Interview with Michał Kunkiel, MD, PhD, Department of Breast Cancer and Reconstructive Surgery, National Institute of Oncology Maria Skłodowskiej-Curie, National Research Institute in Warsaw
Journalists for Health Association: What is the epidemiology of malignant neoplasms in Poland?
Michał Kunkiel, MD, PhD: The number of cases of malignant neoplasms in Poland and in the world is constantly growing. Confirmed risk factors are: unhealthy lifestyle, which includes poor diet, alcohol abuse, smoking, abnormal body weight, excessive exposure to sunlight, as well as genetics and increasing age (aging population).
The ongoing coronavirus pandemic causes additional problems – fewer patients report for oncological diagnostics. Less reporting to doctors and interest in screening tests translates into the diagnosis of a neoplastic disease, often symptomatic at a higher stage of advancement, i.e. where we are dealing with metastases, for example, to the lymph nodes, liver, lungs or bones.
What are bone metastases?
We define them as infiltration of neoplastic cells on the bone structure, causing its pathological reconstruction, weakening and an increased risk of fractures. The frequency of bone metastases differs depending on the organ localization of the primary tumor disease: in men, bone metastases are more common in the prostate gland, and in women – when breast cancer is diagnosed. However, it should be emphasized that virtually every malignant tumor can metastasize to the bone.
How are bone metastases formed?
The manner in which neoplastic disease is metastatic is complicated. For the sake of simplicity, we can assume that if the neoplastic mass in the primary focus is untreated or not treated optimally, over the course of therapy, clones of neoplastic cells resistant to the applied oncological drugs may emerge. Such cells separate from the primary focus and through the blood and lymphatic vessels reach other locations in the body, e.g. the skeletal system.
What are their symptoms?
The most common symptom is persistent bone pain that is independent of the time of day and not responding to background pain relievers or anti-inflammatory drugs. We make the diagnosis on the basis of imaging tests: X-ray examination, computed tomography with contrast or bone scintigraphy.
What is the greatest risk for a patient with known bone metastases?
We are most concerned about the so-called skeletal-related events (SRE). These are pathological fractures (e.g. of the femoral neck), pressure on the spinal cord by bone fragments, which may cause, e.g. limb paresis, and the necessity to apply palliative radiotherapy to a given bone area. Bone events also include hypercalcemia, i.e. excessive calcium levels caused by the release of this element from damaged bones into the blood. Hypercalcaemia can be life-threatening.
How are bone metastases treated?
It should be emphasized that oncological treatment of the underlying disease is the most important, i.e. the primary disease, regardless of its location. When it comes to bone metastases, we use local surgical treatment (surgery), radiation treatment (radiotherapy) and symptomatic therapy, i.e. the administration of strong painkillers from the opioid group. In addition, we are introducing – no less important – treatments that support the action of basic medications, preventing or delaying skeletal events. This is the main task of adjuvants: to prevent skeletal events from occurring despite existing bone metastases, or to extend the time until they occur. Once we have diagnosed a skeletal event, we should continue with supportive care to maximize the time until the next skeletal event occurs. Modern oncology today is based on treatment with the use of targeted drugs, which are increasingly replacing or superseding classic chemotherapy. However, it should be remembered that the goal of oncological treatment is also to reduce the symptoms of neoplastic disease and improve the patient’s quality of life. We can achieve this thanks to the implementation of modern supportive treatment accompanying anti-cancer therapy.
What supportive drugs are currently used to treat bone metastases?
The drugs used in adjunctive therapy are: zoledronic acid (a chemical compound from the bisphosphonate group) and the biological drug denosumab monoclonal antibody. The biological drug is much more effective in reducing pain and better protecting patients against skeletal events, as well as significantly longer time to the occurrence of another such event compared to zoledronic acid. This is due to, inter alia, by a targeted mechanism of action on a specific receptor located on bone cells changed by the neoplastic process. This drug additionally strengthens the bone structure by reducing the inflammation that is on the way, reducing the production of inflammatory proteins triggered by cancer cells. To sum up: denosumab significantly reduces the activity of cells responsible for bone destruction. Zoledronic acid is reimbursed and denosumab is not.
Would the reimbursement of denosumab significantly improve the situation of patients?
It should be emphasized that the diagnosis of distant metastases, regardless of their location, is a difficult situation for the patient, his family and the treatment team. However, taking into account the type of metastases, the involvement of the skeletal system has many unfavorable parameters. The patient (especially with diagnosed skeletal events) loses his mobility, and consequently his everyday social functions deteriorate, which is often associated with abandoning his current professional activity, as well as with a significant deterioration in the quality of life. Compared to other very expensive oncological therapies, the cost of the aforementioned adjunctive treatment of bone metastases and bone events is relatively low. It should also be remembered that in patients with pathological fractures, emergency orthopedic procedures are often complicated, it is difficult to perform anastomosis, so the patient often stays in orthopedic wards for many weeks. This hinders proper oncological care, an immobilized patient cannot visit his oncology center for continued anticancer treatment, which in turn increases the risk of dying from cancer. That is why all of us – doctors, patients and the media – should strive for wider availability of this supportive therapy.
What can be done to reduce the risk of cancer?
In primary prevention, a healthy lifestyle and regular screening tests are important, as well as contacting a doctor when something bothers us, e.g. persistent fever, hoarseness, thickening of the skin or unintentional, progressive weight loss. When it comes to the situation where bone metastases already exist, the most important thing is to prevent skeletal events. Therefore, in addition to the basic oncological treatment of cancer, it is very important – even necessary – to conduct supportive treatment based on modern drugs in accordance with international guidelines.
Authorized press interview prepared by the Journalists for Health Association in connection with a lecture by Dr. Michał Kunkiel, PhD, during the 19th National Conference “Polish Woman in Europe”, organized under the slogan Not only COVID-XNUMX! Medicine in the era of the coronavirus pandemic.