Clinical features of metastatic bone disease and risk of skeletal morbidity

The skeleton is the most common organ to be affected by metastatic cancer and the site of disease that produces the greatest morbidity. Skeletal morbidity includes pain that requires radiotherapy, hypercalcemia, pathologic fracture, and spinal cord or nerve root compression. From randomized trials in advanced cancer, it can be seen that one of these major skeletal events occurs on average every 3 to 6 months. Additionally, metastatic disease may remain confined to the skeleton with the decline in quality of life and eventual death almost entirely due to skeletal complications and their treatment. The prognosis of metastatic bone disease is dependent on the primary site, with breast and prostate cancers associated with a survival measured in years compared with lung cancer, where the average survival is only a matter of months. Additionally, the presence of extraosseous disease and the extent and tempo of the bone disease are powerful predictors of outcome. The latter is best estimated by measurement of bone-specific markers, and recent studies have shown a strong correlation between the rate of bone resorption and clinical outcome, both in terms of skeletal morbidity and progression of the underlying disease or death. Our improved understanding of prognostic and predictive factors may enable delivery of a more personalized treatment for the individual patient and a more cost-effective use of health care resources.

Increased incidence of hip fractures in dialysis patients with low serum parathyroid hormone

To study the complications of renal osteodystrophy in patients with end-stage renal disease, we reviewed the incidence of hip fractures in our outpatient dialysis population from 1988 to 1998. One thousand two hundred seventy-two patients were treated for a total of 4,039 patient-years; 56 hip fractures were documented during this period. The incidence of hip fractures was many times greater in the dialysis patients than in the general population in each of the age-, race-, and sex-matched subgroups. The 1-year mortality rate from the hip fracture event was nearly two and a half times greater in the dialysis patients compared with the general population. The incidence of hip fractures in the first half of the decade was similar to that observed in the second half. When parathyroid hormone (PTH) levels were evaluated, we determined that patients with lower serum PTH levels were more likely to sustain a hip fracture than patients with higher PTH levels (P: < 0.006). In addition, we determined that patients with lower PTH levels had an earlier mortality than patients with higher PTH levels (P: < 0.03). We conclude that despite more aggressive therapy directed toward bone health in our dialysis patients in recent years, the incidence of hip fractures and their devastating morbidity and mortality remained unchanged over the past decade. Lower PTH levels may predispose to earlier mortality.

Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies' Environmental Committee, Part 2: Air Pollution and Organ Systems

Although air pollution is well known to be harmful to the lung and airways, it can also damage most other organ systems of the body. It is estimated that about 500,000 lung cancer deaths and 1.6 million COPD deaths can be attributed to air pollution, but air pollution may also account for 19% of all cardiovascular deaths and 21% of all stroke deaths. Air pollution has been linked to other malignancies, such as bladder cancer and childhood leukemia. Lung development in childhood is stymied with exposure to air pollutants, and poor lung development in children predicts lung impairment in adults. Air pollution is associated with reduced cognitive function and increased risk of dementia. Particulate matter in the air (particulate matter with an aerodynamic diameter < 2.5 μm) is associated with delayed psychomotor development and lower child intelligence. Studies link air pollution with diabetes mellitus prevalence, morbidity, and mortality. Pollution affects the immune system and is associated with allergic rhinitis, allergic sensitization, and autoimmunity. It is also associated with osteoporosis and bone fractures, conjunctivitis, dry eye disease, blepharitis, inflammatory bowel disease, increased intravascular coagulation, and decreased glomerular filtration rate. Atopic and urticarial skin disease, acne, and skin aging are linked to air pollution. Air pollution is controllable and, therefore, many of these adverse health effects can be prevented.

Differences in vitamin D status between countries in young adults and the elderly

PURPOSE

To compare vitamin D status between countries in young adults and in the elderly.

MATERIALS AND METHODS

Reports on vitamin D status (as assessed by serum 25-hydroxyvitamin D) from 1971 to 1990 were reviewed. Studies were grouped according to geographic regions: North America (including Canada and the United States); Scandinavia (including Denmark, Finland, Norway, and Sweden); and Central and Western Europe (including Belgium, France, Germany, Ireland, The Netherlands, Switzerland, and the United Kingdom).

RESULTS

Vitamin D status varies with the season in young adults and in the elderly, and is lower during the winter in Europe than in both North America and Scandinavia. Oral vitamin D intake is lower in Europe than in both North America and Scandinavia. Hypovitaminosis D and related abnormalities in bone chemistry are most common in elderly residents in Europe but are reported in all elderly populations.

CONCLUSIONS

The vitamin D status in young adults and the elderly varies widely with the country of residence. Adequate exposure to summer sunlight is the essential means to ample supply, but oral intake augmented by both fortification and supplementation is necessary to maintain baseline stores. All countries should adopt a fortification policy. It seems likely that the elderly would benefit additionally from a daily supplement of 10 micrograms of vitamin D.

Epidemiology of musculoskeletal impairments and associated disability

Data from the US Health and Nutrition Examination Survey (HANES I) of 1971-1975 confirm the high prevalence of musculoskeletal impairments among United States adults. Musculoskeletal impairments tend to be more prevalent among older persons, and persons with less education and with lower annual family incomes. Prevalence rates are slightly higher in females than in males, while Whites and non-Whites are affected with almost equal frequency. Among persons reporting a history of musculoskeletal symptoms, those who have some disability tend to be older, non-White, of lower education and income, and widowed, separated, or divorced. Persons with multiple parts of the body involved, or reporting that their symptoms are due to accident or injury are also especially likely to report disability. Taken as a whole, the data suggest that medical, social, and economic factors all play a role in determining whether a person with musculoskeletal impairment goes on to develop disability related to his or her impairment.

Bone disease in HIV infection: a practical review and recommendations for HIV care providers

Low bone mineral density (BMD) is prevalent in human immunodeficiency virus (HIV)-infected subjects. Initiation of antiretroviral therapy is associated with a 2%-6% decrease in BMD over the first 2 years, a decrease that is similar in magnitude to that sustained during the first 2 years of menopause. Recent studies have also described increased fracture rates in the HIV-infected population. The causes of low BMD in individuals with HIV infection appear to be multifactorial and likely represent a complex interaction between HIV infection, traditional osteoporosis risk factors, and antiretroviral-related factors. In this review, we make the point that HIV infection should be considered as a risk factor for bone disease. We recommend screening patients with fragility fractures, all HIV-infected post-menopausal women, and all HIV-infected men ⩾50 years of age. We also discuss the importance of considering secondary causes of osteoporosis. Finally, we discuss treatment of the more severe cases of bone disease, while outlining the caveats and gaps in our knowledge.

The effect of vitamin D supplementation on skeletal, vascular, or cancer outcomes: a trial sequential meta-analysis

BACKGROUND

Vitamin D insufficiency is associated with many disorders, leading to calls for widespread supplementation. Some investigators suggest that more clinical trials to test the effect of vitamin D on disorders are needed.

METHODS

We did a trial sequential meta-analysis of existing randomised controlled trials of vitamin D supplements, with or without calcium, to investigate the possible effect of future trials on current knowledge. We estimated the effects of vitamin D supplementation on myocardial infarction or ischaemic heart disease, stroke or cerebrovascular disease, cancer, total fracture, hip fracture, and mortality in trial sequential analyses using a risk reduction threshold of 5% for mortality and 15% for other endpoints.

FINDINGS

The effect estimate for vitamin D supplementation with or without calcium for myocardial infarction or ischaemic heart disease (nine trials, 48 647 patients), stroke or cerebrovascular disease (eight trials 46 431 patients), cancer (seven trials, 48 167 patients), and total fracture (22 trials, 76 497 patients) lay within the futility boundary, indicating that vitamin D supplementation does not alter the relative risk of any of these endpoints by 15% or more. Vitamin D supplementation alone did not reduce hip fracture by 15% or more (12 trials, 27 834 patients). Vitamin D co-administered with calcium reduced hip fracture in institutionalised individuals (two trials, 3853 patients) but did not alter the relative risk of hip fracture by 15% or more in community-dwelling individuals (seven trials, 46 237 patients). There is uncertainty as to whether vitamin D with or without calcium reduces the risk of death (38 trials, 81 173).

INTERPRETATION

Our findings suggest that vitamin D supplementation with or without calcium does not reduce skeletal or non-skeletal outcomes in unselected community-dwelling individuals by more than 15%. Future trials with similar designs are unlikely to alter these conclusions.

FUNDING

Health Research Council of New Zealand.

Cerebro-hepato-renal syndrome of Zellweger. A report of eight cases with comments upon the incidence, the liver lesion, and a fault in pipecolic acid metabolism

Studies of eight patients with this syndrome confirm the characteristic pattern of abnormalities and the autosomal recessive mode of inheritance. The incidence is estimated to be approximately 1 in 100,000 live births. The liver lesion proved to be variable, with features of progressive parenchymal damage rather than a developmental defect of small bile ducts as previously suggested. Elevated levels of pipecolic acid were found in blood and urine and may be related to the basic defect.

Bone disease in thalassemia: a frequent and still unresolved problem

Adults with beta thalassemia major frequently have low BMD, fractures, and bone pain. The purpose of this study was to determine the prevalence of low BMD, fractures, and bone pain in all thalassemia syndromes in childhood, adolescence, and adulthood, associations of BMD with fractures and bone pain, and etiology of bone disease in thalassemia. Patients of all thalassemia syndromes in the Thalassemia Clinical Research Network, > or =6 yr of age, with no preexisting medical condition affecting bone mass or requiring steroids, participated. We measured spine and femur BMD and whole body BMC by DXA and assessed vertebral abnormalities by morphometric X-ray absorptiometry (MXA). Medical history by interview and review of medical records, physical examinations, and blood and urine collections were performed. Three hundred sixty-one subjects, 49% male, with a mean age of 23.2 yr (range, 6.1-75 yr), were studied. Spine and femur BMD Z-scores < -2 occurred in 46% and 25% of participants, respectively. Greater age, lower weight, hypogonadism, and increased bone turnover were strong independent predictors of low bone mass regardless of thalassemia syndrome. Peak bone mass was suboptimal. Thirty-six percent of patients had a history of fractures, and 34% reported bone pain. BMD was negatively associated with fractures but not with bone pain. Nine percent of participants had uniformly decreased height of several vertebrae by MXA, which was associated with the use of iron chelator deferoxamine before 6 yr of age. In patients with thalassemia, low BMD and fractures occur frequently and independently of the particular syndrome. Peak bone mass is suboptimal. Low BMD is associated with hypogonadism, increased bone turnover, and an increased risk for fractures.

Prevalence of the female athlete triad syndrome among high school athletes

OBJECTIVE

To estimate the prevalence of the female athlete triad (disordered eating, menstrual irregularity, and low bone mass) among high school athletes.

DESIGN

Observational cross-sectional study.

SETTING

High school.

PARTICIPANTS

Female athletes (n= 170) representing 8 sports were recruited from 6 high schools in southern California.

MAIN OUTCOME MEASURES

Disordered eating and menstrual status were determined by interviewer-assisted questionnaires. Bone mineral density was measured by dual-energy x-ray absorptiometry of the hip, spine (L1-L4), and total body.

RESULTS

Among all athletes, 18.2%, 23.5%, and 21.8% met the criteria for disordered eating, menstrual irregularity, and low bone mass, respectively. Ten girls (5.9%) met criteria for 2 components of the triad, and 2 girls (1.2%) met criteria for all 3 components. Oligomenorrheic/amenorrheic athletes had higher mean +/- SD eating restraint (1.55 +/- 1.60 vs 1.04 +/- 1.27; P = .02) and Eating Disorder Examination Questionnaire global scores (1.68 +/- 1.20 vs 1.33 +/- 1.14; P = .03) than eumenorrheic athletes. After controlling for age, age at menarche, body mass index, race/ethnicity, and sport type, athletes with oligomenorrhea/amenorrhea had significantly lower mean +/- SD bone mineral densities for the trochanter (0.884 +/- 0.090 g . cm(-2)) than eumenorrheic athletes (0.933 +/- 0.130 g . cm(-2); P = .04).

CONCLUSIONS

The prevalence of the full female athlete triad was low in our sample; however, a substantial percentage of the athletes may be at risk for long-term health consequences associated with disordered eating, menstrual irregularity, or low bone mass. Preparticipation screening to identify these components should be encouraged as a preventive approach to identify high-risk athletes.

Copper as an essential nutrient

Animal and human studies have shown that copper is involved in the function of several enzymes. Studies have also shown that copper is required for infant growth, host defense mechanisms, bone strength, red and white cell maturation, iron transport, cholesterol and glucose metabolism, myocardial contractility, and brain development. Copper deficiency can result in the expression of an inherited defect such as Menkes syndrome or in an acquired condition. Acquired deficiency is mainly a pathology of infants; however, it has been diagnosed also in children and adults. Most cases of copper deficiency have been described in malnourished children. The most constant clinical manifestations of acquired copper deficiency are anemia, neutropenia, and bone abnormalities. Other, less frequent manifestations are hypopigmentation of the hair, hypotonia, impaired growth, increased incidence of infections, alterations of phagocytic capacity of the neutrophils, abnormalities of cholesterol and glucose metabolism, and cardiovascular alterations. Measurements of serum copper and ceruloplasmin concentrations are currently used to evaluate copper status. These indexes are diminished in severe to moderate copper deficiency; however, they are less sensitive to marginal copper deficiency. Erythrocyte superoxide dismutase and platelet cytochrome c activities may be more promising indexes for evaluating marginal copper deficiency.

Gastrointestinal and nutritional problems occur frequently throughout life in girls and women with Rett syndrome

OBJECTIVE

We conducted a nationwide survey to determine the prevalence of common gastrointestinal and nutritional disorders in Rett syndrome (RTT) based on parental reporting and related the occurrence of these problems to age and methyl-CpG-binding protein 2 (MECP2) gene status.

METHODS

We designed a questionnaire that probed symptoms, diagnoses, diagnostic tests, and treatment interventions related to gastrointestinal and nutritional problems in RTT. The International Rett Syndrome Foundation distributed the questionnaire to 1666 family-based members and forwarded their responses for our review. We interrogated the Rare Disease Clinical Research Network database to supplement findings related to medications used to treat gastrointestinal problems in RTT.

RESULTS

Parents of 983 female patients with RTT (59%) responded and identified symptoms and diagnoses associated with gastrointestinal dysmotility (92%), chewing and swallowing difficulties (81%), weight deficits or excess (47%), growth deficits (45%), low bone mineral content or fractures (37%), and biliary tract disorders (3%). Height-for-age, weight-for-age, and body mass index z scores decreased significantly with age; height- and weight-, but not body mass index-for-age z scores were significantly lower in female subjects with MECP2 mutations than in those without. Vomiting, nighttime awakening, gastroesophageal reflux, chewing difficulty, and choking with feeding were significantly less likely to occur with increasing age. Short stature, low bone mineral content, fractures, and gastrostomy placement were significantly more likely to occur with increasing age. Chewing difficulty, choking with feeding, and nighttime awakening were significantly less likely to occur, whereas short stature was significantly more likely to occur, in female subjects with MECP2 mutations than in those without. Diagnostic evaluations and therapeutic interventions were used less frequently than the occurrence of symptoms or diagnoses in the RTT cohort.

CONCLUSIONS

Gastrointestinal and nutritional problems perceived by parents are prevalent throughout life in girls and women with RTT and may pose a substantial medical burden for their caregivers. Physician awareness of these features of RTT may improve the health and quality of life of individuals affected with this disorder.

The epidemiology of selenium deficiency in the etiological study of endemic diseases in China

The distribution of chemical elements in rocks and soils varies widely. Selenium is one of the elements that has remarkable regional variations in distribution and bioavailability. This paper reviews the epidemiology of selenium deficiency in China in connection with the etiology of human selenium-responsive diseases, the well-defined Keshan disease (KD) and the less-well-defined Kashin-Beck disease (KBD).

Prevalence of significant noncardiac findings on electron-beam computed tomography coronary artery calcium screening examinations

BACKGROUND

Screening electron-beam computed tomography (EBCT) examinations for the detection and quantification of coronary artery calcification are being performed throughout the country. In addition to information about the heart, great vessels, and coronary arteries, these examinations include portions of the lungs, bony thorax, and upper abdomen. The purpose of this study was to determine the prevalence of significant noncardiac findings in a series of patients undergoing coronary artery calcification screening studies with EBCT scanning.

METHODS AND RESULTS

Between January 1, 2001, and October 1, 2001, 1326 consecutive patients underwent coronary artery calcification screening with EBCT (3-mm-thick slices were obtained at 3-mm intervals). Two board-certified radiologists reviewed the examinations on a workstation using standard mediastinal windows, lung windows, and bone windows. Significant extracardiac abnormalities were noted. Of 1326 patients, 103 (7.8%) had significant extracardiac pathology requiring clinical or imaging follow-up. These included 53 patients with noncalcified lung nodules <1 cm, 12 patients with lung nodules > or =1 cm, 24 patients with infiltrates, 7 patients with indeterminate liver lesions, 2 patients with sclerotic bone lesions, 2 patients with breast abnormalities, 1 patient with polycystic liver disease, 1 patient with esophageal thickening, and 1 patient with ascites.

CONCLUSIONS

In this study, 7.8% of patients undergoing screening EBCT examinations for coronary artery calcification were found to have important extracardiac pathology requiring additional work-up. Therefore, it is essential that a radiologist review the entire examination.

Growth and nutrition disorders in children with cerebral palsy

Growth and nutrition disorders are common secondary health conditions in children with cerebral palsy (CP). Poor growth and malnutrition in CP merit study because of their impact on health, including psychological and physiological function, healthcare utilization, societal participation, motor function, and survival. Understanding the etiology of poor growth has led to a variety of interventions to improve growth. One of the major causes of poor growth, malnutrition, is the best-studied contributor to poor growth; scientific evidence regarding malnutrition has contributed to improvements in clinical management and, in turn, survival over the last 20 years. Increased recognition and understanding of neurological, endocrinological, and environmental factors have begun to shape care for children with CP, as well. The investigation of these factors relies on advances made in the assessment methods available to address the challenges inherent in measuring growth in children with CP. Descriptive growth charts and norms of body composition provide information that may help clinicians to interpret growth and intervene to improve growth and nutrition in children with CP. Linking growth to measures of health will be necessary to develop growth standards for children with CP in order to optimize health and well-being.

The prevalence of acetabular retroversion among various disorders of the hip

BACKGROUND

Acetabular retroversion can result from posterior wall deficiency in an otherwise normally oriented acetabulum or from excessive anterior coverage secondary to a malpositioned acetabulum, or both. Theoretically, a retroverted acetabulum, which adversely affects load transmission across the hip, may occur more frequently in hips with degenerative arthritis. The aim of this study was to assess the prevalence of acetabular retroversion in normal hips and in hips with osteoarthritis, developmental dysplasia, osteonecrosis, and Legg-Calvé-Perthes disease.

METHODS

We retrospectively examined anteroposterior radiographs of the pelvis of 250 patients (342 hips). Fifty-six patients (112 hips) had normal findings; sixty-six patients (seventy hips) had osteoarthritis; sixty-four (seventy-four hips), developmental dysplasia; thirty (thirty-six hips), osteonecrosis of the femoral head; and thirty-four (fifty hips), Legg-Calvé-Perthes disease. The sole criterion for a diagnosis of acetabular retroversion was the presence of a so-called cross-over sign on the anteroposterior radiograph of the pelvis.

RESULTS

The prevalence of acetabular retroversion was 6% (seven of 112 hips) in the normal group, 20% (fourteen of seventy hips) in the osteoarthritis group, 18% (thirteen of seventy-four hips) in the developmental dysplasia group, 6% (two of thirty-six hips) in the group with osteonecrosis of the femoral head, and 42% (twenty-one of fifty hips) in the group with Legg-Calvé-Perthes disease. In patients with Legg-Calvé-Perthes disease, the prevalence of acetabular retroversion was 68% in twenty-five hips with Stulberg class-III, IV, or V involvement. In contrast, only four (16%) of twenty-five hips with Stulberg class-I or II involvement had acetabular retroversion. The difference was significant (p = 0.0002). Patients with osteoarthritis, developmental dysplasia, or Legg-Calvé-Perthes disease are significantly more likely to have acetabular retroversion than are normal subjects (p < 0.05).

CONCLUSIONS

Acetabular retroversion occurs more commonly in association with a variety of hip diseases, in which the prevalence of subsequent degenerative arthritis is increased, than has been previously noted.

Viewpoints on vessels and vanishing bones in Gorham-Stout disease

Gorham-Stout disease (GSD) is a rare disorder characterized by the proliferation of endothelial-lined vessels in bone and the progressive destruction of bone. Although Jackson described the first case of GSD in 1838, the clinical and histological features of GSD were not defined until Gorham and Stout published their report on massive osteolysis in 1955. In the years since Gorham and Stout's groundbreaking publication, more than 300 cases of GSD have been described in the literature. These reports have revealed that the progressive resorption of bone in GSD causes severe physical deformities, disabilities, and life-threatening complications. Unfortunately, the underlying cause of GSD remains unknown and, as a result, the therapeutic options for individuals with GSD are limited. Here we review the latest advances in GSD research and present strategies to address basic and clinical research questions related to GSD.

Unilateral hearing loss in children

Recent reports suggest that early onset, severe unilateral sensorineural hearing loss (USNHL) in children may be associated with significant deficits in auditory and psycholinguistic skills and school performance. This report reviews a consecutive series of 324 children and adolescents (202 males, 122 females) with documented USNHL evaluated at the Boys Town National Research Hospital. The left ear was affected in 168 (52%) and the right ear in 156 (48%). Based on speech frequency threshold averages (i.e., 500, 1000, and 2000 Hz), the losses were classified by severity as follows: borderline, 43 (13%); mild, 51 (16%); moderate, 40 (12%); severe, 19 (6%); profound, 31 (10%), and anacusic, 50 (15%). The remaining 90 children (28%) had high frequency losses (i.e., above 2000 Hz). The mean and median age of diagnosis were 8.78 years and 7.75 years. Temporal bone imaging studies, auditory brainstem responses (ABRs), and vestibular evaluations were performed on selected cases. Etiology was uncertain in 34.8% of cases, while hereditary factors (12.6%), head trauma (10.8%), and perinatal risk factors (10.7%) were the most commonly identified etiologies. Thirty-one percent of the children had scholastic or behavioral problems in school. A concerted effort aimed at early identification and intervention in cases of USNHL is warranted.

Reduced bone cortical thickness in boys with autism or autism spectrum disorder

Bone development, casein-free diet use, supplements, and medications were assessed for 75 boys with autism or autism spectrum disorder, ages 4-8 years. Second metacarpal bone cortical thickness (BCT), measured on hand-wrist radiographs, and % deviations in BCT from reference medians were derived. BCT increased with age, but % deviations evidenced a progressive fall-off (p = .02): +3.1 +/- 4.7%, -6.5 +/- 4.0%, -16.6 +/- 3.4%, -19.4 +/- 3.7%,-24.1 +/- 4.4%, at ages 4-8, respectively, adjusting for height. The 12% of the boys on casein-free diets had an overall % deviation of -18.9 +/- 3.7%, nearly twice that of boys on minimally restricted or unrestricted diets (-10.5 +/- 1.3%, p < .04), although even for boys on minimally restricted or unrestricted diets the % deviation was highly significant (p < .001). Our data suggest that the bone development of autistic boys should be monitored as part of routine care, especially if they are on casein-free diets.

Soft tissue disorders in the upper limbs of female garment workers

In this cross-sectional investigation of female garment workers the prevalence of soft tissue disorders of the hands and arms was studied. The findings were compared with the prevalence of disorders in a group of female hospital employees not required to use repetitive hand motion. One hundred and eighty-eight garment workers and 76 hospital employees were surveyed by questionnaire and physical examination. The prevalences of persistent shoulder, wrist, and hand pain were significantly greater among the garment workers (rate ratio 2, 4, and 3, respectively). In both groups about 60% of the persistent hand pain was consistent with carpal tunnel syndrome (rate ratio 3). These associations held when the comparisons were stratified by age and by length of employment. Workers whose native language was not English were significantly less likely to report symptoms (rate ratio 0.6). Workers in hand sewing and trimming suffered especially high prevalences of persistent pain in all upper limb sites. Stitchers had elevated rates of pain in the shoulders, wrists, and hands. Workers ironing by hand had a significant elevation in elbow pain rates. Garment assembly tasks appear to be associated with cumulative trauma of the hands and wrists; the biomechanical features of these jobs should be studied in greater detail.

Cancer-associated bone disease

Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.