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Sulistio M, Gorelik A, Tee HJ, Wojnar R, Kissane D, Michael N. Methadone versus other opioids for refractory malignant bone pain: a pilot randomised controlled study. Support Care Cancer 2024; 32:495. [PMID: 38980427 PMCID: PMC11233296 DOI: 10.1007/s00520-024-08706-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/01/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE Refractory cancer-induced bone pain (CIBP) affects a patient's functional capacity and quality of life, but there is limited evidence to guide opioid choice. We assessed the feasibility, tolerability and possible efficacy of methadone rotation (MR) compared to other opioid rotations (OOR) in this cohort. METHODS Adults with CIBP and worst pain intensity ≥ 4/10 and/or opioid toxicity graded ≥ 2 on the Common Terminology Criteria for Adverse Events were randomised 1:1 to methadone or another opioid rotation. Standardised assessment tools were used at pre-defined study time points up to 14 days. RESULTS Of 51 eligible participants, 38 (74.5%) consented, and 29 (76.3%, MR: 14, OOR: 15) completed the fourteen days follow-up post-opioid rotation. Both groups displayed significant reduction in average (MR: d = - 1.2, p = 0.003, OOR: d = - 0.8, p = 0.015) and worst pain (MR: d = - 0.9, p = 0.042, OOR: d = - 0.6, p = 0.048) and total pain interference score (MR: d = - 1.1, p = 0.042, OOR: d = - 0.7, p = 0.007). Oral morphine equivalent daily dose was reduced significantly in MR compared to the OOR group (d = - 0.8, p = 0.05). The incidence of opioid-related adverse events following MR was unchanged but lower in the OOR group (d = 0.9, 95% CI 0.1,1.7, p = 0.022). There were no within-group or between-group differences in satisfaction with analgesia at the end of the study. CONCLUSION This pilot study demonstrated that MR and OOR in patients with refractory CIBP are feasible, safe and acceptable to patients. Appropriately powered multi-centre randomised controlled studies are needed to confirm the efficacy of MR and OOR in this cohort. TRIAL REGISTRATION ACTRN12621000141842 registered 11 February 2021.
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Affiliation(s)
- Merlina Sulistio
- Cabrini Health, Melbourne, VIC, 3144, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia.
| | - Alexandra Gorelik
- Musculoskeletal Health and Wiser Healthcare Units, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Hoong Jiun Tee
- Cabrini Health, Melbourne, VIC, 3144, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | | | - David Kissane
- Cabrini Health, Melbourne, VIC, 3144, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
| | - Natasha Michael
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- School of Medicine, University of Notre Dame Australia, Fremantle, Australia
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Cursano MC, Valsecchi AA, Pantano F, Di Maio M, Procopio G, Berruti A, Bertoldo F, Tucci M, De Giorgi U, Santini D. Bone health and body composition in prostate cancer: Meet-URO and AIOM consensus about prevention and management strategies. ESMO Open 2024; 9:103484. [PMID: 38901175 PMCID: PMC11252762 DOI: 10.1016/j.esmoop.2024.103484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 06/22/2024] Open
Abstract
BACKGROUND Prostate cancer (PCa) treatments are associated with a detrimental impact on bone health (BH) and body composition. However, the evidence on these issues is limited and contradictory. This consensus, based on the Delphi method, provides further guidance on BH management in PCa. MATERIALS AND METHODS In May 2023, a survey made up of 37 questions and 74 statements was developed by a group of oncologists and endocrinologists with expertise in PCa and BH. In June 2023, 67 selected Italian experts, belonging to the Italian scientific societies Italian Association of Medical Oncology and Italian Network for Research in Urologic-Oncology (Meet-URO), were invited by e-mail to complete it, rating their strength of agreement with each statement on a 5-point scale. An agreement ≥75% defined the statement as accepted. RESULTS In non-metastatic hormone-sensitive PCa, the panel agreed that androgen deprivation therapy (ADT) alone implies sufficient fracture risk to warrant antifracture therapy with bone-targeting agents (BTAs) for cancer treatment-induced bone loss (CTIBL) prevention (79%). Therefore, no consensus was reached (48%) for the treatment with BTAs of patients receiving short-term ADT (<6 months). All patients receiving active treatment for metastatic hormone-sensitive PCa (75%), non-metastatic castration-resistant PCa (89%) and metastatic castration-resistant PCa (mCRPC) without bone metastases (84%) should be treated with BTAs at the doses and schedule for CTIBL prevention. All mCRPC patients with bone metastasis should be treated with BTAs to reduce skeletal-related events (94%). In all settings, the panel analyzed the type and timing of treatments and examinations to carry out for BH monitoring. The panel agreed on the higher risk of sarcopenic obesity of these patients and its correlation with bone fragility. CONCLUSIONS This consensus highlights areas lacking major agreement, like non-metastatic hormone-sensitive prostate cancer patients undergoing short-term ADT. Evaluation of these issues in prospective clinical trials and identification of early biomarkers of bone loss are particularly urgent.
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Affiliation(s)
- M C Cursano
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola
| | - A A Valsecchi
- Department of Oncology, University of Turin, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Turin
| | - F Pantano
- Department of Medical Oncology, Campus Bio-Medico University, Rome
| | - M Di Maio
- Department of Oncology, University of Turin, A.O.U. Città della Salute e della Scienza di Torino, Ospedale Molinette, Turin
| | - G Procopio
- Programma Prostata Fondazione Istituto Nazionale Tumori Milano, Milan
| | - A Berruti
- Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia and ASST SpedaliCivili di Brescia, Brescia
| | - F Bertoldo
- Emergency Medicine, Department of Medicine, University of Verona, Verona
| | - M Tucci
- Department of Medical Oncology, Cardinal Massaia Hospital, Asti
| | - U De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola
| | - D Santini
- Oncologia Medica A, Policlinico Umberto 1, La Sapienza Università Di Roma, Rome, Italy.
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Fusco V, Di Maio M, Valsecchi AA, Santini D, Tucci M, De Giorgi U, Bossi P, Ibrahim T, Cavanna L, Lanzetta G, Rossi M, Rossetti G, Airoldi M, Comandone A, Cinieri S. Treatment of bone metastases from solid tumors with bone-modifying agents: a web survey of Italian oncologists investigating patterns of practice drug prescription and prevention of side effects. Support Care Cancer 2024; 32:202. [PMID: 38427111 PMCID: PMC10907460 DOI: 10.1007/s00520-024-08392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 02/16/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Optimal use of bone-modifying agents (BMAs) in patients with bone metastases from solid tumors is uncertain in some aspects: the drug choice; the planned treatment duration and long-term therapy; the prevention and management of possible side effects, including renal toxicity, hypocalcaemia, and medication-related osteonecrosis of the jaw (MRONJ). METHODS Italian oncologists were invited to fulfil a 24-question web survey about prescription of BMAs for bone metastases of breast cancer, prostate cancer, and other solid tumors. Prevention and management of side effects were also investigated. RESULTS Answers of 191 oncologists were collected. BMAs are usually prescribed at the time of diagnosis of bone metastases by 87.0% (breast cancer) and 76.1% (solid tumors except breast and prostate cancers) of oncologists; the decision is more articulated for prostate cancer (endocrine-sensitive versus castration-resistant). The creatinine level (32.3%), the availability of patient venous access (15.8%), and the type of primary neoplasm (13.6%) are the most reported factors involved in choice between bisphosphonates and denosumab. Zoledronic acid every 3 months was considered as a valid alternative to monthly administration by 94% of Italian oncologists. Oncologists reported a good confidence with measures aimed to prevent MRONJ, whereas uncertainness about prevention and management of hypocalcemia was registered. CONCLUSION Italian oncologists showed a high attitude in prescribing bisphosphonates or denosumab at the time of diagnosis of bone metastases, with a large application of preventive measures of side effects. Further studies are needed to investigate some controversial aspects, such as optimal drug treatment duration and long-term drug schedules.
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Affiliation(s)
- Vittorio Fusco
- Oncology Unit, Department of Medicine, Azienda Ospedaliera-Universitaria "SS Antonio E Biagio e Cesare Arrigo", Alessandria, Italy.
- Translational Medicine Unit, DAIRI Department of Integration, Research and Innovation, Azienda Ospedaliera-Universitaria "SS Antonio E Biagio e Cesare Arrigo", Alessandria, Italy.
| | - Massimo Di Maio
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - Anna Amela Valsecchi
- Department of Oncology, University of Turin, Ordine Mauriziano Hospital, Turin, Italy
| | - Daniele Santini
- UOC Oncologia A, Policlinico Umberto 1, La Sapienza Università, Rome, Italy
| | - Marcello Tucci
- Department of Medical Oncology, Cardinal Massaia Hospital, Asti, Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo Per Lo Studio Dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Paolo Bossi
- Medical Oncology, Humanitas Cancer Center, Milan, Italy
- Italian Network for Supportive Care in Cancer (NICSO), Milan, Italy
| | - Toni Ibrahim
- Osteoncology, Bone and Soft Tissue Sarcomas and Innovative Therapies Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Italian Society of Osteoncology (ISO), Bologna, Italy
| | - Luigi Cavanna
- Medicine and Oncology Area, Clinica Piacenza" Hospital, Piacenza, Italy
- Collegio Italiano Dei Primari Oncologi Medici Ospedalieri (CIPOMO), Genoa, Italy
| | - Gaetano Lanzetta
- Medical Oncology Unit, Italian Neuro-Traumatology Institute, Grottaferrata, Italy
- AIOM Guidelines Working Group, Grottaferrata, Italy
| | - Maura Rossi
- Oncology Unit, Department of Medicine, Azienda Ospedaliera-Universitaria "SS Antonio E Biagio e Cesare Arrigo", Alessandria, Italy
| | - Giorgia Rossetti
- Oncology Unit, Department of Medicine, Azienda Ospedaliera-Universitaria "SS Antonio E Biagio e Cesare Arrigo", Alessandria, Italy
| | - Mario Airoldi
- Head Office, Rete Oncologica Di Piemonte E Valle d'Aosta, Turin, Italy
| | | | - Saverio Cinieri
- Medical Oncology Unit, Ospedale Di Summa A. Perrino, Brindisi, Italy
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Nguyen CB, Kobe C, Kumbier KE, Bauman J, Burns JA, Tsao PA, Sparks JB, Skolarus TA, Caram ME. Determinants of Bone-Modifying Agent Prescribing for Metastatic Castration-Resistant Prostate Cancer in a National Health Care Delivery System. JCO Oncol Pract 2024; 20:59-68. [PMID: 38085028 PMCID: PMC10827294 DOI: 10.1200/op.23.00258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 01/13/2024] Open
Abstract
PURPOSE Despite guidelines recommending bone-modifying agents (BMAs) to decrease skeletal-related events (SREs) in men with metastatic castration-resistant prostate cancer (mCRPC), BMAs are underutilized. In this retrospective cohort study, we report the factors associated with BMA use in a national health care delivery system. METHODS We used the Veterans Affairs Corporate Data Warehouse to identify men with mCRPC between 2010 and 2017. BMA prescribing frequency was evaluated, and the association between patient- and disease-specific factors with BMA use was assessed using multivariable logistic regression. RESULTS Among 3,980 men identified with mCRPC (mean age 73.5 years, 29% Black), 47% received a BMA; median time to BMA from start of mCRPC treatment was 102 days. Factors associated with BMA use included previous BMA use (adjusted odds ratio [aOR], 7.81 [95% CI, 6.48 to 9.47]), diagnosis code for bone metastases (aOR, 1.26 [95% CI, 1.08 to 1.46]), and concomitant corticosteroid use (aOR, 1.53 [95% CI, 1.29 to 1.82]). Decreased BMA use was associated with advancing age (aOR, 0.85 per 10 years [95% CI, 0.78 to 0.92]), Charlson comorbidity index ≥2 (aOR, 0.76 [95% CI, 0.63 to 0.93]), Black race (aOR, 0.83 [95% CI, 0.70 to 0.98]), and decreased estimated glomerular filtration rate (eGFR; aOR, 0.19 [95% CI, 0.11 to 0.32] for eGFR 0-29 mL/minutes; aOR, 0.76 [95% CI, 0.64 to 0.91] for 30-59 mL/minutes). CONCLUSION Patients who are older, Black, or have more comorbidities are less likely to receive guideline concordant care to prevent SREs. These observations highlight the unique challenges of caring for patients with mCRPC and the need for future studies to increase BMA use in these populations.
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Affiliation(s)
- Charles B. Nguyen
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Christopher Kobe
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Kyle E. Kumbier
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan Bauman
- Division of Geriatric & Palliative Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Jennifer A. Burns
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Phoebe A. Tsao
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Ted A. Skolarus
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
- Department of Surgery, Section of Urology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Megan E.V. Caram
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
- VA Health Services Research & Development, Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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Noonan K, Ko JJ, Black PC, Peacock M, Finch D, Kollmannsberger C, Martins I, So AI, Pai HH. BeTTer Outcomes Workgroup Health Quality Initiative to optimize bone health for prostate cancer patients in the British Columbia Cancer System. Can Urol Assoc J 2023; 17:cuaj.8477. [PMID: 37882539 PMCID: PMC10697704 DOI: 10.5489/cuaj.8477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Bone-targeted therapies (BTTs) are integral to the management of bone metastases in metastatic castration-resistant prostate cancer (mCRPC). BTTs vary considerably in referral and drug access pathways and optimal BTT use requires multi-specialty consultation and supervision. Health quality improvement (HQI) has become the predominant framework to improve patient care in multidisciplinary settings. METHODS HQI initiatives on use of BTT in mCRPC were developed and evaluated in five centers of a provincial cancer center network using Plan-Do-Study-Act (PDSA) methodology. Multidisciplinary teams (MDTs) completed a common quality assessment form and an HQI template and then implemented an HQI initiative. Feedback and findings were shared and discussed at regional events. It was subsequently determined whether to adopt, adapt, or abandon initiatives. RESULTS Patterns of unmet needs varied across type of BTT. Gaps in use of radium-223 were mostly referral and education issues that could be directly addressed at the local level by participating clinician teams. Conversely, most supportive BTT gaps were related to coverage and resourcing support. HQI initiatives selected by each site consisted of implementation or expansion of local MDT meetings, referral documents, databases, and improvement charters. The main HQI initiative was completed in four sites and was adapted or adopted in three. Improvements in BTT use were observed in two of three centers with data on HQI process measures. CONCLUSIONS Despite the overall heterogenous structure of the groups and metrics used, this study demonstrated that the PDSA framework provides the needed structure for improvements in BTT use in mCRPC across multiple sites.
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Affiliation(s)
| | | | - Peter C. Black
- Vancouver Prostate Centre, Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
| | | | | | | | | | - Alan I. So
- Department of Urologic Sciences, University of British Columbia, Vancouver, BC, Canada
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Colosia A, Njue A, Bajwa Z, Dragon E, Robinson RL, Sheffield KM, Thakkar S, Richiemer SH. The Burden of Metastatic Cancer-Induced Bone Pain: A Narrative Review. J Pain Res 2022; 15:3399-3412. [PMID: 36317162 PMCID: PMC9617513 DOI: 10.2147/jpr.s371337] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022] Open
Abstract
Bone pain is one of the most common forms of pain reported by cancer patients with metastatic disease. We conducted a review of oncology literature to further understand the epidemiology of and treatment approaches for metastatic cancer–induced bone pain and the effect of treatment of painful bone metastases on the patient’s quality of life. Two-thirds of patients with advanced, metastatic, or terminal cancer worldwide experience pain. Cancer pain due to bone metastases is the most common form of pain in patients with advanced disease and has been shown to significantly reduce patients’ quality of life. Treatment options for cancer pain due to bone metastases include nonsteroidal anti-inflammatory drugs, palliative radiation, bisphosphonates, denosumab, and opioids. Therapies including palliative radiation and opioids have strong evidence supporting their efficacy treating cancer pain due to bone metastases; other therapies, like bisphosphonates and denosumab, do not. There is sufficient evidence that patients who experience pain relief after radiation therapy have improved quality of life; however, a substantial proportion are nonresponders. For those still requiring pain management, even with available analgesics, many patients are undertreated for cancer pain due to bone metastases, indicating an unmet need. The studies in this review were not designed to determine why cancer pain due to bone metastases was undertreated. Studies specifically addressing cancer pain due to bone metastases, rather than general cancer pain, are limited. Additional research is needed to determine patient preferences and physician attitudes regarding choice of analgesic for moderate to severe cancer pain due to bone metastases.
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Affiliation(s)
- Ann Colosia
- Department of Market Access and Outcomes Strategy, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Annete Njue
- Department of Market Access and Outcomes Strategy, RTI Health Solutions, Manchester, UK
| | - Zahid Bajwa
- Medical Affairs, Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Rebecca L Robinson
- Value, Evidence, and Outcomes, Eli Lilly and Company, Indianapolis, IN, USA,Correspondence: Rebecca L Robinson, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN, 46285, USA, Tel +1 3174331323, Fax +1 3172777444, Email
| | | | | | - Steven H Richiemer
- Division of Pain Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Interplay between fat cells and immune cells in bone: Impact on malignant progression and therapeutic response. Pharmacol Ther 2022; 238:108274. [DOI: 10.1016/j.pharmthera.2022.108274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/11/2022] [Accepted: 08/23/2022] [Indexed: 11/20/2022]
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8
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Jakob A, Zahn MO, Nusch A, Werner T, Schnell R, Frank M, Hamm N, Däßler KU, Losem C, Welslau M, Hoevel P, Potthoff K. Real-world patient-reported outcomes of breast cancer or prostate cancer patients receiving antiresorptive therapy for bone metastases: Final results of the PROBone registry study. J Bone Oncol 2022; 33:100420. [PMID: 35340302 PMCID: PMC8941198 DOI: 10.1016/j.jbo.2022.100420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/15/2022] [Accepted: 02/27/2022] [Indexed: 11/27/2022] Open
Abstract
Background In breast cancer and prostate cancer patients, bone metastases (BM) present the main cause of morbidity and often cause debilitating pain, impaired functioning and subsequent deterioration of quality of life (QoL). The management of BM is still challenging. Maintenance or improvement in QoL is the main goal of treatment. Antiresorptive treatment, such as denosumab and bisphosphonates, can help to reduce the frequency of skeletal complications, to control bone pain and potentially to improve QoL. The optimal time point for initiation of antiresorptive therapy is still discussed controversially. In patients with BM, bone pain can be used as a surrogate measure of QoL. However, limited data exist on health-related QoL in patients with BM under antiresorptive treatment. The PROBone registry study evaluated complaints and limitations caused by BM of breast and prostate cancer patients using patient-reported outcomes (PROs) in real-world in Germany. Methods Between 2014 and 2019, 500 patients with histological confirmation of advanced breast or prostate cancer, diagnosed with BM at start of their first antiresorptive therapy were prospectively enrolled in 65 outpatient-centers specialized in medical oncology across Germany. Changes of QoL were assessed monthly from baseline until a maximum of 12 months using the validated pain score Functional Assessment of Cancer Therapy Quality of Life Measurement in patients with bone pain (FACT-BP) supplemented by questions on general pain and on the impact of time spent for treatment of illness on patients' daily activities. Statistical analysis was performed descriptively by relative and absolute frequencies. Results In total, 486 patients were eligible for final analysis, of these 310 were diagnosed with breast cancer and 176 with prostate cancer. Median age was 67 years for breast cancer and 76 years for prostate cancer patients. 79.7% of breast cancer and 59.7% of prostate patients started antiresorptive treatment within 3 months after diagnosis of BM. More than 75% of patients suffered from bone pain at study inclusion. In total 52% of breast cancer patients and 47.9% of prostate cancer patients reported to take pain medication during the observation period. In breast and prostate cancer patients an initial pain reduction after start of BTA was observed: General pain and bone pain levels as well as the median FACT-BP score showed a constant improvement over the first months and maintained stable at a constant level afterwards. Subgroup analysis showed that patients without pain at baseline reported distinctly better FACT-BP scores throughout the whole observation period than patients with pain at baseline. Looking at time-stress (M)-scores, younger breast cancer patients (<65 years) showed highest burden especially during the first months of treatment. Conclusions Our results indicate overall good adherence to current guideline recommendation, with most breast and prostate cancer patients starting antiresorptive therapy within the first 3 months after diagnosis of BM. This point gains even more importance as our data support current recommendations by ESMO guidelines as well as by German evidence-based S3-guidelines for diagnosis and treatment of breast and prostate cancer to initiate bone-targeted agents (BTA) as soon as BM are diagnosed, to keep pain levels at the lowest level possible, to minimize the debilitating effects of metastatic bone pain and maintain a good QoL. Bone pain management by an early use of BTA following BM diagnosis might improve patient care.
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Affiliation(s)
- Andreas Jakob
- Tumor Center Aarau, Hirslanden Medical Center, Switzerland
| | | | - Arnd Nusch
- Practice for Hematology and Internal Oncology, Ratingen, Germany
| | | | - Roland Schnell
- Practice for Internal Oncology and Hematology, Frechen, Germany
| | | | | | | | - Christoph Losem
- Medical Care Center for Oncology and Hematology, Neuss, Germany
| | - Manfred Welslau
- Medical Care Center at Hospital Aschaffenburg GmbH, Aschaffenburg, Germany
| | - Petra Hoevel
- Medical Care Center at General Hospital Celle, Celle, Germany
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Marhold M, Kramer G, Krainer M, Le Magnen C. The prostate cancer landscape in Europe: Current challenges, future opportunities. Cancer Lett 2022; 526:304-310. [PMID: 34863887 DOI: 10.1016/j.canlet.2021.11.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 11/24/2021] [Accepted: 11/30/2021] [Indexed: 01/03/2023]
Abstract
Prostate cancer (PCa) is the most common non-cutaneous cancer in men in Europe and is predicted to exhibit declining mortality in the European Union (EU) due to various recent improvements in treatment. The goal of this short review is to give insight into the European treatment landscape of PCa, while focusing on improvements in care.
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Affiliation(s)
- Maximilian Marhold
- Division of Oncology, Department for Medicine I, Medical University of Vienna, Vienna, Austria.
| | - Gero Kramer
- Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Michael Krainer
- Division of Oncology, Department for Medicine I, Medical University of Vienna, Vienna, Austria
| | - Clémentine Le Magnen
- Pathology, Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland; Department of Urology, University Hospital Basel, Basel, Switzerland
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Kuppen MCP, Westgeest HM, van den Eertwegh AJM, van Moorselaar RJA, van Oort IM, Tascilar M, Mehra N, Lavalaye J, Somford DM, Aben KKH, Bergman AM, de Wit R, van den Bergh ACMF, de Groot CAU, Gerritsen WR. Symptomatic Skeletal Events and the Use of Bone Health Agents in a Real-World Treated Metastatic Castration Resistant Prostate Cancer Population: Results From the CAPRI-Study in the Netherlands. Clin Genitourin Cancer 2022; 20:43-52. [PMID: 34848157 DOI: 10.1016/j.clgc.2021.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/10/2021] [Accepted: 10/28/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patients with metastatic castration resistant prostate cancer (mCRPC) are at risk of symptomatic skeletal events (SSE). Bone health agents (BHA, ie bisphosphonates and denosumab) and new life-prolonging drugs (LPDs) can delay SSEs. The aim of this study is to investigate the use of BHAs in relation to SSEs in treated real-world mCRPC population. PATIENTS AND METHODS We included patients from the CAPRI registry who were treated with at least one LPD and diagnosed with bone metastases prior to the start of first LPD (LPD1). Outcomes were SSEs (external beam radiation therapy (EBRT) to the bone, orthopedic surgery, pathologic fracture or spinal cord compression) and SSE-free survival (SSE-FS) since LPD1. RESULTS One-thousand nine hundred and twenty-three patients were included with a median follow-up from LPD1 of 16.7 months. Fifty-two percent (n = 996) started BHA prior or within 4 weeks after the start of LPD1 (early BHA). In total, 41% experienced at least one SSE. SSE incidence rate was 0.29 per patient year for patients without BHA and 0.27 for patients with early BHA. Median SSE-FS from LPD1 was 12.9 months. SSE-FS was longer in patients who started BHA early versus patients without BHA (13.2 vs. 11.0 months, P = .001). CONCLUSION In a real-world population we observed an undertreatment with BHAs, although patients with early BHA use had lower incidence rates of SSEs and longer SSE-FS. This finding was irrespective of type of SSE and presence of risk factors. In addition to LPD treatment, timely initiation of BHAs is recommended in bone metastatic CRPC-patients with both pain and/or opioid use and prior SSE.
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Affiliation(s)
- Malou C P Kuppen
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands.
| | - Hans M Westgeest
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | - Alfons J M van den Eertwegh
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | | | - Inge M van Oort
- Department of Urology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Metin Tascilar
- Department of Internal Medicine, Isala, Zwolle, the Netherlands
| | - Niven Mehra
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jules Lavalaye
- Department of Nuclear Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Diederik M Somford
- Department of Urology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Katja K H Aben
- Department for Health Evidence, Radboud university medical center, Nijmegen, the Netherlands; Netherlands Comprehensive Cancer Organisation, Utrecht, the Netherlands
| | - Andre M Bergman
- Division of Medical Oncology, the Netherlands Cancer Institute Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Ronald de Wit
- Department of Medical Oncology, Erasmus MC Daniel den Hoed Cancer Center, Rotterdam
| | - A C M Fons van den Bergh
- Department of Radiation Oncology, University Medical Center Groningen, Groningen, the Netherlands
| | - Carin A Uyl- de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud University Medical Center, Nijmegen, the Netherlands
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11
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Anton A, Wong S, Shapiro J, Weickhardt A, Azad A, Kwan EM, Spain L, Gunjur A, Torres J, Parente P, Parnis F, Goh J, Semira MC, Gibbs P, Tran B, Pezaro C. Real-world incidence of symptomatic skeletal events and bone-modifying agent use in castration-resistant prostate cancer - an Australian multi-centre observational study. Eur J Cancer 2021; 157:485-492. [PMID: 34344533 DOI: 10.1016/j.ejca.2021.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/12/2021] [Accepted: 06/06/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Bone metastases occur frequently in castration-resistant prostate cancer (CRPC) and may lead to skeletal-related events (SREs), including symptomatic skeletal events (SSEs). Bone-modifying agents (BMAs) delay SREs and SSEs. However, the real-world use of BMAs is debated given the absence of demonstrated survival advantage and potential adverse events (AEs). Our retrospective study examined BMA use and SSE rates in Australian patients with CRPC. METHODS Patients with CRPC and bone metastases were identified from the electronic CRPC Australian Database. Patient characteristics, treatment patterns and AEs were analysed. Descriptive statistics reported baseline characteristics, SSE rates and BMA use. Comparisons between groups used t-tests and Chi-square analyses. Overall survival was calculated by the Kaplan-Meier method. RESULTS A total of 532 eligible patients were identified with a median age of 73 years (range: 44-97 years). BMAs were prescribed in 232 men (46%), 183 of whom received denosumab. Patients receiving first-line docetaxel for CRPC were more likely to commence BMAs than those receiving abiraterone or enzalutamide (51% vs 31% vs 38%; p = 0.004). SSEs occurred in 148 men (28%), most commonly symptomatic lesions requiring intervention (75%). At the time of initial SSEs, only 28% were receiving BMAs. Patients treated at sites with lower BMA use (<median) had higher SSE rates (32% vs 22%, p = 0.019). CONCLUSION In our real-world cohort, SSEs occurred in almost one-third of patients with CRPC and bone metastases, whereas less than half of patients received BMAs. The lower rate of SSEs in treatment sites with increased BMA use supports their benefit in this setting.
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Affiliation(s)
- Angelyn Anton
- Walter and Eliza Hall Institute, Melbourne, Australia; Eastern Health, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | | | - Andrew Weickhardt
- Olivia Newton John Cancer Wellness and Research Centre, Melbourne, Australia
| | - Arun Azad
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Edmond M Kwan
- Monash University, Melbourne, Australia; Monash Health, Melbourne, Australia
| | - Lavinia Spain
- Eastern Health, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Ashray Gunjur
- Olivia Newton John Cancer Wellness and Research Centre, Melbourne, Australia
| | | | - Phillip Parente
- Eastern Health, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Francis Parnis
- Adelaide Cancer Centre, Adelaide, Australia; University of Adelaide, Adelaide, Australia
| | - Jeffrey Goh
- Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Peter Gibbs
- Walter and Eliza Hall Institute, Melbourne, Australia; Western Health, Melbourne, Australia
| | - Ben Tran
- Walter and Eliza Hall Institute, Melbourne, Australia; Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Carmel Pezaro
- Eastern Health, Melbourne, Australia; Monash University, Melbourne, Australia; Weston Park Cancer Centre, Sheffield, United Kingdom.
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12
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Santini D, Berruti A, Di Maio M, Procopio G, Bracarda S, Ibrahim T, Bertoldo F. Bone health management in the continuum of prostate cancer disease: a review of the evidence with an expert panel opinion. ESMO Open 2021; 5:S2059-7029(20)30062-4. [PMID: 32220946 PMCID: PMC7174015 DOI: 10.1136/esmoopen-2019-000652] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 12/20/2022] Open
Abstract
Bone health impairment is a frequent detrimental consequence of the high bone tropism of prostate cancer (PCa) cells. It is further worsened by administration of androgen-deprivation therapy (ADT), the current standard of care in the management of advanced PCa, through a rapid and dramatic increase in bone turnover and body mass changes. As a result, patients may experience substantial pain and poor quality of life (QoL) and have an increased risk of death. Notwithstanding the importance of this issue, however, bone health preservation is not yet a widespread clinical goal in daily practice. To address this urgent unmet need, following a thorough discussion of available data and sharing of their clinical practice experience, a panel of Italian experts in the field of bone health and metabolism formulated a number of practical advices for optimising the monitoring and treatment of bone health in men undergoing ADT during all phases of the disease. The rationale behind the venture was to raise awareness on the importance of bone preservation in this complex setting, while providing an instrument to support physicians and facilitate the management of bone health. Current evidence regarding the effects on bone health of ADT, of novel hormone therapies (which improve progression delay, pain control and QoL while consistently carrying the risk of non-pathological fractures in both non-metastatic and metastatic PCa) and of bone turnover inhibitors (whose use is frequently suboptimal) is reviewed. Finally, the expert opinion to optimise bone health preservation is given.
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Affiliation(s)
- Daniele Santini
- Department of Oncology, Campus Bio-Medico University, Roma, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Massimo Di Maio
- Department of Oncology, AO Ordine Mauriziano, Universita degli Studi di Torino, Torino, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Sergio Bracarda
- Medical Oncology, Department of Oncology, Azienda Ospedaliera S.Maria, Terni, Italy
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori Srl, Meldola, Italy
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13
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Wong V, de Boer R, Dunn C, Anton A, Malik L, Greenberg S, Yeo B, Nott L, Collins IM, Torres J, Barnett F, Nottage M, Gibbs P, Lok SW. Uptake of bone modifying agents in patients with HER2+ metastatic breast cancer with bone metastases - prospective data from a multi-site Australian registry. Intern Med J 2021; 52:1707-1716. [PMID: 34002929 DOI: 10.1111/imj.15376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/15/2021] [Accepted: 04/22/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM International practice guidelines recommend administration of bone modifying agents (BMA) in metastatic breast cancer (MBC) patients with bone metastases to reduce skeletal related events (SRE). Optimal delivery of BMA in routine clinical practice including agent selection and prescribing intervals remains unclear. We aim to describe real-world practice of Australian breast oncologists. METHODS Prospective data from February 2015 to July 2020 on BMA delivery to MBC patients with bone metastases was analysed from TABITHA, a multi-site Australian HER2+ MBC registry. RESULTS Of 333 HER2+ MBC patients, 171 (51%) had bone metastases at diagnosis, with a mean age of 58.1 years [range 32-87]. 130 (76%) patients received a BMA, with 90 (69%) receiving denosumab and 40 (31%) receiving a bisphosphonate. Patients who received a BMA were more likely to have received concurrent first line systemic anti-HER2 therapy (95% vs 83%, p=0.04), to present with bone-only metastases at diagnosis (24% vs 7%, p=0.02) and less likely to have visceral metastases (51% vs 71%, p=0.03). Ten of 40 (25%) bisphosphonate patients and 45 of 90 (50%) denosumab patients received their BMA at the recommended 4-weekly interval. Prescribing intervals varied over time. Adverse events reported were consistent with clinical trial data. CONCLUSION Three-quarters of Australian HER2+ MBC patients with bone metastases receive a BMA, often at different schedules than guidelines recommend. Further studies, including of all MBC subtypes, are warranted to better understand clinicians' prescribing rationale and potential consequences of current prescribing practice on SRE incidence. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Vanessa Wong
- Walter and Eliza Hall Institute of Medical Research, VIC.,Ballarat Health Services, VIC
| | - Richard de Boer
- Epworth-Freemasons Hospital, VIC.,St Vincent's Private Hospital, VIC
| | - Catherine Dunn
- Walter and Eliza Hall Institute of Medical Research, VIC
| | - Angelyn Anton
- Walter and Eliza Hall Institute of Medical Research, VIC.,Eastern Health, VIC
| | | | | | - Belinda Yeo
- Austin Health, Olivia Newton-John Cancer Research Institute, VIC
| | | | | | | | | | | | - Peter Gibbs
- Walter and Eliza Hall Institute of Medical Research, VIC.,Western Health, VIC
| | - Sheau Wen Lok
- Walter and Eliza Hall Institute of Medical Research, VIC.,Peter MacCallum Cancer Centre, VIC
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14
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Hardtstock F, Kocaata Z, Wilke T, Dittmar A, Ghiani M, Belozeroff V, Harrison DJ, Maywald U, Tesch H. Healthcare resource utilization and associated cost of patients with bone metastases from solid tumors who are naïve to bone-targeting agents: a comparative analysis of patients with and without skeletal-related events. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:243-254. [PMID: 33459901 PMCID: PMC7881971 DOI: 10.1007/s10198-020-01247-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/16/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study analyzes the impact of skeletal-related events (SRE) on healthcare resource utilization (HCRU) and costs incurred by patients with bone metastases (BM) from solid tumors (ST), who are therapy-naïve to bone targeting agents (BTAs). METHODS German claims data from 01/01/2010 to 30/06/2018 were used to conduct a retrospective comparative cohort analysis of BTA-naive patients with a BM diagnosis and preceding ST diagnosis. HCRU and treatment-related costs were compared in two matched cohorts of patients with and without a history of SREs, defined as pathological fracture, spinal cord compression, surgery to bone and radiation to bone. The first SRE was defined as the patient-individual index date. Conversely, for the non-SRE patients, index dates were assigned randomly. RESULTS In total, 45.20% of 9,832 patients reported experiencing at least one SRE (n = 4444) while 54.80% experienced none (n = 5388); 2,434 pairs of SRE and non-SRE patients were finally matched (mean age: 70.87/71.07 years; females: 39.07%/38.58%). Between SRE and non-SRE cohorts, significant differences in the average number of hospitalization days per patient-year (35.80/30.80) and associated inpatient-care costs (14,199.27€/10,787.31€) were observed. The total cost ratio was 1.16 (p < 0.001) with an average cost breakdown of 23,689.54€ and 20,403.27€ per patient-year in SRE and non-SRE patients. CONCLUSION The underutilization of BTAs within a clinical setting poses an ongoing challenge in the real-world treatment of BM patients throughout Germany. Ultimately, the economic burden of treating SREs in patients with BM from ST was found to be considerable, resulting in higher direct healthcare costs and increased utilization of inpatient care facilities.
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Affiliation(s)
- Fränce Hardtstock
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany.
| | - Zeki Kocaata
- Ingress-Health HWM GmbH, Alter Holzhafen 19, 23966, Wismar, Germany
| | - Thomas Wilke
- IPAM e.V., University of Wismar, 23966, Wismar, Germany
| | - Axel Dittmar
- IPAM e.V., University of Wismar, 23966, Wismar, Germany
| | - Marco Ghiani
- IPAM e.V., University of Wismar, 23966, Wismar, Germany
| | | | | | - Ulf Maywald
- AOK PLUS, Sternplatz 7, 01067, Dresden, Germany
| | - Hans Tesch
- Centrum for Hematology and Oncology, Im Prüfling 17-19, 60389, Frankfurt a. Main, Germany
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15
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Ribi K, Thürlimann B, Schär C, Dietrich D, Cathomas R, Zürrer-Härdi U, von Briel T, Anchisi S, Bohanes P, Blum V, von Burg P, Mannhart M, Caspar CB, von Moos R, Mark M. Quality of life and pain in patients with metastatic bone disease from solid tumors treated with bone-targeted agents- a real-world cross-sectional study from Switzerland (SAKK 95/16). BMC Cancer 2021; 21:182. [PMID: 33607966 PMCID: PMC7893880 DOI: 10.1186/s12885-021-07903-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Bone-targeted agents (BTAs) are widely used in the management of patients with bone metastases from solid tumors. Knowledge of the impact of their routine care use on patient-reported pain and bone pain-related quality of life (QoL) is limited. Methods This real world, cross-sectional study enrolled patients over a 3-month period through oncologists across Switzerland. Patients were ≥ 18 years, had solid tumors and at least one bone metastasis, and received routine care for bone metastases. Physicians provided data on BTA-related practices, risk of bone complications and BTA regimen. Patients completed questionnaires about pain (BPI-SF), general and bone pain-related QoL (FACT-G, FACT-BP) and treatment satisfaction (FACIT-TS-G). Results Eighteen sites recruited 417 patients. Based on the FACT-BP, 42% of the patients indicated not having bone pain. According to the BPI-SF, 28% reported no, 43% mild, 14% moderate, and 15% severe pain, respectively. Patients not treated with a BTA had better overall QoL (FACT-G: p = 0.031) and bone pain-related QoL (FACT-BP, p = 0.007) than those treated with a BTA. All pain and other QoL scales did not differ between groups. Patients perceived at ‘low risk of bone complications’ by their physician not receiving a BTA reported less pain and better QoL than those considered at ‘low risk’ but receiving BTA treatment or those considered at ‘high risk’ regardless of BTA treatment. Overall satisfaction with the treatment was good; almost 50% of patients reporting that they were completely satisfied. Conclusions Overall, pain and QoL did not differ according to BTA treatment or physicians’ risk perception. Patient with low risks not receiving BTA treatment reported least pain and highest QoL scores. These results may suggest that treating physicians assess bone complication risk appropriately and treat patients accordingly, but they need to be confirmed by objective determination of longitudinal skeletal complication risk. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-07903-8.
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Affiliation(s)
- Karin Ribi
- International Breast Cancer Study Group (IBCSG), Bern, Switzerland.
| | | | - Corinne Schär
- Swiss Group for Clinical Cancer Research (SAKK) Coordinating Center, Bern, Switzerland
| | - Daniel Dietrich
- Swiss Group for Clinical Cancer Research (SAKK) Coordinating Center, Bern, Switzerland
| | | | | | | | | | - Pierre Bohanes
- Centre de Chimiothérapie Anti-Cancéreuse, Lausanne, Switzerland
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Mollica V, Rizzo A, Rosellini M, Marchetti A, Ricci AD, Cimadamore A, Scarpelli M, Bonucci C, Andrini E, Errani C, Santoni M, Montironi R, Massari F. Bone Targeting Agents in Patients with Metastatic Prostate Cancer: State of the Art. Cancers (Basel) 2021; 13:cancers13030546. [PMID: 33535541 PMCID: PMC7867059 DOI: 10.3390/cancers13030546] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 02/03/2023] Open
Abstract
Simple Summary Over the disease course of metastatic prostate cancer, approximately the 90% of patients develops bone metastases, with bone involvement frequently leading to various skeletal complications including pathological fractures, spinal cord compression, and pain. Notably enough, the peculiar inclination of prostate cancer cells to seed the bone is considered an important cause of morbidity for prostate cancer patients. Recent years have witnessed the advent of several novel treatments for prostate cancer, and therapeutic paradigms are rapidly shifting. In this review, we aim at giving an overview of current knowledge on the relationship between prostate cancer and bone, especially focusing on the use of bone-targeted agents in this setting. Abstract Bone health represents a major issue in castration-resistant prostate cancer (CRPC) patients with bone metastases; in fact, the frequently prolonged use of hormonal agents causes important modifications in physiological bone turnover and most of these men will develop skeletal-related events (SREs), including spinal cord compression, pathologic fractures and need for surgery or radiation to bone, which are estimated to occur in almost half of this patient population. In the last decade, several novel therapeutic options have entered into clinical practice of bone metastatic CRPC, with recent approval of enzalutamide and abiraterone acetate, cabazitaxel chemotherapy and radium-223, on the basis of survival benefit suggested by landmark Phase III trials assessing these agents in this setting. Conversely, although bone-targeted agents (BTAs)—such as the bisphosphonate zoledronic acid and the receptor activator of nuclear factor kappa-B (RANK) ligand inhibitor denosumab—are approved for the prevention of SREs, these compounds have not shown benefit in terms of overall survival. However, emerging evidence has suggested that the combination of BTAs and abiraterone acetate, enzalutamide and the radiopharmaceutical radium-223 could result in improved clinical outcomes and prolonged survival in bone metastatic CRPC. In this review, we will provide an overview on bone tropism of prostate cancer and on the role of BTAs in metastatic hormone-sensitive and castration-resistant prostate cancer.
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Affiliation(s)
- Veronica Mollica
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Alessandro Rizzo
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Matteo Rosellini
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Andrea Marchetti
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Angela Dalia Ricci
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Alessia Cimadamore
- Section of Pathological Anatomy, School of Medicine, United Hospitals, Polytechnic University of the Marche Region, 60121 Ancona, Italy; (A.C.); (M.S.); (R.M.)
| | - Marina Scarpelli
- Section of Pathological Anatomy, School of Medicine, United Hospitals, Polytechnic University of the Marche Region, 60121 Ancona, Italy; (A.C.); (M.S.); (R.M.)
| | - Chiara Bonucci
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Elisa Andrini
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
| | - Costantino Errani
- Department of Musculo–Skeletal Oncology, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Matteo Santoni
- Oncology Unit, Macerata Hospital, 62100 Macerata, Italy;
| | - Rodolfo Montironi
- Section of Pathological Anatomy, School of Medicine, United Hospitals, Polytechnic University of the Marche Region, 60121 Ancona, Italy; (A.C.); (M.S.); (R.M.)
| | - Francesco Massari
- Division of Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (V.M.); (A.R.); (M.R.); (A.M.); (A.D.R.); (C.B.); (E.A.)
- Correspondence: or
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Three years' clinical practice of Radium-223 therapy in patients with symptomatic bone metastases from metastatic castrate-resistant prostate cancer: a single-centre experience. Nucl Med Commun 2021; 41:300-307. [PMID: 32049940 DOI: 10.1097/mnm.0000000000001164] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Radium-223 was a treatment approved for patients with metastatic castrate-resistant prostate cancer, symptomatic bone metastases and no-visceral metastases, in progression after at least two prior lines of systemic therapy, or ineligible for any available systemic treatment. The aim of this study was to provide further characterization and sub-selection of patients who would benefit most with Radium-223 treatment. METHODS We retrospectively analysed 38 patients treated with Radium-223 between 2015 and 2018. All patients underwent a baseline visit and a bone scintigraphy. Bone scan, ALP and PSA levels were repeated after third and after the end of therapy. All patients were re-evaluated after 2 months from the end of therapy. Survival curves were plotted according to the Kaplan-Meier method and differences between groups were analysed by using a two-tailed log-rank test. RESULTS The response to the treatment in term of change in pain was reduction in 16 patients; no change in 14 and increased in eight. We arbitrarily established a cut-off 10 bone lesions to evaluate the response: patients with less than 10 metastasis had significant differences in PFS (P < 0.001) compared to patients with more than 10, no statistical significance was found considering the OS (P = 0.23) between the two groups. The same results were founded in patients with baseline ALP <220 U/L with a PFS (P < 0.001) and OS (P = 0.027). CONCLUSION The most important finding was the correlation between the number of bone metastasis and ALP with outcome survival and efficacy of Radium-223 treatment.
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18
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Santini D, Cinieri S, Gasparro D, Bordonaro R, Guglielmini PF, Chiuri VE, D'Angelillo RM, Ceresoli GL, Fagnani D, Acquati M, Mencoboni M, Lanzetta G, Sartori D, Carlini P, Panebianco F, Beccaglia P, Procopio G. Effects of abiraterone acetate plus prednisone on bone turnover markers in chemotherapy-naïve mCRPC patients after ADT failure: A prospective analysis of the italian real-world study ABITUDE. J Bone Oncol 2020; 26:100341. [PMID: 33425672 PMCID: PMC7779770 DOI: 10.1016/j.jbo.2020.100341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/06/2020] [Accepted: 11/06/2020] [Indexed: 12/19/2022] Open
Abstract
Bone remodeling is disrupted in metastatic disease, affecting > 70% of mCRPC men. In metastatic disease, abnormal levels of specific BTMs are released. We prospectively measured four BTMs markers in chemotherapy-naïve mCRPC men on AAP therapy. AAP seems to act on the microenvironment of metastatic but not of normal bone. This action likely contributes to the antitumoral activity of AAP.
Background Bone remodeling is disrupted in metastatic disease, which affects > 70% of metastatic castration-resistant prostate cancer (mCRPC) patients. As a result, abnormal levels of specific bone turnover biomarkers (BTMs) are released. In this prospective ancillary analysis of the Italian real-world study ABITUDE, four markers were measured during abiraterone acetate plus prednisone (AAP) treatment in chemotherapy-naïve mCRPC men failing androgen-deprivation therapy. Methods Patients were enrolled if a blood sample was obtained before the first administration of abiraterone (baseline); ad-hoc blood samples were withdrawn during routine tests after 3, 6, and 12 months. A centralized lab measured bone alkaline phosphatase (BALP, osteoblast activity marker), type-I collagen-C-telopeptide (CTX-1, bone resorption marker), parathyroid hormone (PTH) and vitamin D (vitD). At each time point, intra-patient variations vs baseline were compared by the signed-rank test (statistical significance: P-value < 0.05). Results Of 481 patients enrolled in ABITUDE, 186 (median age: 76 [range: 53–93] years) met the substudy criteria: 74.7% had bone metastases, 11.8% were on bone-targeted therapies (BTT) and 14.0% on vitD supplementation. BALP decreased significantly at month 6 (P = 0.0010) and 12 (P < 0.0001) and CTX-1 at month 6 (P = 0.0028); PTH increased at month 3 (P < 0.0001); no significant difference in vitD levels was observed. Similar findings were observed in BTT-untreated patients. The reduction in BALP and CTX-1 levels was more pronounced in patients with than without bone metastases; in the latter group, no significant variation in BALP and CTX-1 levels was observed. Conclusions AAP seems to exert an effect on the microenvironment of metastatic but not of normal bone, which likely contributes to its antitumoral activity.
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Affiliation(s)
- Daniele Santini
- Department of Oncology, Campus Bio-Medico University, Rome, Italy
| | - Saverio Cinieri
- Medical Oncology Unit, Antonio Perrino Hospital, Brindisi, Italy
| | - Donatello Gasparro
- Medical Oncology Unit, Department of General & Specialistic Medicine, University Hospital of Parma, Italy
| | | | | | | | | | | | | | - Mirko Acquati
- Unit of Medical Oncology, Azienda Ospedaliera San Gerardo, Monza, Italy
| | | | - Gaetano Lanzetta
- Department Oncology and Palliative Care, INI Grottaferrata, Rome, Italy
| | | | - Paolo Carlini
- Division of Medical Oncology 1, IRCCS "Regina Elena" National Cancer Institute, Rome, Italy
| | - Fabiana Panebianco
- Medical Affairs Department, Oncology, Janssen-Cilag SpA, Cologno Monzese, Milan, Italy
| | - Patrizia Beccaglia
- Medical Affairs Department, Oncology, Janssen-Cilag SpA, Cologno Monzese, Milan, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Payne H, Bahl A, O'Sullivan JM. Use of bisphosphonates and other bone supportive agents in the management of prostate cancer-A UK perspective. Int J Clin Pract 2020; 74:e13611. [PMID: 32654366 DOI: 10.1111/ijcp.13611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 07/08/2020] [Indexed: 11/26/2022] Open
Abstract
AIM To explore the practice and views of uro-oncologists in the UK regarding their use of bone supportive agents in patients with prostate cancer. METHODS An expert-devised online questionnaire was completed by members of the British Uro-oncology Group (BUG). RESULTS Of 160 uro-oncologists invited, 81 completed the questionnaire. Approximately 70% of respondents never use a bone supportive agent in patients with metastatic hormone-naïve prostate cancer on androgen deprivation therapy (ADT). However, use was more frequent in men with metastatic castration-resistant prostate cancer, from first-line treatment onwards. The majority of uro-oncologists do not use a bone supportive agent to prevent skeletal-related events in men with non-metastatic disease unless the individual patient is at an increased risk of osteoporosis. In men with more advanced disease, respondents would use an oral or intravenous (IV) bisphosphonate in 41% and 61% of patients, respectively. Zoledronic acid is the first-choice bone supportive treatment in 77% of cases, with the lack of clinical data cited as a barrier to use for other IV bisphosphonates. Local guidelines also have a significant influence on the use of bone supportive agents, especially with respect to denosumab. Bone mineral density measurement is conducted in approximately 40% of men with ADT exposure of 2 years or longer, or those with metastatic prostate cancer. CONCLUSION Uro-oncologists in the UK generally do not use bone supportive agents for men with metastatic hormone-naïve prostate cancer or those with non-metastatic disease. However, increasing the duration of ADT and the presence of castration-resistant metastatic prostate cancer increases use.
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Affiliation(s)
| | - Amit Bahl
- University Hospitals Bristol NHS Foundation Trust, Bristol Haematology and Oncology Centre, Bristol, UK
| | - Joe M O'Sullivan
- Queen's University Belfast and The Northern Ireland Cancer Centre, Belfast, Northern Ireland, UK
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20
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Guerrieri AN, Montesi M, Sprio S, Laranga R, Mercatali L, Tampieri A, Donati DM, Lucarelli E. Innovative Options for Bone Metastasis Treatment: An Extensive Analysis on Biomaterials-Based Strategies for Orthopedic Surgeons. Front Bioeng Biotechnol 2020; 8:589964. [PMID: 33123519 PMCID: PMC7573123 DOI: 10.3389/fbioe.2020.589964] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/07/2020] [Indexed: 12/27/2022] Open
Abstract
Bone is the third most frequent site of metastasis, with a particular incidence in breast and prostate cancer patients. For example, almost 70% of breast cancer patients develop several bone metastases in the late stage of the disease. Bone metastases are a challenge for clinicians and a burden for patients because they frequently cause pain and can lead to fractures. Unfortunately, current therapeutic options are in most cases only palliative and, although not curative, surgery remains the gold standard for bone metastasis treatment. Surgical intervention mostly provides the replacement of the affected bone with a bioimplant, which can be made by materials of different origins and designed through several techniques that have evolved throughout the years simultaneously with clinical needs. Several scientists and clinicians have worked to develop biomaterials with potentially successful biological and mechanical features, however, only a few of them have actually reached the scope. In this review, we extensively analyze currently available biomaterials-based strategies focusing on the newest and most innovative ideas while aiming to highlight what should be considered both a reliable choice for orthopedic surgeons and a future definitive and curative option for bone metastasis and cancer patients.
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Affiliation(s)
- Ania Naila Guerrieri
- Unit of Orthopaedic Pathology and Osteoarticular Tissue Regeneration, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Monica Montesi
- Institute of Science and Technology for Ceramics, National Research Council, Faenza, Italy
| | - Simone Sprio
- Institute of Science and Technology for Ceramics, National Research Council, Faenza, Italy
| | - Roberta Laranga
- Unit of Orthopaedic Pathology and Osteoarticular Tissue Regeneration, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Laura Mercatali
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | - Anna Tampieri
- Institute of Science and Technology for Ceramics, National Research Council, Faenza, Italy
| | - Davide Maria Donati
- Third Orthopaedic and Traumatologic Clinic Prevalently Oncologic, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Enrico Lucarelli
- Unit of Orthopaedic Pathology and Osteoarticular Tissue Regeneration, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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21
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Targeting of radioactive platinum-bisphosphonate anticancer drugs to bone of high metabolic activity. Sci Rep 2020; 10:5889. [PMID: 32246003 PMCID: PMC7125202 DOI: 10.1038/s41598-020-62039-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/06/2020] [Indexed: 11/08/2022] Open
Abstract
Platinum-based chemotherapeutics exhibit excellent antitumor properties. However, these drugs cause severe side effects including toxicity, drug resistance, and lack of tumor selectivity. Tumor-targeted drug delivery has demonstrated great potential to overcome these drawbacks. Herein, we aimed to design radioactive bisphosphonate-functionalized platinum (195mPt-BP) complexes to confirm preferential accumulation of these Pt-based drugs in metabolically active bone. In vitro NMR studies revealed that release of Pt from Pt BP complexes increased with decreasing pH. Upon systemic administration to mice, Pt-BP exhibited a 4.5-fold higher affinity to bone compared to platinum complexes lacking the bone-seeking bisphosphonate moiety. These Pt-BP complexes formed less Pt-DNA adducts compared to bisphosphonate-free platinum complexes, indicating that in vivo release of Pt from Pt-BP complexes proceeded relatively slow. Subsequently, radioactive 195mPt-BP complexes were synthesized using 195mPt(NO3)2(en) as precursor and injected intravenously into mice. Specific accumulation of 195mPt-BP was observed at skeletal sites with high metabolic activity using micro-SPECT/CT imaging. Furthermore, laser ablation-ICP-MS imaging of proximal tibia sections confirmed that 195mPt BP co-localized with calcium in the trabeculae of mice tibia.
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22
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George G, Garmo H, Rudman S, Holmberg L, Robinson D, Stattin P, Adolfsson J, Van Hemelrijck M. Long-term adherence to GnRH agonists in men with prostate cancer. A nation-wide population-based study in prostate cancer data base Sweden. Scand J Urol 2019; 54:20-26. [PMID: 31842658 DOI: 10.1080/21681805.2019.1702093] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: Gonadotropin-releasing hormone (GnRH) agonists are used to treat men with prostate cancer (PCa). To date, no study has fully assessed patterns of adherence to GnRH agonists. We investigated patterns of adherence to GnRH agonists using data from Prostate Cancer data Base Sweden (PCBaSe).Methods: PCBaSe links the National Prostate Cancer Register (NPCR) Sweden to other healthcare registers and demographic databases. Men on primary or secondary GnRH agonists between 2006-2013 entered the study 45 days after GnRH agonists' initiation (run-in period) and exited at 3 years. Medication possession ratio quantified adherents (≥80%). Multivariable logistic regression models included age, injection interval, PCa risk categories, Charlson Comorbidity Index, prior PCa treatment, civil status and year of GnRH initiation. Odds ratios (OR) and 95% confidence intervals (CI) expressed odds of adherence.Results: Men on primary GnRH agonists (n = 8,105) were more adherent with increasing age (75-84 years compared to ≤65 years OR: 1.49; 95% CI: 1.23-1.81), longer injection intervals (365 days compared to 90 days OR: 3.29; 95% CI: 2.52-4.30) and higher PCa risk categories at diagnosis (distant metastasis compared to low risk PCa OR: 3.56; 95% CI: 2.54-5.00). Men on secondary GnRH agonists (n = 4,738) were more adherent with increasing age (≥85 years compared to ≤65 years OR: 1.65; 95% CI: 1.23-2.22) and prior PCa treatment (anti-androgens compared to deferred treatment OR: 1.50; 95% CI: 1.23-1.82), (radiotherapy compared to deferred treatment OR: 1.35; 95% CI: 1.11-1.64).Conclusions: Longer injection intervals could be addressed in the clinical setting to improve adherence.
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Affiliation(s)
- Gincy George
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Hans Garmo
- Translational Oncology and Urology Research, King's College London, London, UK
| | - Sarah Rudman
- Medical Oncology, Guy's and St Thomas' Foundation Trust, London, UK
| | - Lars Holmberg
- Translational Oncology and Urology Research, King's College London, London, UK.,Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - David Robinson
- Department of Urology, Ryhov Hospital, Jönköping, Sweden
| | - Pär Stattin
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Jan Adolfsson
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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23
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Tan B, Li B, An Y, Ma X, Jiang Y, Song Y, Ge X, Yuan S, Liu L, Dou Y, Yu Y, Ji P, Li X, Cheng Y. A multicentre survey of pain management in cancer patients and physicians attending radiotherapy clinics in Shandong Province, China. J Int Med Res 2019; 47:5711-5722. [PMID: 31588825 PMCID: PMC6862914 DOI: 10.1177/0300060519867168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective To obtain a better understanding of the prevalence and management of pain in patients undergoing radiotherapy for cancer in Shandong Province, China. Methods This cross-sectional study used a questionnaire during face-to-face interviews to collect data from physicians and patients regarding the recognition, prevalence and treatment of pain during the waiting period before commencement of radiotherapy and during the radiotherapy period. Physicians and patients were recruited from 10 tertiary Class A hospitals across Shandong Province, China. Results A total of 184 patients and 87 physicians were recruited to the study. During the waiting period, pain was reported by the physicians according to their experience to affect 26.0% of patients, which almost agreed with the patients’ data (36.5%; 160 of 438). During the radiotherapy period, there was a significant difference in the reported prevalence of pain during the radiotherapy period between the physicians’ data (23.0%) based on their experience and the patients’ data (84.1%; 169 of 201 patients). The majority of physicians (98.9%; 86 of 87) agreed to the use opioids for pain management and 90.8% (79 of 87) were satisfied with the analgesic effect, but more than half of the patients who received pain treatment reported inadequate analgesia. Conclusion There was a high incidence of cancer pain, but insufficient assessment, inadequate treatment and inadequate education about pain in both the waiting and radiotherapy periods.
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Affiliation(s)
- Bingxu Tan
- Department of Radiotherapy, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Baosheng Li
- Department of Radiotherapy, Shandong Cancer Hospital, Jinan, Shandong Province, China
| | - Yongheng An
- Department of Radiotherapy, Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Xuezhen Ma
- Department of Radiotherapy, Qingdao Centre Medical Group, Qingdao, Shandong Province, China
| | - Yuhua Jiang
- Department of Radiotherapy, Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Yipeng Song
- Department of Radiotherapy, Yantai YuHuangDing Hospital, Yantai, Shandong Province, China
| | - Xingping Ge
- Department of Radiotherapy, Yantaishan Hospital, Yantai, Shandong Province, China
| | - Shengli Yuan
- Department of Radiotherapy, Qingdao Municipal Hospital, Qingdao, Shandong Province, China
| | - Liping Liu
- Department of Radiotherapy, Jining No.1 People's Hospital, Jining, Shandong Province, China
| | - Yan Dou
- Department of Radiotherapy, Jinan Central Hospital, Jining, Shandong Province, China
| | - Yanxia Yu
- Department of Radiotherapy, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
| | - Pu Ji
- Mundipharma (China) Pharmaceutical Co., Ltd., Beijing, China
| | - Xia Li
- Mundipharma (China) Pharmaceutical Co., Ltd., Beijing, China
| | - Yufeng Cheng
- Department of Radiotherapy, Qilu Hospital of Shandong University, Jinan, Shandong Province, China
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