Management of bone metastasis and cancer treatment-induced bone loss during the COVID-19 pandemic: An international perspective and recommendations

Abstract

Optimum management of patients with cancer during the COVID-19 pandemic has proved extremely challenging. Patients, clinicians and hospital authorities have had to balance the risks to patients of attending hospital, many of whom are especially vulnerable, with the risks of delaying or modifying cancer treatment. Those whose care has been significantly impacted include patients suffering from the effects of cancer on bone, where delivering the usual standard of care for bone support has often not been possible and clinicians have been forced to seek alternative options for adequate management. At a virtual meeting of the Cancer and Bone Society in July 2020, an expert group shared experiences and solutions to this challenge, following which a questionnaire was sent internationally to the symposium's participants, to explore the issues faced and solutions offered. 70 respondents, from 9 countries (majority USA, 39%, followed by UK, 19%) included 50 clinicians, spread across a diverse range of specialties (but with a high proportion, 64%, of medical oncologists) and 20 who classified themselves as non-clinical (solely lab-based). Spread of clinician specialty across tumour types was breast (65%), prostate (27%), followed by renal, myeloma and melanoma. Analysis showed that management of metastatic bone disease in all solid tumour types and myeloma, adjuvant bisphosphonate breast cancer therapy and cancer treatment induced bone loss, was substantially impacted. Respondents reported delays to routine CT scans (58%), standard bone scans (48%) and MRI scans (46%), though emergency scans were less affected. Delays in palliative radiotherapy for bone pain were reported by 31% of respondents with treatments often involving only a single dose without fractionation. Delays to, or cancellation of, prophylactic surgery for bone pain were reported by 35% of respondents. Access to treatments with intravenous bisphosphonates and subcutaneous denosumab was a major problem, mitigated by provision of drug administration at home or in a local clinic, reduced frequency of administration or switching to oral bisphosphonates taken at home. The questionnaire also revealed damaging delays or complete stopping of both clinical and laboratory research. In addition to an analysis of the questionnaire, this paper presents a rationale and recommendations for adaptation of the normal guidelines for protection of bone health during the pandemic.

Keywords: Bisphosphonates; Bone health; Bone metastasis; COVID-19; Denosumab; Zoledronic acid.

Fig. 1

Demographic data Area of work and global distribution of questionnaire respondents. (A) Country of practice of the respondents to the survey – 49 responses. Global distribution of respondents – encompassing Europe, Asia and America / Canada. (B) Area of work of the respondents – 50 responses, (C) Cancer types treated by the clinician respondents – 47 responses.

Fig. 2

Effect of COVID-19 upon tumour imaging and radiotherapeutic treatments of bone cancers: The effects of COVID19 upon tumour imaging and use of radiotherapies for bone cancers was assessed using a series of questions. (A) Have there been delays to routine bone imaging such as CT? – 48 responses, (B) Have there been delays in getting bone scans due to COVID19? – 48 responses (C) Have there been delays in getting MRI scans due to COVID19? – 48 responses, (D) Has there been an impact on palliative external beam radiotherapy at your centre due to COVID19? – 48 responses, (E) Has there been an impact upon access to stereotactic radiotherapy at your centre due to COVID19? – 47 responses and (F) Has there been an impact upon access to iMRT for small volume bone metastases at your centre due to COVID19? – 47 responses.

Fig. 3

COVID-19 and Bone Health: The effects of COVID19 upon bone health was assessed via the following questions: (A) Are adjuvant bisphosphonates used for patients with breast cancer at your centre? – 47 responses. Among respondents who answered “yes” the following questions were then asked: (B) If yes, has this been impacted by COVID19? – 47 responses. (C) Has bone health monitoring e.g. bone density DEXA scans, been impacted by COVID19 at your centre? – 47 responses. (D) Has your treatment of cancer treatment induced bone loss been changed due to COVID19? – 46 responses, and (E) Have you changed your antiresorptive therapy regimens for cancer treatment induced bone loss due to the COVID19 pandemic? – 47 responses.

Fig. 4

Follow-up and management of patients with bone metastases: Within the questionnaire 85% of respondents indicated that their patients did have non face to face consultations. Further questions were asked relating to patient care and treatments including (A) For non-face to face meetings have you been using video conferencing, telephone or both? – 45 responses, (B) Has there been increased use of local provider(s) for local care? – 47 responses, (c) Has the use of prophylactic surgery for patients at risk of fracture been affected at your centre? – 46 responses, (D) Has access to palliative care for pain control been affected in your centre due to COVID19? – 47 responses, (E) Has access to outpatient pharmacies and associated medications been impacted by COVID19 for your patients with bone metastases? – 47 responses, and (F) Have you noticed a change in your opiate for bone pain prescribing pattern during COVID19? – 48 responses.

Fig. 5

COVID-19 and Bone Research: Effects of COVID19 upon bone research was addressed by asking the following questions: (A) Have bone directed clinical trials been affected at your institution during COVID19? – 59 responses, (B) Have bone oriented or cancer oriented labs been affected at your institution during COVID19? – 66 responses, (c) Have the trainees in the cancer and bone field experienced significant changes to their learning opportunities during COVID19? – 66 responses, and (D) Have there been financial constraints to cancer and bone research funding during COVID19? – 61 responses.