Retrospective evaluation of the clinical benefit of long-term continuous use of zoledronic acid in patients with lung cancer and bone metastases

Long-term outcomes of prolonged bisphosphonates more than 2 years in bone metastatic breast cancer: risk vs benefit

BACKGROUND

Bisphosphonates are the mainstay therapeutic options for prevention of skeletal-related events and generally used for up to 2 years in bone metastatic cancer patients.

AIM

We aimed to evaluate the long-term outcomes of prolonged (> 2 years) bisphosphonate usage in bone metastatic breast cancer (BMBC) patients.

METHODS

Ninety-nine BMBC patients who had prolonged bisphosphonates were evaluated retrospectively for long-term outcomes and survival rates.

RESULTS

Median duration of bisphosphonate therapy was 46.8 (24-198) months. Seven patients had bisphosphonate-related adverse events (osteonecrosis of the jaw (ONJ) (n = 6), ONJ and renal failure (n = 1)). Bisphosphonate was switched to another one because of bone metastasis progression in more than one-third of the patients (n = 36, 36.3%). The patients who had bisphosphonate switch therapy had statistically significant longer overall survival (p < 0.01). Neither duration nor type of bisphosphonates had effect on frequency of bisphosphonate-related adverse events.

CONCLUSION

Bisphosphonates might be prolonged for more than 2 years in BMBC patients with an acceptable toxicity profile. In addition, bisphosphonates switch therapy should be preferred in those with progressive bone metastasis since it might contribute to better survival despite bisphosphonates could not have been shown to have survival benefit in previous studies.

Skeletal-related events and overall survival of patients with bone metastasis from nonsmall cell lung cancer - A retrospective analysis

Because of improving treatments and survival, 40% to 58% of patients with bone metastases from nonsmall cell lung cancer (NSCLC) will suffer from at least one skeletal-related event (SRE), affecting their quality of life, but the natural history of SRE is poorly understood. The study aimed to examine the factors involved in SRE-free survival (SRS) and overall survival (OS) of patients with NSCLC and bone metastases.This was a retrospective study of 211 patients with bone metastasis from NSCLC and treated at the Tumor Hospital Affiliated to Harbin Medical University between January 2007 and January 2012. OS and SRS were evaluated by the Kaplan-Meier method. The factors associated with SRS and OS were examined using multivariate Cox analyses.The 1 year OS was 55.9% and the median OS was 30 months (range, 1-98 months). Multivariate analyses showed that clinical staging at initial diagnosis (P < .001) and SRE (P = .033) were independently associated with OS, and clinical staging at initial diagnosis (P = .009), bone pain (P = .008), primary tumor radiotherapy (P < .001), and chemotherapy (P = .031) were independently associated with SRS. Stage I, II, and III patients under biphosphonate therapy fared better than those without biphosphonate treatment, but there was no difference for stage IV patients.The identification of factors associated with OS and SRS of patients with NSCLC and bone metastases should provide new clues for a better management of these patients.

Use of intravenous bisphosphonates in patients with breast, lung, or prostate cancer and metastases to bone: a 15-year study in two large US health systems

PURPOSE

The purpose of this paper is to document the use of intravenous (IV) bisphosphonates for prevention of skeletal-related events (SREs) in patients with bone metastases (BM) due to breast cancer (BC), lung cancer (LC), or prostate cancer (PC).

METHODS

Using data from two large US health systems, we identified all patients aged ≥ 18 years with primary BC, LC, or PC and newly diagnosed BM between 1/1/1995 and 12/31/2009. Starting with the diagnosis of BM, we reviewed medical and administrative records for evidence of receipt of IV bisphosphonates (zoledronic acid or pamidronate) and occurrence of SREs. Initiation of IV bisphosphonates prior to occurrence of an SRE was designated "primary prophylaxis"; use following an SRE was designated "secondary prophylaxis".

RESULTS

We identified a total of 1,193 patients with newly diagnosed BM, including 400 with BC, 332 with LC, and 461 with PC. Use of IV bisphosphonates was substantially higher in BC (55.8 % of all patients) than in LC (14.8 %) or PC (20.2 %). Use of IV bisphosphonates was fairly evenly split between primary and secondary prophylaxis in BC (26.3 vs. 29.5 %, respectively) and PC (10.6 vs 9.5 %); in LC, however, primary prophylaxis was much less common than secondary prophylaxis (4.8 vs 9.9 %).

CONCLUSIONS

Almost one half of all patients with BM due to BC, and substantially more with LC and PC, do not receive IV bisphosphonates. Among patients receiving such therapy, treatment often is not initiated until after the occurrence of an SRE. Our study suggests that IV bisphosphonates may be substantially underutilized in patients with BM due to these common cancers.

Incidence and consequences of bone metastases in lung cancer patients

Background

Bone metastases (BM) are common in NSCLC patients. Despite some potential positive effects of bone-targeted therapies, their use in NSCLC is infrequent, which may relate to the overall poor prognosis of advanced lung cancer. We reviewed the literature to evaluate the incidence, consequences and use of bone-targeting agents in lung cancer patients with BM in both the trial and non-trial clinical setting.

Methods

Published prospective and retrospective papers investigating lung cancer and BM, in trial and non-trial settings, were identified and are discussed in this review.

Results

BM are common in patients with advanced lung cancer and often present symptomatically with pain and skeletal related events (SREs). Patients with high bone turnover marker levels, multiple BM, and history of pathological fractures have shorter overall survival. In randomized studies bone-targeted therapies reduced the risk of SREs and prolonged the time to first SRE. The use of bone-targeted agents may also be associated with a survival benefit.

Conclusion

BM are a common problem in advanced lung cancer. While the benefits of bone-targeted therapies have been demonstrated, their use is limited in non-trial populations. If better predictive markers of individual risk were available this might increase the appropriate use of bone-targeted agents.

Pharmacoeconomics of bisphosphonates for skeletal-related event prevention in metastatic non-breast solid tumours

Bisphosphonates reduce the risk of skeletal-related events (SREs; i.e. spinal cord compression, pathological fracture, radiation or surgery to the bone, and hypercalcaemia) in patients with metastatic cancer. A number of analyses have been conducted to assess the cost effectiveness of bisphosphonates in patients with bone metastases secondary to breast cancer, but few in other solid tumours. This is a review of cost-effectiveness analyses in patients with non-breast solid tumours and bone metastases. A literature search was conducted to identify cost-effectiveness analyses reporting the cost per QALY gained of bisphosphonates in patients with metastatic bone disease secondary to non-breast solid tumours. Four analyses met inclusion criteria. These included two in prostate cancer (one of which used a global perspective but expressed results in $US, and the other reported from a multiple country perspective: France, Germany, Portugal and the Netherlands). The remaining analyses were in lung cancer (in the UK, France, Germany, Portugal and the Netherlands), and renal cell carcinoma (in the UK, France and Germany). In each analysis, the cost effectiveness of zoledronic acid versus placebo was analysed. Zoledronic acid was found to be cost effective in all European countries across all three indications but not in the sole global prostate cancer analysis. Across countries and indications, assumptions regarding patient survival, drug cost and baseline utility (i.e. patient utility with metastatic disease but without an SRE) were the most robust drivers of modelled estimates. Assumptions of SRE-related costs were most often the second strongest cost driver. Further review indicated that particular attention should be paid to the inclusion or exclusion of nonsignificant survival benefits, whether health state utilities were elicited from community or patient samples or author assumptions, delineation between symptomatic and asymptomatic SREs, and the methods with which SRE disutility was modelled over time. While the field of cost-effectiveness analysis in solid tumours other than breast cancer is still evolving, outcomes will likely continue to be driven by drug cost and assumptions regarding treatment benefits. Although considerations such as adverse events and administration costs are important, they were not found to influence cost-effectiveness estimates greatly. As zoledronic acid will lose patent protection in 2013 and subsequently be greatly reduced in price, it is likely that the field of cost effectiveness will change with regard to SRE-limiting agents. Meanwhile, research should be conducted to improve our understanding of the impact on quality of life and medical costs of preventing SREs.