MASCC’s Bone & Musculoskeletal Study Group (BMSG) represents a natural evolution of the former Bone Study Group, which was founded in the 1990s under the direction of Chair Jean-Jacques Body, MD. The BMSG is currently chaired by Ourania Nicolatou-Galitis, DDS (Greece), who is assisted by Vice-Chairs Beatrice Edwards, MD (USA) and Winston Tan, MD (USA).
Over the years, the Bone Study Group’s members have been committed to research and education in dental and periodontal complications of cancer treatment, osteonecrosis of the jaw, osteoporosis and bone loss prevention, bone health, fractures, and metastases, and treatment of cancer-related bone pain, among other areas.
Members have presented workshops at past MASCC Annual Meetings — a Workshop on Improving Adherence in Elderly Cancer Patients Receiving Oral Agents in 2013 and a Workshop on Educational Challenges: Strategies to Provide Excellent Cancer Care to Underserved Populations in 2015. Study Group members Dr. Ourania Nicolatou-Galitis and Dr. Cesar Migliorati have been instrumental in designing an e-learning module on osteonecrosis of the jaw (available for 1 CME credit from ecancer.org). The module is designed to support the clinical practice of oncologists, dentists, and oral surgeons and focuses on management strategies for ONJ, and it covers ONJ prevention, early diagnosis, and management. The module also addresses the critical question of dental extraction during therapy with bone-targeting agents and the importance of collaboration between dental and oncology professionals, as well as patients.
From 2015-2017, the Bone Study Group undertook a systematic review to address three specific clinical research issues regarding osteonecrosis of the jaw (ONJ):
- when to do or not do dental extraction in patients receiving bone-targeting agents (presented as a proffered paper at the 2018 Annual Meeting);
- how to manage ONJ (presented as an e-poster at the 2018 Annual Meeting);
- clinical characteristics of ONJ in cancer patients receiving medications without known antiresorptive properties, for which the term non-antiresorptives was proposed (presented as an e-poster at the 2018 and submitted to Supportive Care in Cancer).
A total of 23 Bone Study Group members participated in this project and were assigned to one of three collaborative groups. The review concluded that (1) dental extractions are not always contraindicated in such patients, (2) surgical resection may be a better intervention to achieve complete mucosal healing at all stages of ONJ, and (3) ONJ related to non-antiresorptives may have a better prognosis compared to that related to bone-targeting agents. However, delays in diagnosis were noted. This work clarified the need for updating the classification and staging of ONJ for all classes of medications and the need for educational programs to increase knowledge about ONJ. Ways to meet these needs include development of educational materials for oncologists, dentists, and patients, as well as training in early recognition and management of ONJ. Study Group members are also preparing a manuscript regarding the systematic review of the literature on management of ONJ in cancer patients.
This year, the Study Group expanded its sphere of interests and activities to advance the understanding of bone and musculoskeletal health in cancer patients. The Group is conducting research and plans to develop guidelines for the prevention and treatment of skeletal complications associated with cancer and its treatments — complications that can affect quality of life and shorten survival. The BMSG seeks to identify new methods for preventing, identifying, and treating fractures and bone metastases and plans to establish guidelines for the management of skeletal complications (such as fractures and osteonecrosis of the jaw). It also serves as a resource for multicenter clinical trials and aims to improve patients’ knowledge of bone health.
In 2017, BMSG members at the MD Anderson Cancer Center in Houston, Texas, reported that 82% of older cancer patients have bone health issues (osteopenia and osteoporosis), making them the most common conditions in older cancer patients. Further, more than 10% of these patients subsequently sustained fractures in the next 12 months. The fracture rate was found to be 2.8 times higher than those observed in national databases. This study was published in the MASCC journal, Supportive Care in Cancer.1 Vitamin D is also a focus of investigation, as more than half of older adults studied had vitamin D insufficiency. This is important, since epidemiologic studies have associated a higher vitamin D status with improved overall survival in breast, prostate, and colorectal cancer. Currently, the BMSG is working on a review paper on the relevance of Vitamin D in supportive care.
Members of the BMSG have conducted epidemiological studies in Manitoba, Canada, where 122,000 patients with cancer (aged 40 to 89) were followed for 15 years. These patients presented a dramatic increase in the risk of fractures starting at the time of cancer diagnosis. Also, the risk of fractures remained elevated for more than 10 years. Other studies will assess whether cancer survivors who suffer an osteoporotic fracture are identified and treated for osteoporosis, and whether fractures in cancer survivors increase disability and mortality in this population. The (US) National Health and Nutrition Survey (NHANES 2007-2010) is a national database. The BMSG is analyzing NHANES date concerning the relation between fractures in cancer survivors and overall survival. Finally, the BMSG plans to propose research (2018-2019) to review the largest national US database for skeletal complications in cancer patients, including fractures and medication-related osteonecrosis of the jaw. This analysis will evaluate complications in cancer survivors such as functional decline, increase in hospitalizations, disability, mortality, and effects on healthcare expenditures.
Topics of recent publications by BMSG members include bone management in hematologic stem cell transplant recipients, effects of high-dose calcitriol and exercise on bone metabolism in cancer survivors, fractures and risk factors for falls in older cancer patients, ONJ in patients receiving bone-targeting agents, bone metastases and skeletal health of cancer survivors, and the development of drugs for cancer-related bone pain, among others. (See BMSG Publications for a list of recent papers.) Raising awareness of bone health consequences in the supportive care community could lead to international studies and improved medical and oral care. Another aim of the BMSG is to develop MASCC bone health and Vitamin D guidelines. BMSG members are currently taking part in updating bone health guidelines for the American Society of Clinical Oncology (2018).
The BMSG leaders invite all MASCC members to consider joining this new, expanded Study Group and to participate in new research on skeletal complications. The leaders plan to coordinate with the American Society of Clinical Oncology (ASCO) the American Society of Bone and Mineral Research (ASBMR), and the International Society of Clinical Densitometry (ISCD), among others, to enrich the supportive care field. Anyone who is interested or has research interests to share should contact the Study Group leaders or Study Group Coordinator Leslie Johnson.
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1Edwards BJ, Sun M, Zhang X, Holmes HM, Song J, Khalil P, et al. Fractures Frequently Occur in Older Cancer Patients: The MD Anderson Cancer Center Experience. Support Care Cancer. 2018 May;26(5):1561-1568.
Biographical Notes
Jean-Jacques Body, MD, PhD, is Honorary Head of the Department of Medicine at University Hospital Brugmann in Brussels and is a Professor of Medicine at the Université LIbre de Bruxelles. He was previously Head of the Supportive Care Clinic at Institute Bordet (Cancer Centre of the University of Brussels). Dr. Body is a member of MASCC’s Bone & Musculoskeletal Study Group.
Ourania Nicolatou-Galitis, DDS, MSc, DrDent, is an oral oncologist, Professor at the Dental School, National and Kapodistrian University of Athens, in Athens, Greece. She is a Founder and current President of the Hellenic Society of Oral Oncology. Dr. Nicolatou-Galitis has been a MASCC and ISOO member for more than a decade. She has served as President of ISOO (2015-2017) and as Chair of the Bone Study Group since 2015. In addition to chairing the BMSG, Dr. Nicolatou-Galitis is a member of MASCC Study Groups on Mucositis and Oral Care.
Beatrice Edwards, MD, MHP is a Geriatrician and Palliative Care Physician, and Associate Professor at the University of Texas, Dell Medical School in Austin, Texas. Her research focuses on epidemiology of bone health and the prevention of disability in older cancer patients. Dr. Edwards has been a member of MASCC for the past 5 years. In addition to the BMSG, she belongs to MASCC Study Groups on Geriatrics and Nutrition & Cachexia.
Winston Tan, MD, is an oncologist at the Mayo Clinic in Jacksonville, Florida, USA, with a particular interest in translating basic science into treatment options for people with cancer. Besides the BMSG, Dr. Tan is a member of the Education Study Group and the Rehabilitation, Survivorship, and Quality of Life Study Group.
