Research Sheds Light on Gaps in Care Faced by Patients With MBD From Primary Cancers

R. Lor Randall, MD, FACS

Patients with secondary metastatic involvement in the musculoskeletal system due to primary cancers face high risks of health-related challenges, especially due to metastases or metastatic bone disease (MBD), which can severely impair quality of life, according to a scoping review of supportive care interventions in MBD.¹

To better understand available supportive care interventions for patients with MBD, investigators reviewed published clinical trials, systematic reviews, and meta-analyses to determine the main areas of need for improved research on MBD, according to R. Lor Randall, MD, FACS, who explained that there are few specific controlled trials for skeletal-related events and their effects on social determinants of health, emphasizing the need for further research.

“There’s a dearth in this area of MBD. [This disease is] limited and quite heterogeneous. There’s no routine standardized collection that can enhance treatment evaluation in this cohort of patients,” Randall said.

In an interview with OncLive^®, he shared supportive care interventions for patients with MBD that are being reviewed in ongoing research initiatives, highlighted care interventions that better address the complex needs of patients with MBD based upon this research, and noted the unique burdens and disparities that patients within this patient population face.

Randall serves as the David Linn Endowed Chair for Orthopedic Surgery, the chair of the Department of Orthopedic Surgery, and a professor at the University of California Davis Comprehensive Cancer Center in Sacramento, California.

OncLive: What unique burdens do patients with MBD face when seeking medical intervention?

Randall: Socioeconomically, it’s important to point out that just shy of 20% of the cancer care economy involves musculoskeletal-related events. A given patient with MBD incurs a mean cost of $75,325 [or more] compared with other patients with advanced stage IV cancers that don’t involve the musculoskeletal system, [who incur a mean cost of] $31,382.² [In comparison], patients whose cancers are nonmetastatic [incur costs of approximately] $15,000 to $16,000.

However, the big issue here [is that] the MBD component of advanced cancer is the leading cause of chronic pain. This leads to frailty, sarcopenia, and further complications. It requires surgical interventions, which can lead to their own sets of issues that can [elicit] profound mental and social changes, and it [creates] a vulnerable population who, in some ways, face barriers to accessing the specialized care necessary to intervene.

What research has been done to classify the disparities faced by patients with MBD?

[My colleagues and] I conducted a scoping review of supportive care interventions in MBD to see what was out there, investigating how patients with MBD are being supported. We reviewed 572 publications, and 13 were deemed relevant. Seven were clinical trials, 2 were trial protocols, and 4 were interviews, [in which the subjects] talked through enhanced palliative care, palliative radiotherapy, and alternative therapies.¹ [The trial] end points tended to be in the domains of fatigue, pain, and cancer-related symptoms. Interestingly, there were no end points assessing fractures or complications from the musculoskeletal system.

We [pulled data from] the American College of Surgeons database [to better understand the] information they have around the socioeconomic- and insurance-related disparities in patients with MBD. We found patients with lung cancer who were adversely affected [by MBD] based on race and socioeconomic status. Patients with breast cancer [and BMD] were affected negatively [based on] race and insurance status, and patients with colon cancer in the lowest socioeconomic group also had worse outcomes in terms of patient-reported outcome data.

How did this analysis assess such varying groups of patients, all with 1 common disease from their primary cancer?

[Outcomes from a study using] the Bone Metastases Quality of Life [BOMET-QOL] 10 questionnaire for patients with breast cancer [with bone metastasis] were published in 2019; [this study] evaluated 172 patients.³ [The BOMET-QOL 10 questionnaire includes] general questions like: Do I feel tired? Do I have malaise? Do I avoid activities with my family? [This study] found a significant difference between patients who had MBD vs patients who had metastatic disease that did not involve the musculoskeletal system. [The findings showed that the BOMET-QOL 10 questionnaire] is a burning platform for patients who are facing a lot of issues with their advanced cancer, but for whom their musculoskeletal system is foremost on their mind.

Orthopedic oncologists ought to own the [management of] MBD; we feel passionately about this, and we have forayed into this. We’ve published preliminary data on patient-reported outcomes [of patients with MBD] in the Journal of Surgical Oncology, showing that patients who receive interventions for MBD can return to function within 6 weeks of that intervention and that their pain interference can improve back to baseline relatively quickly.

Since pain can be a relative term, how do you create a generalized pain scale for all patients to respond to?

Some people will stub their toe and scale [their pain] as a 10 out of 10, and some people will break their femur and call [their pain] a 5 out of 10. [Pain] is subjective. The beauty of the patient-reported outcomes data is that [they come from] huge national databases; the variability is removed, and that scales the pain. When [a patient scales their] pain and answers [a questionnaire, their answers] get referenced according to a large population database to control for that variability. What we try to do is normalize what a 5 out of 10 would be for a population based upon statistical population size.

References

1. Simister SK, Bhale R, Cizik AM, et al. Supportive care interventions in metastatic bone disease: scoping review. BMJ Support Palliat Care. 2024;0:1–10. doi:10.1136/spcare-2024-00496
2. Schulman KL, Kohles J. Economic burden of metastatic bone disease in the U.S. Cancer. 2007 Jun 1;109(11):2334-42. doi: 10.1002/cncr.22678
3. Barnadas A, Muñoz M, Margelí M, et al. BOMET-QoL-10 questionnaire for breast cancer patients with bone metastasis: the prospective MABOMET GEICAM study. J Patient Rep Outcomes. 2019;3(1):72. doi:10.1186/s41687-019-0161-y