women without evident LS bone metastasis (7 clodronate-treated and 8 controls), LS BMD increased in the clodronate-treated group by +5.2 +/- 2.5% vs. -0.3 +/- 1.4%, and +8.1 +/- 4.7 vs. -0.9 +/- 1.7, after 10.3 +/- 0.4 and 17.3 +/- 1.2 months, respectively (p < 0.01), as compared with pretreatment values. These results indicate that clodronate treatment decreased bone turnover and attenuated cancer-related bone morbidity. In addition, clodronate increased LS BMD in apparently unaffected bone of women with relapsing breast cancer.

Pain and Symptom Management in Palliative Care

BACKGROUND: Pain, dyspnea, and anorexia are common symptoms experienced by patients with cancer and often are poorly managed. METHODS: The incidence and causes of these symptoms are described, as well as factors that exacerbate or ameliorate their impact. RESULTS: Pharmacologic management of cancer pain is based on the use of a sequential "ladder" that incorporates nonopioid, opioid, and adjuvant drugs, depending on the severity of the pain. This approach usually is effective. Other symptoms of advanced disease may be more difficult to control. CONCLUSIONS: Adherence to an adequate pain-control strategy will significantly enhance palliation of pain in patients with cancer.

Metabolic effects of pamidronate in patients with metastatic bone disease

We have evaluated the value of specific bone resorption markers in monitoring metastatic bone disease to define the duration of action of a single high-dose pamidronate infusion. Twenty patients received a single infusion of pamidronate 120 mg for painful bone metastases. Ten out of these 20 patients also received a second infusion. They were evaluated at baseline, 2, 4 and 8 weeks after each infusion. A composite pain questionnaire, serum and urine tests were carried out at these time points. Bone resorption markers measured included urinary calcium, hydroxyproline and two new markers: pyridinoline and deoxypyridinoline. Reference values were defined by 20 healthy controls matched by age and sex. Pamidronate induced a profound fall in bone resorption with a maximal effect within the first month after therapy. Changes in urinary calcium levels were confounded by a rise of 100% in the parathyroid hormone levels. Before treatment, pyridinoline and deoxypyridinoline were increased in 70% of patients, while urinary calcium was increased in only 40% of them. Thirteen patients had a > or = 50% fall in deoxypyridinoline levels and were considered as biochemical responders. These patients had a mean reduction in pain score of about 30% of baseline levels, which was significantly higher than the seven non-biochemical responders. In conclusion, urinary calcium is not a precise marker of bone resorption. Deoxypyridinoline seems to be the most specific bone resorption marker in cancer patients. Biochemical responders have the most benefit from pamidronate in terms of pain relief. This suggests that patients may benefit from more potent or repeated infusions of bisphosphonates.

The role of bisphosphonates in the treatment of bone metastases--the U.S. experience

Frequent complications of bone metastases include pain, pathologic fracture, hypercalcemia and spinal cord compression. Lytic bone metastases result from excessive activation of osteoclasts by tumor-produced cytokines. Aredia (pamidronate) is a potent bisphosphonate that inhibits osteoclast activation. In two dose-seeking phase I trials in patients with breast cancer and prostate cancer, repeated intravenous infusion of Aredia was shown to be safe and effective in reducing bone resorption and pain. In a randomized phase III trial of 377 patients with multiple myeloma, Aredia was administered in a dosage of 90 mg i.v. every 4 weeks. Compared with placebo, treatment with Aredia was associated with a significant decrease in bone pain and in the incidence and time to development of all skeleton-related events. Data from two phase III breast cancer trials each involving 300 patients are now being analyzed. The newer bisphosphonates can safely be used together with standard anticancer therapy to provide effective palliation of symptoms caused by lytic bone metastases.

Does supportive pamidronate treatment prevent or delay the first manifestation of bone metastases in breast cancer patients?

The effect of pamidronate treatment on the first development of bone metastases was investigated in 124 patients with breast cancer, with either locally advanced disease (n = 33) or extraskeletal metastases (n = 91), but no bone metastases in a randomised, multicentre, open controlled study. Patients were assigned to treatment with oral pamidronate, 300 mg/day, (n = 65) or to a control group (n = 59). Tumour therapy was freely allowed. A first clinical event of skeletal morbidity occurred in 22% pamidronate and 20% control patients; unequivocal first radiological manifestation of bone metastases was found in 36% pamidronate and 27% control patients (n.s.). The actuarial risk of a first skeletal event was similar in both groups. Quality-of-life measurements of bone metastases-related aspects showed no differences between the two groups. 19 patients withdrew from the study because of gastrointestinal complaints attributed to pamidronate. We conclude that supportive oral pamidronate treatment (300 mg/day) does not prevent nor delay the development of bone metastases in breast cancer patients at risk.

Increased bone mass with pamidronate treatment in rheumatoid arthritis. Results of a three-year randomized, double-blind trial

OBJECTIVES

Osteoporosis is a frequent complication of rheumatoid arthritis (RA). We therefore investigated the effect of oral pamidronate therapy as a specific bone-sparing agent in RA.

METHODS

The study design was a 3-year randomized, double-blind trial of 300 mg oral pamidronate/day compared with placebo in 105 RA patients. Bone mineral density (BMD) measured at 12-month intervals was the primary efficacy parameter.

RESULTS

In 3 years, lumbar spine and forearm BMD increased significantly in the pamidronate-treated group (by 8.4 +/- 6.9% [mean =/- SEMI] [P < 0.00011 and 5.2 =/- 6.5% [P < 0.005], respectively), compared with nonsignificant changes in the placebo-treated patients (increase of 0.6 =/- 5.2% and decrease of 1.2 =/- 5.8%, respectively). Femoral neck BMD increased in the pamidronate-treated group (by 2.6 =/- 8.6%) and decreased significantly in the placebo-treated group (by 4.0=/- 1.3% [P < 0.005]). The changes in BMD with time at all 3 measurement sites were significantly different between the treatment groups (P < 0.0001). Changes in radiographic signs of joint damage and in disease activity were similar in the 2 groups.

CONCLUSION

The present study provides the first evidence that long-term treatment with an orally administered bisphosphonate overcomes bone loss and increases bone mass when compared with placebo. This finding may have significance with regard to the treatment of patients with RA.

Causes and treatment of bone pain of malignant origin

Pain relief has been one of the oldest and most important duties of the physician. There has been little change with regard to this obligation of all caregivers. One-third of patients with advanced cancer will develop clinically relevant skeletal metastases and chronic pain during the course of their disease. All physicians involved in the treatment of cancer patients should know the basic principles of pain treatment. These are described in the following article with special regard to bone pain of malignant origin. Correct assessment of pain intensity and frequency, as well as of the probable causes of pain, and the administration of adequate analgesic treatment should achieve satisfactory results in the vast majority of patients. Every physician should obtain detailed knowledge of the indications and adequate administration of pain-killing therapy as well as possible adverse effects and their successful treatment. It is important in particular to concentrate on a few nonsteroidal anti-inflammatory drugs (NSAIDs) as well as opiates. Knowledge of adequate doses, maximal recommended daily doses, pharmacological properties, important adverse effects and interactions is essential for success in the daily routine. Only by selecting 2 or 3 drugs from each step in the analgesic ladder (WHO) will the nonspecialised physician obtain sufficient experience for optimal analgesia. Physicians should also not hesitate to contact other specialists (medical oncologists, radiotherapists, neurosurgeons, anaesthesiologists and others) in order to maximise benefit for an individual patient.

Palliative medicine and the medical oncologist. Defining the purview of care

The fusion of palliative medicine and medical oncology, in practice and in education, can provide a better standard of patient care, reduce the risk of oncologist burnout, and increase the likelihood of patient family and physician satisfaction. There need be no gulf between these disciplines, and only together do they represent truly comprehensive cancer care. The realization of this fusion will require the participation of individual clinicians, program directors, and the policy makers for cancer centers, professional organizations, and the health care regulatory authorities. It is a logical next step in the evolution of medical oncology.

Adjuvant analgesic agents

Adjuvant analgesics are usually considered when the patient with cancer pain fails to attain a satisfactory balance between analgesia and side effects during opioid therapy, or experiences a comorbid symptom or disorder that may be amenable to one of the adjuvant drugs. When pain is the primary indication, the use of adjuvant analgesics is one strategy that must be evaluated in comparison with other potentially analgesic approaches. The potential costs, inconvenience, and risks associated with polypharmacy must be balanced by demonstrable benefits. To offer the most informed recommendation, the clinician must have a strong working knowledge of the many drugs currently used as adjuvant analgesics and a detailed assessment of the patient and pain syndrome.

Rationale for the use of bisphosphonates in breast cancer

The variability of different breast cancers in the susceptibility to metastatic bone disease is poorly understood. Factors that determine the viability of metastatic cells are also poorly understood, but may depend in part upon gene expression of PTHrP and the vitamin D receptor. In contrast, much more is known of the manner in which metastatic breast disease affects bone remodelling to induce osteolytic bone disease. Mechanisms include a generalized increase in activation frequency at sites close to metastatic tissue, an imbalance between the amount of bone formed and that resorbed within resorption cavities, and uncoupling of bone formation from bone resorption. The greatest morbidity from metastatic bone disease arises from osteolytic disease and gives rise to hypercalcaemia, bone pain and fractures. Since osteolysis is primarily mediated by the activation of osteoclasts, there has been a great deal of interest in the use of agents which primarily affect bone metabolism to alter the natural history of metastatic bone disease. Non-steroidal anti-inflammatory agents and cytotoxic agents are capable of inducing responses in bone, but are limited by their toxicity when effective doses are utilized. The use of calcitonin in the long-term suppression of osteolysis has also been disappointing. The bisphosphonates are, however, capable of inducing sustained decreases in osteoclast activity and numbers in patients with osteolytic bone disease. There are now several studies which have examined the effects of the bisphosphonates on skeletal morbidity in breast cancer. Both clodronate and pamidronate decrease the incidence of hypercalcaemia, bone pain and pathological fractures, but do not significantly alter mortality. Given, however, the unchanging survival in patients with metastatic bone disease, significant improvements in the quality of remaining life is an important therapeutic effect.

Skeletal metastases

This synthesis of the literature on radiotherapy for skeletal metastases is based on 171 scientific articles, including 13 randomized studies, 24 prospective studies, and 79 retrospective studies. These studies involve 13054 patients. Radiotherapy has been well documented as a method for alleviating pain, but the mechanisms underlying this effect are largely unknown. When used for pain palliation, radiotherapy achieves freedom from pain, or substantial alleviation of pain in nearly all cases, with few side effects. Half-body irradiation is effective in treating multiple metastatic sites and should be considered for use more frequently. However, this increases the requirements on equipment, dosimetry, and hospital beds. Systemic radiotherapy with radionuclides may be indicated for generalized skeletal pain. The role of radiotherapy in preventing or healing fractures is not fully evaluated. Optimum dose levels and fractionation schedules have not been established. Early radiotherapy for spinal cord compression may prevent symptoms from worsening, but the effects on existing paralysis are modest.

The future of bisphosphonates in cancer

Bisphosphonates, in conjunction with rehydration, are now the treatment of choice for hypercalcaemia of malignancy. They can also relieve bone pain and improve quality of life as single agent therapy and, in conjunction with systemic anticancer treatments, can prevent skeletal complications and slow down the metastatic process. The clinical effects are greatest and most clearly defined in breast cancer and multiple myeloma, but, theoretically, clinical benefit should be achievable across the entire spectrum of metastatic bone disease. The new biochemical markers for measuring bone resorption are for the first time providing a direct assessment of the effects of treatment on bone. It is hoped that they will enable a more scientific selection of the type, dose and schedule of bisphosphonate required for the best compromise between efficacy, convenience and patient acceptability. We can expect to see a rapid increase in the use of bisphosphonates in malignancy (especially breast cancer and myeloma). Careful assessment of the health-care economics of this new treatment modality is urgently needed.

Bisphosphonate therapy in metastatic breast cancer

Five long-term controlled studies on the effect of supportive bisphosphonate treatment in metastatic breast cancer with bone metastases have been published. In two of the studies pamidronate was used and in three clodronate. According to these trials supportive bisphosphonate treatment in metastatic breast cancer diminishes the risk of malignant, pathological fractures and bone pain. In several of these trials a retarding effect on the progression of previous and new bone metastases could also be documented. One further large trial, hitherto published only in abstract form, indicates that the development of bone invasion can also be retarded by bisphosphonate treatment in patients with metastatic breast cancer without bone metastases.

Bone and cancer: pathophysiology and treatment of metastases

The variability of different primary tumors in the susceptibility to metastatic bone disease is poorly understood. Factors that determine the viability of metastatic cells are also poorly understood, but may depend in part upon gene expression of PTHrP and the vitamin D receptor. In contrast, much more is known of the manner in which metastatic disease affects bone remodeling to induce osteolytic bone disease. Mechanisms include a generalized increase in activation frequency at sites close to metastatic tissue, an imbalance between the amount of bone formed and that resorbed within resorption cavities, and uncoupling of bone formation from bone resorption. The greatest morbidity from metastatic bone disease arises from osteolytic disease and gives rise to hypercalcemia, bone pain, and fractures. Because osteolysis is primarily mediated by the activation of osteoclasts, there has been a great deal of interest in the use of agents which primarily affect bone metabolism to alter the natural history of metastatic bone disease. Nonsteroidal antiinflammatory agents and cytotoxic agents are capable of inducing responses in bone, but are limited by their toxicity when effective doses are utilized. The use of calcitonin in the long-term suppression of osteolysis has also been disappointing. The bisphosphonates are, however, capable of inducing sustained decreases in osteoclast activity and numbers in patients with osteolytic bone disease. There are now several studies which have examined the effects of the bisphosphonates on skeletal morbidity in breast cancer. Both clodronate and pamidronate decrease the incidence of hypercalcemia, bone pain, and pathological fractures, but do not significantly alter mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous pamidronate in patients with tumor-induced osteolysis: a biochemical dose-response study

Bisphosphonates are used increasingly in normocalcemic patients for treating tumor-induced osteolysis (TIO) but little is known about the metabolic effects and the most appropriate therapeutic regimen. In 21 patients with breast cancer and TIO, we determined the biochemical effects of a single infusion of pamidronate given at 30 mg (n = 5), 60 mg (n = 5), 90 mg (n = 5), or 120 mg (n = 6). Patients received no other systemic antineoplastic therapy during the trial. We selected patients with baseline fasting urinary Ca/Creat (creatinine) > 0.105 mg/mg (median value of our normal range) and they were followed weekly for up to 14 weeks. The biochemical effects were maximal at day 7. For the whole group, mean (+/- SEM) Ca/Creat levels fell from 0.208 +/- 0.018 to 0.048 +/- 0.008 mg/mg on day 7 and remained significantly ( p < 0.01) lower than baseline up to day 56. Hydroxyproline excretion fell to a lesser degree, from 7.0 +/- 1.2 to 4.0 +/- 0.6 mg x 100/mg of Creat. The falls in Ca/Creat and hydroxyproline excretion were dose-related (ANCOVA, p < 0.05). Changes in serum parameters of calcium metabolism were, however, not significantly dose-related. Serum Ca levels fell from 9.3 +/- 0.1 to 8.7 +/- 0.1 mg/dl on day 7, but not patients developed symptomatic hypocalcemia, and the decrease within each dose group was significant only at 120 mg. Ca2+ levels followed a similar pattern. There was a slight increase in Mg levels and a pronounced fall in Pi levels, from 3.6 +/- 0.2 to 2.8 +/- 0.1 mg/dl. Intact PTH levels increased from 29 +/- 4 to 91 +/- 13 pg/ml and remained significantly (p < 0.05) elevated up to day 28.(ABSTRACT TRUNCATED AT 250 WORDS)

Clodronate and other bisphosphonates as supportive therapy in osteolysis due to malignancy

Clodronate, one of the most investigated bisphosphonates, has been clinically utilised for over 10 years in malignancy. It is the most used, most effective and safest drug in the treatment of hypercalcaemia. It inhibits lytic bone destruction, prevents bone fractures and relieves bone pain. Supportive clodronate therapy may even reduce hypercalcaemia mortality and the morbidity caused by osteolysis. These results have stimulated studies on the patients' quality of life. New methods for the measurement of bone resorption, such as the degradation product of type I collagen (ICTP), may improve the possibility of monitoring the effect of clodronate. Comparative studies with different bisphosphonates in hypercalcaemia and long-term controlled trials using bisphosphonates as supportive therapy in osteolysis due to malignancy are reviewed.

Hypercalcemia in patients with breast cancer: a survival study

In a retrospective study survival after hypercalcemia in breast cancer patients has been investigated. A group of 72 patients were treated with bisphosphonate APD [3-(amino-1,1-hydroxypropylidene)bisphosphonate] and third-generation amino-containing bisphosphonates between January 1980 and October 1992. A median survival of 4.5 months was found. In a multivariate analysis, four independent prognostic factors for survival have been found: the interval between first relapse and hypercalcemia, sites of metastases at the moment of hypercalcemia, primary treatment, and the level of serum alkaline phosphatase. Patients with a "flare" reaction on tamoxifen treatment and patients with a normal serum alkaline phosphatase level and bone metastases only had a prolonged survival. Hypercalcemia associated with visceral metastases carried a very poor prognosis. The level of serum calcium in this series of patients was no prognostic indicator for survival.

High-dose intravenous pamidronate for metastatic bone pain

The bisphosphonates are able to relieve pain from metastatic bone disease and, when given intravenously, may promote bone healing of lytic metastases. In this study, the aim was to assess the acute effects of a single 'high-dose' intravenous treatment with pamidronate on pain, mobility, analgesic consumption and quality of life (QOL). Thirty-four normocalcaemic patients with painful progressing bone metastases (22 from breast, five prostate and seven others) received a single intravenous infusion of 120 mg of pamidronate as palliative therapy. No other systemic therapy or drugs known to influence bone metabolism were administered during the study. Patients' subjective response to treatment was assessed weekly with a pain questionnaire recording a composite of pain intensity, mobility, performance status and analgesic consumption. In addition, patients completed the Rotterdam Symptom Check List (RSCL) for measurement of QOL and a mobility questionnaire. The mean reduction in the pain questionnaire score (recorded on at least two occasions) was 25% [standard error (s.e.) 3%, range 0-75%]. Twenty patients (59%) showed a > or = 20% improvement and were classified as responders. The median duration of symptomatic response was 12 (range 4-24 +) weeks. The responding patients showed a reduction in RSCL score (improvement in QOL) from 35% before treatment to 27% at 6 weeks, but no significant improvement was noted in non-responders. Twenty-one patients were retreated with pamidronate when their symptoms deteriorated again. Eight out of 15 responders showed a second reduction in pain score of > or = 20%, but this was not seen in any of the six non-responders. Five patients have remained well with no additional treatment for their disease other than repeat infusions of pamidronate every 3-6 months. Treatment was well tolerated. Eight (24%) experienced fever after the first treatment only, and four had asymptomatic, biochemical evidence of hypocalcaemia. The acute inhibition of osteoclastic bone resorption induced by a single high-dose treatment with pamidronate can provide useful palliation for patients with bone metastases. Responding patients may be retreated as symptoms dictate to good effect. We are currently running a phase III double-blind trial with high-dose pamidronate for progressive painful metastatic bone disease to exclude any placebo effect and observer bias.