Bone Health Management for Myeloma: More Active Living with Less Worry

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Topics include: Treatment and Living Well

Dr. James Berenson, who has played a key role in the study of zoledronic acid, provides an overview of bone health management for patients living with myeloma.  While fractures have been minimized over the last ten years through the use of biphosphonates, Dr. Berenson details treatment options should damage occur.  He also explains how vitamin D and the drugs used to treat the cancer itself may be having a positive impact on patients' bone health.

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor.  Please have this discussion with your own doctor. That’s how you’ll get care that’s most appropriate for you.

So in fact in data that we generated back in the 90s before we were using these drugs patients would have a number of events, two on the average per year, usually either a fracture or the requirement for radiation treatment to bone areas, could be less commonly skeletal complications that were related to spinal cord being compressed by the tumor or also in rare circumstances surgery on the spine, major surgery.  But what’s happened over the last two decades, that number, too, has plummeted.  In our recent publication instead of two a year we’re down to about one every 10 years, 20-fold decrease.  And most of the skeletal complications today are occurring at the time of diagnosis or just before, so we are really taking these away as a major problem. 

Now, when the skeletal complications do occur, they often involve the spine, and the reason that’s true is the spine is a weight-bearing area so often the vertebral bodies, the bones in the spine get crushed, kind of what happens to ladies who are osteoporosis and have it from, say, being after the menopause.  So when that occurs, when these events occur what happens, these patients often get pain, and they may have disability and inability to get around.  So about a quarter of patients when they present with myeloma will have one of these compression fractures in the spine. 

Now, up until the last decade these were really troublesome for patients, lots of chronic pain, usually treated simply with pain meds with all of what that does in terms of side effects, with effects on mental function, GI side effects, so they’d have nausea and constipation.  But what we learned about 10 years ago rather than these really cumbersome operative procedures that were not well tolerated in this elderly population with cancer we could simply do what’s called minimally-invasive surgery. 

And in the late 90s that was vertebroplasty in which a needle that looks a lot like a needle used for a bone marrow was placed in the collapsed body and cement shoved in to this collapsed body, and that cement would then harden and stabilize the fracture.  What would happen, though, is sometimes that material, that cement, could get out of the spine and travel.  It could go into the spinal canal.  It could go to the lungs and cause a lot of complications. 

So a surgeon at UC San Francisco about a decade ago developed another technique called balloon kyphoplasty in which the needle is placed in the collapsed body and then you blow up that because it has a balloon at the end of it, and now you’re able to actually take the height that was lost, you’re able to restore the height but more importantly you can put the cement into an empty area so it doesn’t have the tendency to move out into the spinal canal and the lung.  It’s a lot safer. 

And we recently showed in a large international trial that patients who underwent this procedure immediately who had cancer with a vertebral fracture, about a third had myeloma, they had a variety of other cancers, those patients who underwent the procedure immediately had a marked reduction in pain, marked reduction in back disability, better quality of life, less use of pain meds.  It was very effective.  And those patients then who were on the nonsurgical side, once they were able to get the procedure in the trial after a month they also derived benefit.  So we believe that’s a very important procedure to think about in a patient with a fracture in the back. 

In the past these were largely managed also with radiation therapy.  The problem with that is a lot of your bone marrow function is in your spine.  You radiate it, you permanently damage it, and therefore you can no longer receive therapies that affect bone marrow function like chemotherapy agents, like some of the new agents we’re using to treat myeloma.  So we really want to emphasize that radiation therapy should be at a minimum to myeloma.  This is a systemic disease involving the entire bone marrow, so we really like to keep patients away from the radiation therapist’s office unless it’s absolutely necessary. 

Now, in terms of the management beyond simply these minimally surgical procedures and bisphosphonates, we’ve also learned that a lot of our patients are vitamin D deficient.  And that’s not only because they may live in locales without a lot of sun, but it also is because they’re inside a lot because their quality of life may be poor.  But even without that, even sunny areas like Southern California, young patients with myeloma, a lot are vitamin D deficient, so we recommend vitamin D levels on our patients with myeloma be done at baseline, be followed with regularity, that they get supplemented appropriately, so that they get kept in the proper level. 

That not only helps with bone health, we’re learning it also helps with a lot of other things: heart, even neuro function, both your mind function and peripheral neuropathy, there’s data to suggest vitamin D is important.  Also immune function.  All of these relate to vitamin D. 

In addition, the other part of the story is to keep the patients from falling down, because if you don’t fall down you’re much less likely to fracture.  Of course, we know a lot of the new drugs that we’re using, drugs like thalidomide, Velcade, cause neuropathy, so minimizing that risk and its severity and learning how to deal with the drugs to reduce the severity in incidence or the frenzy of this complication is really important.  Because if patients can’t feel their feet they lose balance, they fall.  It’s also important in the work or in the home environment to make sure that it’s set up so that the rugs and areas around the house are not conducive to patients falling down.  That’s also important because if patients fall, again, with their brittle bones they’re a lot more likely to fracture.

But I would also say in general today we are recommending our patients avail themselves the opportunity to do everything they did before they had myeloma.  So we’re no longer saying, take it easy, don’t go skiing, don’t go surfing, don’t go mountain climbing.  We’re saying the opposite.  Go do all those things because we believe the risk of bone events is pretty small today thanks to all the advances we’ve had over the last 20 years. 

 

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor.  Please have this discussion with your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on September 5, 2014