16001110 Overview of Cancer-Related Vertebral Compression Fractures

16001110

Overview of Cancer-Related Vertebral Compression

Fractures

16001110

Objectives

Describe Vertebral Compression Fractures (VCF)

Describe the scope of the problem in patients with cancer

Review evidence-based interventions

16001110

Wedge Biconcave Crush

1. Genant HK et al. J Bone Miner Res. 1993;8:1137–1148.

Vertebral Compression Fractures

VCFs are fractures of the bones of the spinal column Occur when the vertebral body fractures or collapses because the

bone is too weak Weakness can be caused by primary bone cancer, metastatic bone

disease, and cancer- or chemotherapy- related osteoporosis

16001110

Cancer-Related VCFs

An estimated 75K-100K cancer-induced VCFs occur annually in the U.S. Stage IV breast and lung

cancers All stages of Multiple

Myeloma Stages III and IV of

prostate cancer

Additional data calculations on file, Medtronic Spine LLC. Compiled from the following articles: 1.Hortobagy et al. NEJM. 1996;335:1785-1791.2.Berenson et al. NEJM. 1996;334:488-493.3.Brincker et al. Brit J Haematol. 1998;101:280-286.4.McCloskey et al. Brit J Haematol. 1998;100:317-325.5.Melton et al. J Bone Miner Res. 2005 ;20:487-493.6.Djulbegovic et al. Cochrane Database Syst Rev. 2002; 4, CD003188:1-32.7.Berruti et al. J Urol. 2000; 164:1248-1253.8.Diamond et al. J Urol, 2004;172:529-532.

16001110

Metastatic Bone Disease

16001110

Regulation of Bone Metabolism

1. Roodman. NEJM. 2004;350:1655-1664. Images used with permission from NEJM.

16001110

Metastatic Bone DiseaseEpidemiology

Definition: Tumors in bone arising from distant, non-bone sources.

Most skeletal cancers are metastatic rather than primary1

30-70% of the roughly 563,700 people who die annually of all cancers have bone metastasis.1

Patients with cancer are at elevated risk for osteoporosis and fractures because of both disease and treatment1

1. Coleman. Cancer Treat Rev. 2001;27:165-176.

16001110

Metastatic Bone DiseaseLesion Types

Osteoblastic Increased bone density Does not change bone strength

but decrease bone stiffness Common in patients with prostate

cancer

1. Lieberman et al. ClinOrthopaed Rel Res. 2003;415S:S176-186.2. Patel, DeGroot. Ortho J. 2001;24:612-7.

16001110

Metastatic Bone DiseaseLesion Types

Osteolytic Decrease both bone strength and

density Common in patients with

metastatic cancer and multiple myeloma 70% of multiple myeloma patients

present with osteolytic involvement of the spine1

Higher risk for fracture than blastic lesions2

1. Lieberman et al. Clin Orthopaed Rel Res. 2003;415S:S176-186.2. Patel, DeGroot. Ortho J. 2001;24:612-617.

16001110

Metastatic Bone DiseaseRadiographic Appearance of

Skeletal Metastases

Breast Usually Osteolytic or Mixed

Prostate Usually Osteoblastic

Lung Usually Osteolytic

Thyroid Usually Osteolytic

1. Manoso, Healey. In: Cancer: Principles and Practice of Oncology. 7th ed. 2005:2368-2380.

16001110

Metastatic Bone DiseasePrognosis

Variable survival Many live for years with bony

disease Patients live longer with bone

metastases than with both bone metastases and pulmonary metastases1

Potential for improved QoL Patients with longer median

survival will typically require treatment for skeletal complications

Disease TypeMedian Survival (months)

Multiple Myeloma2 36 – 60+

Breast1 19*

Lung1 3*

Thyroid1 19*

* After disease metastasizes to bone

1. Manoso, Healey. In: Cancer: Principles and Practice of Oncology. 7th ed. 2005:2368-2380.2. Ludwig et al. Blood. 2008 Feb 11. [Epub ahead of print]

16001110

Metastatic Bone DiseaseDiagnostic Tools

Imaging X-ray and/or skeletal survey Computed Tomography (CT) Bone Scan Positron Emission Tomography (PET) Magnetic Resonance Imaging (MRI)

Blood Tests Calcium level, Alkaline Phosphatase, etc.

Needle Bone Biopsy1. Manoso, Healey. In: Cancer: Principles and Practice of Oncology. 7th ed. 2005:2368-2380.

16001110

Metastatic Bone DiseaseTreatment Goals

Control pain and symptomsEradicate or reduce tumor when primary

tumors are involved Prevent neurologic complications Treat pathologic fractures and prevent

recurrent fracture

1. American Cancer Society. How is Bone Metastasis Treated? 2007. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_How_Is_Bone_Metastasis_Treated_66.asp?sitearea=

16001110

Surgery Open and minimally invasive

Radiation therapyRadioisotopes

Strontium Samarium Sm-153 lexidronam [Quadramet®, Cytogen]

Systemic treatment Supportive therapy

Bisphosphonates Analgesics

Metastatic Bone DiseaseAvailable Treatments1,2

1. How is Bone Metastasis Treated? 2007. Available at: http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_How_Is_Bone_Metastasis_Treated_66.asp?sitearea=

2. Manoso, Healey. In: Cancer: Principles and Practice of Oncology. 7th ed. 2005:2368-2380.

16001110

Metastatic Bone DiseaseClinical Sequelae

Bone damage leads to bone painPathologic fracture

Vertebral compression fractures (VCFs) Long bones

Spinal cord compressionHypercalcemia

1. Roodman. NEJM. 2004;350:1655-1664.

16001110

Vertebral Compression Fractures

16001110

Signs of Vertebral Compression Fractures

Acute Event Sudden onset of back pain

with little or no trauma Point tenderness Girdle/belt/band-like pain Muscle spasms

Chronic Manifestation(s) Loss of height Spinal deformity - kyphosis

Protuberant abdomen

Compiled from the following articles: 1. Coleman. Cancer. 1997;80:1588-1594.2. Lavelle et al. Med Clin N Am. 2007;91:299-314.

16001110

Biomechanics of VCF

Knees bend, pelvis tilts forward to counteract forward bendingChange in balance1

Decrease in gait velocity1

Increased muscle fatigue1

Increased risk of falls and additional fractures2,3

1. Gold, Lee, Tresolini. Working with patients to prevent, treat and manage osteoporosis, 2001.2. Ross et al. Annals Int Med, 1991; 114(11):919-23.3. Myers, Wilson. Spine. 1997;22(24 Suppl):25S-31S.

16001110

Compiled from the following articles: 1. Gold , Silverman The Downward Spiral of Vertebral Osteoporosis: Consequences. Designated by Cedar Sinai Medical Center Press,

2003.2. Podichetty. J Musculoskel Med. 2004;21:372-378.

Radiculopathy Spinal cord

compression

Neurological Consequences

Compression of the abdominal contents

Early satiety, weight loss Kyphosis – curved back Decreased lung function Increased risk of death from

lung disease Spinal instability Risk of more fractures

Biomechanical Consequences

Consequences of Untreated VCF

16001110

Consequences …

Chronic pain Increased

dependence Decreased ability

for activities of daily living

Partial to complete immobility

Functional Consequences

Depression or clinical anxiety or both

Sleep disorder

Psychological Consequences

Compiled from the following articles: 1. Gold, Silverman . The Downward Spiral of Vertebral Osteoporosis: Consequences. Designated by Cedar Sinai Medical Center Press, 2003.2. Podichetty et al. J Musculoskel Med. 2004;21:372-378.3. Lavelle, Carl, Lavelle, Khaleel. Med Clin N Am. 2007:91:299-314.4. Gold. Rheum Dis Clin North Am. 2001; 27:255-62.

Social Consequences

150,000 annual hospital admissions

Higher medical costs

16001110

Future Fracture Risk

After first VCF, risk of subsequent VCF is increased:5-fold after first VCF12-fold after 2 or more VCFs75-fold after 2 or more VCFs

and low bone mass (below the 33rd percentile)

1. Ross et al. Annals Int Med. 1991; 114(11):919-23

16001110

Tumor-Related VCFsSurgical Management

Medical Management, Radiation to the tumor Open Surgical Procedures

Vertebral column reconstruction Oncology patients are generally poor candidates for

open surgery due to soft bone/tumor mass and co-morbidities

Minimally Invasive Procedures Balloon kyphoplasty Vertebroplasty

Compiled from the following articles:

1. Yeh, Berenson. Clin Cancer Res. 2006, 10: 6279-6284.2. Lieberman, Reinhardt. Clin Orthop Relat Res. 2003;(415 Suppl):S176-186.3. Lavelle, Carl, Cavelle, Khaleel. Med Clin N Am. 2007;91:299-314.4. Pateder, Khanna, Lieberman. Orthop Clin N Am. 2007;38:409-418.

16001110

Percutaneous Vertebroplasty

Augmentation of vertebral compression fractures with polymethylmethacrylate

Uses pressure to introduce the materialUsed successfully to treat painDoes not attempt to restore the height of the

collapsed vertebral bodyCement leakage and extravasation can be

problems

Compiled from the following articles: 1. Lieberman, Reinhardt. Clin Orthop Relat Res. 2003;(415 Suppl):S176-186.2. Lavelle, Carl, Cavelle, Khaleel. Med Clin N Am. 2007;91:299-314.3. Pateder, Khanna, Lieberman. Orthop Clin N Am. 2007;38:409-418.

16001110

Tumor-Related VCFsVertebroplasty vs. Balloon Kyphoplasty

Vertebroplasty Balloon Kyphoplasty

Fracture Reduction

Postural Reduction Inflatable Bone Tamp (IBT)

Cavity Creation

-- Inflatable Bone Tamp

Cement Injection

High-pressure injection into interstices

Low-pressure fill into cavity created by IBT


16001110

Tumor-Related VCFsBalloon Kyphoplasty

Aimed at Stabilizing the Fracture and Correcting Spinal Deformity caused by VCFs

•Indicated for the treatment of pathological fractures of the vertebral body due to osteoporosis, cancer, or benign lesions using a balloon kyphoplasty procedure.

KYPHON® HV-R™ Bone Cement. FDA Premarket Notification Summary. Available at: http://www.fda.gov/cdrh/pdf4/k041584.pdf

16001110

Tumor-Related VCFsBalloon Kyphoplasty Procedure

Minimally invasive Bilateral, 1 cm incisions

Typically one hour per treated fracture General or local anesthesia (supplemented

by conscious sedation) May require an overnight hospital stay


16001110

Balloon Kyphoplasty

16001110

Vertebral Augmentation : Clinical Outcomes for Oncology Patients

16001110

Balloon Kyphoplasty and Vertebroplasty for Vertebral Compression Fractures: A

Comparative Systematic Review of Efficacy and Safety

Taylor, Taylor, Fritzell. Spine. 2006;31:2747–2755

16001110

Meta-Analysis of Complications

Total Procedure-Related

Complications

Cement-Related Complications

Access-Related Complications

Non-Device- Related

Complications

Balloon KyphoplastyN = 1947 patients

14(0.7%)

3(0.2%)

4(0.2%)

7(0.4%)

VertebroplastyN = 6808 patients

199(2.9%)

132(1.9%)

28(0.4%)

39(0.6%)

p-value 0.0002* <0.0001* 0.3791 0.8781

*Balloon kyphoplasty has statistically significant lower complication rates compared to vertebroplasty

Data on file, Medtronic Spine LLC.

16001110

Taylor Study* Cement Leakage Results

p < 0.0001BK: 90/1111 = 8%VP: 614/1551 = 40%

(p-value not reported)BK: 0/1094 = 0%VP: 8/275 = 3%

Taylor, Taylor, Fritzell. Spine. 2006;31:2747–2755 – See Table 6.*Includes fracture of all etiologies. BK = balloon kyphoplasty. VP = vertebroplasty.

16001110

Taylor Study Adverse Events

BK: 1/291 = 0.3%VP: 15/803 = 1.8%

BK: 0/195 = 0%VP: 3/631 = 0.5%

BK: 1/322 = 0.3%VP: 32/1100 = 2.5%

Taylor, Taylor, Fritzell. Spine. 2006;31:2747–2755 – See Table 6.

16001110

Patient IdentificationPatient cancer diagnosis

Metastatic breast cancer, lung cancer, prostate cancer, and others

Multiple myelomaPatient demographics

Age, gender, type of cancer, comorbiditiesPatient self-report of symptoms

Sudden pain in the back Persistent back pain with developing other signs

Kyphosis, incontinence, respiratory difficulties, balance problems

Identification of Fractures

16001110

Patient educationPain is NOT a necessary part of the cancer

experienceVCF treatment options, including balloon

kyphoplastyAdvocacy

Awareness and referrals Where can the procedure be done? Who is qualified to perform it?

Patient Education

16001110

Barriers to useReimbursement

What is your patient’s insurance coverage?Comfort level of spine physician/interventionalist

Does the specialist have a full understanding of balloon kyphoplasty?

Has he/she performed it multiple times? Can she/he refer the patient to a qualified practitioner?

Barriers to Use

16001110

Monitoring post-procedure Immediate post-surgical monitoring usually done

by surgical staffLonger term follow-up may be needed

Monitor symptoms, status changes PCP be the first to note new symptoms, new fractures

Considerations

16001110

Balloon Kyphoplasty Case Study

Patient: 76 YO FemaleDiagnosis: Metastatic Lung CancerFracture Reduced: T8, 8 weeks old

Courtesy of Henry Small, M.D., Houston, TX

16001110

Indications for UseNot Investigational – Indicated for Cancer-Related Fractures

KYPHON® HV-R™ Bone Cement was originally cleared for marketing un the United States in 2004 for treatment of pathologic VCFs using a balloon kyphoplasty procedure

Indicated for the treatment of pathological fractures of the vertebral body due to osteoporosis, cancer, or benign lesions using a balloon kyphoplasty procedure. Cancer includes multiple myeloma and metastatic lesions, including those arising from breast or lung cancer, or lymphoma. Benign lesions include hemangioma and giant cell tumor.

KYPHON® Inflatable Bone Tamps were originally cleared for

marketing in the United States in 1998

Intended to be used as conventional bone tamps for the reduction of fractures and/or creation of a void in cancellous bone in the spine (including use during balloon kyphoplasty with KYPHON®

HV-R™ Bone Cement), hand, tibia, radius and calcaneus.

16001110

Risk Statement

Although the complication rate with KYPHON® Balloon Kyphoplasty has been demonstrated to be low, as with most surgical procedures, there are risks associated with the procedure, including serious complications. For complete information regarding indications for use, contraindications, warnings, precautions, adverse events, and methods of use, please reference the devices’ Instructions for Use.

16001110

Summary

VCFs can be significant problems for patients with cancer Pain Functional impairment

Providers can identify and refer patients for appropriate therapy, including balloon kyphoplasty

Balloon kyphoplasty can provide significant pain relief, restore vertebral body height, and improve function for many patients with cancer

16001110

Disclosures The physicians referenced may be paid consultants of, and

research cited may have been funded partially or in whole by, Medtronic.

Although the complication rate with Balloon Kyphoplasty has been demonstrated to be low, as with most surgical procedures, there are risks associated with Balloon Kyphoplasty, including serious complications. For complete information regarding indications for use, contraindications, warnings, precautions, adverse events and methods of use, please reference the devices’ Instructions for Use.

For further information, please call Medtronic at 1-877-459-7466 and/or visit Medtronic’s web site www.kyphon.com.

KYPHON is a registered trademark, and HV-R is a trademark of Medtronic.

© 2008 Medtronic Spine LLC. All rights reserved. 16001110

16001110

Questions and Discussion

16001110

References 1. American Cancer Society. How is Bone Metastasis Treated? 2007. Available at:

http://www.cancer.org/docroot/CRI/content/CRI_2_4_4X_How_Is_Bone_Metastasis_Treated_66.asp?sitearea=2. Andre F, Slimane K, Bachelot T, et al. Breast cancer with synchronous metastases: trends in survival during a 14-year period. J

of Clin Oncol. 2004;22:3302-3308.3. Berenson JR, Lichtenstein A, Porter L, et al. Efficacy of pamidronate in reducing skeletal events in patients with advanced

multiple myeloma. NEJM. 1996;334:488-493.4. Berruti A, Dogliotti L, Bitossi R, et al. Incidence of skeletal complications in patients with bone metastatic prostate cancer and

hormone refractory disease. J. Urol. 2000;164: 1248-1253.5. Brincker H, Westin J, Abildgaard N, et al. Failure of oral pamidronate to reduce skeletal morbidity in multiple myeloma: a double-

blind placebo controlled trial. Brit J Haematol. 1998;101:280-286.6. Body J. Effectiveness and cost of bisphosphonate therapy in tumor bone disease. Cancer. 2003;Suppl 97:859-865. 7. Clinical Trials. Gov. 2008. Identifier: NCT00211237. Available at http://www.clinicaltrials.gov/ct2/show/NCT00211237?

term=kyphoplasty&rank=28. Coleman RE. Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev.

2001;27:165-176.9. Coleman RE. Uses and abuses of bisphosphonates. Ann Oncol. 2000;11:179-184. 10. Coleman RE. Bisphosphonates: clinical experience. Oncologist. 2004;9(suppl 4):14-27.11. Compression Fractures. 2006. Available at http://health.nytimes.com/health/guides/disease/compression-fractures-of-the-back/

overview.html12. Diamond TH, Bucci J, Kersley JH, et al. Osteoporosis and spinal fractures in men with prostate cancer: risk factors and effects of

androgen deprivation therapy. J. Urol. 2004;172: 529-532.13. Djulbegovic B, Wheatley K, Ross J, et al. Bisphosphonates in multiple myeloma (Review). Cochrane Database Sys Rev. 2002;

Issue 4. Art. No.: CD003188:1-32.14. Durie B. Understanding balloon kyphoplasty and myeloma-induced vertebral compression fractures. International Myeloma

Foundation. 2006; June:16. 15. Falkmer U, Jarhult J, Wersall P, Cavallin-Shahl E. A systematic overview of radiation therapy effects in skeletal metastases. Acta

Oncologica. 2003;42:620-633. 16. Fourney D, Schomer DF, Nader R, et al. Percutaneous vertebroplasty and kyphoplasty for painful vertebral body fractures in

cancer patients. J Neurosurg (Spine 1). 2003;98:21-30. 17. Genant HK , Wu CY, vanKuijk K, Nevitt MC. Vertebral fracture assessment using a semiquantitative technique. J Bone Miner

Res. 1993;8:1137–1148.18. Gold DT, Lee LS, Tresolini CP, eds. Working with patients to prevent, treat and manage osteoporosis: a curriculum guide for the

health professions. 3rd ed. Durham, NC: Center for the Study of Aging and Human Development, Duke University; 2001.19. Gold DT. The nonskeletal consequencesof osteoporotic fractures. Psychologicand social outcomes. Rheum Dis ClinNorth Am.

2001; 27:255-62.20. Gold DT, Silverman SL. The Downward Spiral of Vertebral Osteoporosis: Consequences. Designated by Cedar Sinai Medical

Center Press, 2003.21. Hadjipavlou AG, Tzermiadianos MN, Katonis PG, Szpalski M, et al. Percutaneous vertebroplasty and balloon kyphoplasty for the

treatment of osteoporotic vertebral compression fractures and osteolytic tumours. J. Bone Joint Surg Br. 2005;87:1595-1604.

16001110

References (continued)22. Hortobagyi GN, Theriault RL, Porter L, et al. Efficacy of pamidronate in reducing skeletal complications in patients with breast

cancer and lytic bone metastases. NEJM. 1996;335:1785-1791.23. Hortobagyi GN, Theriault RL, Lipton A, et al. Long-term prevention of skeletal complications of metastatic breast cancer with

pamidronate. J Clin Oncol. 1998;16:2038-2044.24. Hulme PA, Krebs J, Ferguson SJ, Berlemann U, et al. Vertebroplasty and kyphoplasty: a systematic review of 69 clinical studies.

Spine. 2006;31:1983-2001.25. Janjan N. Bone metastases: approaches to management. Sem Oncol. 2001;28:28-34.26. Jemal A, Siegel R, Ward E, Murray T, Xu J, Thun MJ. Cancer statistics, 2007. CA Cancer J Clin. 2007;57:43-66.27. Kyphon Data on File. Literature review conducted as of July, 2004, Kyphon Prospective Study.28. KYPHON® HV-R™ Bone Cement. FDA Premarket Notification Summary. 2004. Available at:

http://www.fda.gov/cdrh/pdf4/k041584.pdf29. Lane J, Hong R, Koob J, et al. (2004) Kyphoplasty enhances function and structural alignment in multiple myeloma. Clin Orthop

Rel Res. 2004;426:49-53.30. Lavelle W, Carl A, Lavelle ED, Khaleel MA. Vertebroplasty and kyphoplasty. Med Clin N Am. 2007:91:299-314.31. Lieberman I, Reinhardt MK. Vertebroplasty and kyphoplasty for osteolytic vertebral collapse. Clin Orthop Rel Res.

2003;415(S):176-186.32. Lipton A, Small E, Saad F, et al. The new bisphosphonate, Zometa (zoledronic acid), decreases skeletal complications in both

osteolytic and osteoblastic lesions: a comparison to pamidronate. Cancer Invest. 2002;20 Suppl. 2:45-54.33. Ludwig Hm Durie BG, Bolejack V, et al. Myeloma in patients under age 50 presents with more favorable features and shows

better survival: an analysis of 10,549 patients from the International Myeloma Working Group. Blood. 2008 Feb 11. [Epub ahead of print]

34. McCloskey EV, Guest JF, Kanis JA. The clinical and cost considerations of bisphosphonates in preventing bone complications in patients with metastatic breast cancer or multiple myeloma. Drugs. 2001;61:1253-1274.

35. McCloskey EV, MacLennan JC, Drayson MT, et al. (1998) A randomized trial of the effect of clodronate on skeletal morbidity in multiple myeloma. Br J. Haematol. 1998;100:317-325.

36. Melton LJ 3d, Kyle RA, Achenbach SJ, et al. Fracture risk with multiple myeloma: a population-based study. J Bone Min Res. 2005;20:487-493.

37. Manoso MM, Healey JH. Metastatic cancer to the bone. In: Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005:2368-2380.

38. Myers ER, Wilson SE. Biomechanics of osteoporosis and vertebral fracture. Spine. 1997;22(24 Suppl):25S-31S .39. National Cancer Institute. SEER Cancer Statistics Review, 1975-2004. 2007. Available at:

http://seer.cancer.gov/csr/1975_2004/results_merged/topic_prevcounts.pdf40. Pateder DB, Khanna AJ, Lieberman IH. Vertebroplasty and kyphoplasty for the management of osteoporotic vertebral

compression fractures. Orthop Clin N Am. 2007;38:409-418 41. Patel B, DeGroot H. Evaluation of the risk of pathologic fractures secondary to metastatic bone disease. Ortho J. 2001;24:612-

617.42. Paterson AH, Powles TJ, Kanis JA, et al. (1993) Double-blind controlled trial of oral clodronate in patients with bone metastases

from breast cancer. J Clin Oncol. 1993;11:59-65.

16001110

References (continued)43. Perez EA. management of bone metastases in advanced breast cancer. Cancer Control. 1999; 6(5 Suppl 2):28-

31.44. Podichetty V, et al. Managing vertebral compression fractures and multiple myeloma in older patients. J

Musculoskel Med. 2004;21:372-378.45. Ray NF, Chan JK, Thamer M, Melton LJ 3rd. Medical expenditures for the treatment of osteoporotic fractures in

the u.s. in 1995: report from the national osteoporosis foundation. J Bone Min Res. 1997;12:24-35.46. Roodman GD. Mechanisms of bone metastases. NEJM. 2004; 350:1655-1664.47. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture

incidence in women. Annals Int Med, 1991; 114(11):919-923.48. Sirohi B, Powles R. Seminar: multiple myeloma. Lancet. 2004;363:875-887.49. Stricker CT. Endocrine effects of breast cancer treatment. Sem Oncol Nurs. 2007;23(1):55-70.50. TaylorRS, Taylor RJ, Ftitzell P. Balloon kyphoplasty and vertebroplasty for vertebral compression fractures: a

comparative systematic review of efficacy and safety. Spine. 2006;31:2747-2755.51. Theriault RL, Lipton A, Hortobagyi GN, et al. Pamidronate reduces skeletal morbidity in women with advanced

breast cancer and lytic bone lesions: a randomized, placebo-controlled trial. Protocol 18 Aredia Breast Cancer Study Group. J Clin Oncol. 1999;17:846-854.

52. Theriault RL. Task force reports on bone health in patients with cancer. J Natl Compr Canc Netw. 2006;4 Suppl 2:S1-20; quiz S21-2.

53. Tong D, Gillick L, Hendrickson FR. The Palliation of symptomatic osseous metastases: final results of the study by the Radiation Therapy Oncology Group. Cancer. 1982;50:893-899.

54. West HJ. Onc.Talk. Bone Metastases. 2007. Available at: http://onctalk.com/2007/02/17/bone-metastases-in-lung-cancer-an-introduction/

55. Yeh HS, Berenson JR. Treatment of myeloma bone disease. Clin Cancer Res. 2006;10:6279-6284. 55. Van Staa TP, Leufkens HG, Abenhaim L, Zhang B, Cooper C. Use of oral corticosteroids and risk of fractures. J

Bone Miner Res. 2000;15:993–1000.

Documents

16001110 Overview of Cancer-Related Vertebral Compression Fractures