From the Guidelines
Bone pain from metastatic cancer should be managed with a combination of medications and therapies, prioritizing bisphosphonates like zoledronic acid (4mg IV every 3-4 weeks) or denosumab (120mg subcutaneously every 4 weeks) to target bone pain from metastases by inhibiting bone resorption, as recommended by the most recent guidelines 1.
Management of Bone Metastases
The management of bone metastases involves a multidisciplinary approach, including the use of bone-modifying agents, radiation therapy, and pain management.
- Bone-modifying agents, such as zoledronic acid or denosumab, are recommended for patients with bone metastases to prevent skeletal-related events (SREs) and reduce bone pain 1.
- Radiation therapy is highly effective for localized bone pain, typically delivered in 1-10 sessions, and can be used in conjunction with bone-modifying agents 1.
- Pain management is crucial and should be assessed using a scale of 0-10, with treatment adjusted based on response and side effects.
Treatment Options
Treatment options for bone pain from metastatic cancer include:
- Analgesics, such as acetaminophen (500-1000mg every 6 hours) and/or NSAIDs like ibuprofen (400-800mg every 6-8 hours), for mild pain.
- Opioids, such as morphine (starting at 5-15mg every 4 hours) or oxycodone (5-10mg every 4-6 hours), for moderate to severe pain, titrating as needed.
- Adjuvant medications, including gabapentin (300mg daily, increasing gradually to 300-600mg three times daily) or pregabalin (75mg twice daily, increasing as needed), to help with neuropathic components.
Recent Guidelines
Recent guidelines from the European Society for Medical Oncology (ESMO) recommend the use of bone-modifying agents, such as zoledronic acid or denosumab, in patients with bone metastases from solid tumors, including breast, lung, and prostate cancer 1. The National Comprehensive Cancer Network (NCCN) also recommends the use of bone-modifying agents in patients with bone metastases from breast cancer, with expected survival of more than 3 months 1.
Quality of Life
The goal of treatment is to improve quality of life by reducing bone pain, preventing SREs, and maintaining functional independence. Proper pain assessment and management are essential to achieve this goal, and treatment should be adjusted based on response and side effects. By prioritizing bisphosphonates and following recent guidelines, patients with bone metastases can experience improved quality of life and reduced morbidity and mortality.
From the FDA Drug Label
The distribution of osteolytic bone metastases in these cancers is predominantly in the axial skeleton, particularly the spine, pelvis, and ribs, rather than the appendicular skeleton, although lesions in the proximal femur and humerus are not uncommon These bone changes can result in patients having evidence of osteolytic skeletal destruction leading to severe bone pain that requires either radiation therapy or narcotic analgesics (or both) for symptomatic relief. In addition, decreases in pain scores from baseline occurred at the last measurement for those pamidronate disodium patients with pain at baseline (P=.026) but not in the placebo group.
Pamidronate disodium may help reduce bone pain associated with osteolytic bone metastases.
- Key benefits of pamidronate disodium include:
- Decreases in pain scores
- Reduction in skeletal-related events (SREs)
- Delayed time to first SRE occurrence 2
From the Research
Bone Metastases and Pain
- Bone metastases are a common cause of pain in patients with advanced cancer, with two-thirds of patients experiencing pain worldwide 3
- Pain from bone metastases can significantly reduce patients' quality of life and is often underreported and poorly managed 4, 5
Treatment Options for Bone Metastases Pain
- Treatment options for cancer pain due to bone metastases include:
- Therapies including palliative radiation and opioids have strong evidence supporting their efficacy in treating cancer pain due to bone metastases 3
Management of Bone Metastases Pain
- The World Health Organization analgesic ladder and the Analgesic Quantification Algorithm are used to evaluate analgesic use in patients with bone metastases 4
- Bone-targeting agents, such as denosumab or bisphosphonates, can prevent skeletal complications and improve pain outcomes in patients with metastatic bone disease 4
- Early intervention with bone-targeting agents and opioids can improve pain outcomes and reduce the risk of increasing pain severity 4, 5