Dr. Sehdev explains bone health as it relates to cancer, including bone metastases, treatment options, the impact of cancer treatment on bone health, and what you can do to keep your bones strong.

1. Bone Health in Cancer
Dr. Sandy Sehdev
Medical Oncologist
William Osler Health Centre

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What will we discuss
● About our bones
● About bone metastases
● The complications of bone metastases
● Treatment options for bone complications
● The impact of cancer treatment on bone health
● What else can you do to keep your bones strong?
● Ask the expert

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Our bones
● Bone is living tissue, which is
constantly being broken down
and rebuilt, a process called
remodeling
● The loss of living bone tissue
makes bones fragile and more
likely to fracture

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Bone function
● The major functions of bones
are to:
● Provide structural support for the
body
● Provide protection of vital organs
● Provide an environment for
marrow (where blood cells are
produced)
● Act as a storage area for minerals
(such as calcium)
“Facts about bones” accessed at http://www.iofbonehealth.org/patients-public/about-osteoporosis/facts-about-bones.html on August 9, 2010

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About bone metastases
● One of the most common places for prostate or breast cancer to
spread is to the bone
● Approximately 65 to 75 per cent of people with advanced prostate or
breast cancer experience bone metastases
● Growing cancer cells weaken and destroy bone around the
tumour
● Can lead to debilitating complications

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Cycle of bone destruction
● Cancer cells travel from original
site to bone where they stimulate
bone cells called osteoclasts
● Osteoclasts increase bone
destruction making room for the
tumour to grow in the bone
● As bone is destroyed, proteins
are released that can cause
cancer cells to grow…
…and the cycle of bone destruction continues

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Warning signs
● No warning signs in some
patients
● Bone pain
● One of the first signs that cancer
has spread to the bone
− Up to two-thirds of people with
bone metastases experience
debilitating pain
● May require pain medication
(may develop tolerance)
● Can severely impact quality of life

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Warning signs
● Fractures (broken bones)
● Hypercalcemia (a result of
excess calcium released into
blood stream)
● Symptoms may include:
− Constipation or diarrhea
− Confusion
− Dehydration
− Nausea or vomiting
− Memory loss and depression

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Diagnosing bone metastases
● To determine if the cancer has spread to the bones, a doctor may
order several tests, including:
● Imaging tests (X-rays and radionuclide bone scans, CT scans, MRI
scans and PET scans)
● Blood tests
● Urine tests
● Biopsies

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Bisphosphonates reduce the risk of SREs in
breast cancer patients

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Study Schema

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Primary End Point: Time to First On-Study SRE

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Secondary End Point: Time to First and
Subsequent SREs

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Pain Progression: Denosumab vs. ZA

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Quality of Life – Denosumab vs. ZA

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ZOOM: A Prospective, Randomized Trial of ZA for Long-Term
Treatment of Bone-metastatic BrCa after 1 Year of ZA Treatment

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ZOOM: Primary Efficacy Analysis: SMR

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Select AEs with ZA and Denosumab During the 2-
Year Open-Label Treatment Phase

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Risk Factors for ONJ in Cancer Patients

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Treatment options for complications of bone
metastases
● Several treatment options are
available
● Your doctor will determine which
is right for you based on your
health needs and lifestyle
Bisphosphonates
RANK-Ligand
inhibitor

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Treatment options for complications of bone
metastases
Medication can be administered in different ways
• By mouth (tablets/liquids)
• By intravenous/IV infusion (into the vein)
• By subcutaneous injection (under the skin)
Many people may go untreated, remaining at risk of
developing serious bone complications
Speak to your doctor about treatment options that are
right for you

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Current approved bone-targeted
therapies in Canada
Breast Cancer
● Denosumab (Xgeva®)
● Administered as subcutaneous
injection every 4 weeks
● Zoledronic acid (Zometa™)
● Administered every 3 or 4 weeks
via a 15-minute infusion
● Pamidronate (Aredia™)
● Administered every 3 or 4 weeks
as a 2 hour intravenous/IV infusion
● Clodronate (Ostac™)
● Administered as oral tablets daily
Prostate Cancer
● Denosumab (Xgeva®)
● Administered as subcutaneous
injection every 4 weeks
● Zoledronic acid (Zometa™)
● Administered every 3 or 4 weeks
via a 15-minute infusion

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Possible side effects
RANK-Ligand Inhibitor
● The most common are fatigue
and asthenia;
hypophosphatemia; and nausea
● It can cause hypocalcemia
● Osteonecrosis of the jaw has
been reported in patients with
denosumab
Bisphosphonates
● Fever, flu-like symptoms, fatigue,
nausea, asthenia, severe
hypophosphatemia
● Osteonecrosis of the jaw
● Worsening of kidney function

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The impact of cancer treatment on bone health
● In addition to bone metastases, some cancer treatments can also
cause bone loss
● Androgen deprivation therapy (prostate)
● Aromatase inhibitors (breast)
● Bone loss can increase risk of fractures
● Fractures can lead to hospitalization, nursing home admissions, and
home care support services
● Currently no drug therapies are specifically approved for cancer
treatment-induced bone loss in Canada

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Tips for maintaining strong bones
● Speak to your doctor before starting a new exercise regimen
● Participate in weight-bearing exercise and strength training
● Brisk walking
● Dancing
● Make your diet count, and include calcium
● Eat low-fat and nonfat dairy products,
leafy greens, and calcium-fortified foods
● Fruits and vegetables provide other
bone-building nutrients
● Avoid falls or injuries

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Tips for maintaining strong bones
● Intake at least 500 mg calcium daily and at least 400 IU vitamin D
daily (except patients with hypercalcemia)
● Limit caffeine to 2-3 cups per day
● Do not smoke
● Take care to avoid falls which can
lead to fracture

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Summary
● Bone is the most common site for cancer to spread in people with
advanced prostate or breast cancer
● Bone pain is often the first sign the cancer has spread
● Bone metastases can be detected with bone scans and other
diagnostic tools
● Bone metastases can lead to serious complications which are
associated with disability, hospitalization and death
● Talk to your doctor about available treatments to reduce the risk of
serious complications

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What else can you do?
● Talk to your doctor about bone
health
● Tell your doctor right away if you
have unexplained pain in your
bones
● Keep active and eat a good diet,
supplement with calcium and
vitamin D

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42. Ask the expert
Questions?

43. Bone Health Awareness Program

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Bone health awareness program objectives
● Raise awareness about the
importance of bone health in
advanced breast and prostate cancer
● Inspire patients to educate others and
take action

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Program overview
Ambassadors Original artwork
Media Events
Website
Awareness with
government

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Program elements
● Men and women who have had
bone metastases OR have an
interest in bone health
● Willing to take action to help
raise awareness and help others
access the treatments they need
Bone health ambassadors

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Program elements
● Local artists engaged in
Vancouver, Calgary & Toronto
● Visual representation of survivor
stories
Original artwork

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Program elements
● Events held in Toronto,
Vancouver, Calgary
● Sunday, June 2: National
Cancer Survivor Day
● Artwork unveiled for
survivors, supporters, groups
Local events

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Program elements
Media
● Generating media coverage of
ambassador stories

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Website: bonehealthincancer.ca

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Program elements
Awareness with government
● Call to action to make bone-targeted
treatment options available to all who
need them
● Awareness that bone metastases as a
concern for cancer survivors
● Advocates creating awareness with
elected and government officials
through letters and meeting

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Public access to bone-targeted treatment
denosumab zoledronic acid
British Columbia Covered (palliative only) Covered (palliative only)
Saskatchewan Covered Covered
Alberta Not covered Not covered
Manitoba Covered Covered
Ontario Covered Covered
Quebec Covered Not covered
Newfoundland and
Labrador
Not covered Covered
New Brunswick Covered Covered
Nova Scotia Covered Covered
Prince Edward
Island
Not covered Not covered
Prostate cancer

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Public access to bone-targeted treatment
Breast cancer
denosumab zoledronic acid pamidrondate clodronate
British Columbia Covered
(palliative only)
Not covered Covered (palliative
or specific criteria)
Covered
(palliative or
specific criteria)
Saskatchewan Not covered Not covered Covered Covered
Alberta Not covered Not covered Covered Covered
Manitoba Not covered Not covered Covered Covered
Ontario Not covered Covered Covered Covered
Quebec Covered Covered Covered Covered
Newfoundland
and Labrador
Not covered Not covered Covered Covered
New Brunswick Not covered Not covered Covered Covered
Nova Scotia Not covered Not covered Covered Covered
Prince Edward
Island
Not covered Not covered Not covered Not covered

54. Will you join us?
Contact:
Jackie Manthorne, President and CEO, CCSN
Phone: 613-898-1871
Email address: jmanthorne@survivornet.ca

55. Questions?

56. Thank you!