Bone Cancer Survey: July 2008

Bone marrow cancers

In 2006, there will be more than 35,000 new cases of leukemia and more than 66,000 new cases of lymphoma, according to the American Cancer Society. While the rates of both leukemia and lymphoma are slightly higher in Whites than Blacks, there have been some new developments in research in these two types of bone marrow cancers.

In a recent study from a group of researchers at the University of Texas M.D. Anderson Cancer Center, patients with a type of bone marrow cancer called myelodysplastic syndrome were treated with the drug decitabine, which is still undergoing clinical trials. Myelodysplastic syndrome generally occurs in patients who are older than 60. In some cases, the disease can progress into acute myeloid leukemia. According to the study, the quality of life of the patients treated with the drug improved significantly. But researchers say the drug has little impact on the patients' survival.

In another study, a group of researchers from the University of Rochester Medical Center's James P. Wilmot Cancer Center discovered that adding monoclonal antibodies to the standard treatment methods for patients with follicular lymphoma helped patients live longer. Three different groups of patients were treated with different treatment regimens, the group of patients who were treated with monoclonal antibodies along with the standard therapy had the highest survival rate of the three groups--which was 91 percent.

Bone marrow or peripheral blood stem cell transplants are treatment options for patients with life-threatening blood, immune system or genetic disorders. Leukemia and lymphoma are two common diseases often treated with bone marrow or peripheral blood stem cell transplants.

While patients with life-threatening bone marrow diseases may have other treatment options, bone marrow or blood stem cell transplants are used to treat patients who have received high doses of chemotherapy and/or radiation therapy. Without healthy bone marrow, the patient is not able to make blood cells needed to carry oxygen, fight infection and prevent bleeding, according to the National Cancer Institute. Medical experts say individuals in need of a transplant have a better chance of finding a donor match with a brother or sister. Yet only about 30 percent of patients who need a bone marrow or blood cell transplant find a matched donor in their family, according to the National Marrow Donor Program. There are more than 6 million donors registered with the National Marrow Donor Program, but less than 8 percent of those registered donors are African-Americans. And while it's possible to receive a donor match from another racial or ethnic group, the most likely match is found within one's own racial background. African-Americans have the toughest challenge because of the lack of African-American registered bone marrow donors. To find out more information about how you can became a donor you can go to www.marrow.org or greekgrayleukemiafoundation.org.

Ebony, July, 2006

New drug combo better for bone cancer treatment

The first and largest trial to test the combination of bortezomib (Velcade) and lenalidomide (Revlimid) to treat bone cancer (multiple myeloma) has shown promise in heavily pre-treated relapsed patients with progressive and/ or therapy-resistant disease. Most in the 38-patient Phase I clinical trial previously had been given both drugs individually.

The goal was to assess patient benefit and dose size. Participants were divided into groups with increasing drug doses. Fifty-eight percent had a significant response to the twofold combination. of these, six percent had complete remission. While for some, remission lasted over 30 months, the median was six months, considered remarkable for such advanced disease. Patients whose disease progressed on the drug combination also received dexamethasone to boost the combination cocktail. About 75 percent of those given dexamethasone improved. Side-effects--mild fatigue, blood count suppression (reversible) and/or nerve tingling or numbness--were manageable. The study was presented at the American Society of Hematology's 2006 meeting.

Chinese medicine & metastatic bone cancer

Metastatic bone cancer occurs when cancer cells from the original tumor area travel (or metastasize) through the body and move into the bone. Metastatic lesions are common with cancer of the breast, lung, prostate, kidney, and thyroid. One of the main symptoms of bone cancer is bone pain. The treatment of cancer of the bone, especially metastatic cancer, has two goals: 1) management of the neoplasm and 2) management of the symptoms produced by the local lesion. Prognosis is affected by a patient's age, the size of the primary tumor, grade and stage, degree of lymphatic and blood vessel invasion, the duration of symptoms and the location of the tumor on the arm, leg, or trunk. There are two ways bone metastasis is treated in standard Western medicine. Systemic therapy, aimed at cancer cells that have spread throughout the body, includes chemotherapy, hormone therapy, and immunotherapy. Local therapy, aimed at killing cancer cells in one specific part of the body, includes radiation therapy and surgery. At present, there is no cure for metastatic bone disease.

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On pages 16-17 of issue #1, 2005 of the Zhe Jiang Zhong Yi Za Zhi (Zhejiang Journal of Chinese Medicine), Wang Yunqi, of the Hunan Provincial Tumor Hospital, published an article titled, "Clinical Observations on the Treatment of 30 Cases of Metastatic Bone Cancer with Yang He Tang Jia Wei (Yang-harmonizing Decoction with Added Flavors) Combined with 99m Technetium-Methylene Diphosphate [TC-MDP] Compared to 30 Cases Only Treated with TC-MDP." Since this study suggests that the combination of Chinese herbal medicine in tandem with chemotherapy gets better results than chemotherapy alone in the treatment of metastatic bone cancer, a summary of this study is presented below.

Cohort description

Altogether, there were 60 patients enrolled in this two-wing comparison study. All 60 patients were seen as inpatients at the Hunan Provincial Tumor Hospital between August, 2002 and March, 2004, and all suffered from a confirmed diagnosis of metastatic bone cancer. This diagnosis was confirmed by cellular pathology, CT scan, ECT, MRI, and X-ray, and all had marked bone pain. These patients had either not yet been treated with radiation and chemotherapy, or it had been at least 3-4 weeks since they had been treated with radiation and chemotherapy. All patients were over 18 years of age, and none had any abnormalities of heart, liver, or kidney function. Further, all had a life expectancy of more than two months.

These 60 patients were randomly divided into two groups, a so-called treatment group and a comparison group. In the treatment group, there were 18 males and 12 females age 35-72 years, with an average age of 48 years. Twelve of these patients had lung cancer, eight had breast cancer, four had nasal and/or throat cancer, two had prostate cancer, one had stomach cancer, two had intestinal cancer, and one had kidney cancer. Eight cases had a Karnofsky score of 60-70 points, 15 had a score of 70-80 points, and seven had a score of 80-90 points. In the comparison group, there were 19 males and 11 females aged 37-73 years, with an average age of 49.5 years. Thirteen of these patients had lung cancer, seven had breast cancer, two had prostate cancer, two had nasal and/or throat cancer, one had esophageal cancer, two had intestinal cancer, one had multiple osteosarcoma, one had kidney cancer, and one had malignant lymphoma. Nine of these cases had a Karnofsky score of 60-70 points, 15 had a score of 70-80 points, and seven had a score of 80-90 points. Therefore, there was no significant statistical differences between these two groups in terms of sex, age, type of cancer, Karnofsky score, or degree of bone pain. Hence these two groups were considered comparable.

Pain rating scale

A pain rating scale was used in this study to determine the severity of the bone pain suffered by these 60 patients. Zero meant that there was no pain. One meant there was slight pain which was bearable and did not require pain medication. In addition, patients were able to carry on with their normal lifestyle and sleep. Two meant that there was moderate pain which did disturb sleep. Patients in this case did desire to use pain-killing medication. Three meant there was severe pain with accompanying vegetative nerve disorder, severe disturbance of sleep, and the most definite desire to use pain-stopping medications.

Treatment method

Members of both groups received 100mg of TC-MDP in 250ml of saline solution via intravenous drip over a period of 3-4 hours once per day. During this time, they did not use pain-stopping medications. In addition, members of the treatment group were administered the following version of Yang He Tang:

Shu Di (cooked Radix Rehmanniae Glutinosae)

Huang Qi (Radix Astragali Membranacei), 30g each

Lu Jiao Jiao (Gelatinum Cornu Cervi), dissolved in the decocted liquid after straining

Xu Duan (Radix Dipsaci), 15g each

Pao Jiang (scorched Rhizoma Zingiberis Officinalis)

Gui Zhi (Ramulus Cinnamomi Cassiae), 12g each

Rou Gui (Cortex Cinnamomi Cassiae)

processed Ru Xiang (Resina Olibani)

processed Mo Yao (Resina Myrrhae)

Da Huang (Radix Et Rhizoma Rhei), added later, 6g each

Ma Huang (Herba Ephedrae), 5g

Bai Jie Zi (Semen Sinapis Albae), 2g

Wu Gong (Scolopendra Subspinipes), 3 strips

Quan Xie (Buthus Martensis), 9g

Gou Ji (Rhizoma Cibotii Barometsis)

Bu Gu Zhi (Fructus Psoralease Corylifoliae), 20g each

One packet of these medicinals were decocted in water per day and administered in two divided doses. After four weeks of continuous treatment, results were analyzed for both groups.

Study outcomes

Marked effect was defined as a reduction in pain by two degrees on the pain rating scale. Some effect was defined as a reduction in pain by one degree. No effect meant that the pain did not decrease or got worse. The following table shows the outcomes based on these criteria.

            Marked  Some    No      Total
Group       effect  effect  effect  effectiveness

Treatment   13      14       3      90%
Comparison   7      13      10      66.7%

In addition, in the treatment group, the mean Karnofsky score was 80.20[+ or -]5.68, while the mean Karnofsky score was only 73.66[+ or -]4.92 in the comparison group. This meant that the median quality of life was better in the treatment group than in the comparison group. There were no significant changes in mean blood calcium levels from before to after treatment in either of these two groups or between these two groups. Likewise, there were no obvious side effects in either group. Therefore, in terms of pain reduction and quality of life, the combination of Chinese herbal medicine with chemotherapy appears to have been superior to chemotherapy alone.

Discussion

According to Dr. Wang, metastatic bone cancer corresponds to the traditional Chinese medical disease categories of bone impediment and yin impediment. Its root is vacuity and its tips or branches are repletions. This root vacuity is mainly a yang qi vacuity, while the tips are mainly cold, phlegm, [blood] stasis, and [qi] stagnation. Therefore, Dr. Wang believes that the Chinese medical treatment of this condition should warm yang and free the flow of the vessels, scatter cold and transform phlegm, and Yang He Tang Jia Wei conforms to these needs. Within this formula, Shu Di is the sovereign which greatly supplements the blood and qi. Lu Jiao Jiao is a bloody, meaty natured ingredient which is able to engender the essence and supplement the marrow, strengthen the sinews and strengthen the bones. It acts as Shu Di's assistant or adjuvant. Pao Jiang warms the center, breaks yin, and rescues yang. Rou Gui enters the constructive [aspect] where it warms and frees the flow of the blood vessels. Ma Huang spreads the defensive [qi] and scatters cold. When used along with Pao Jiang and Rou Gui, these medicinals are able to promote the diffusion and free flow of the qi and blood. When used with Shu Di and Lu Jiao Jiao, there is supplementation without stagnation. Bai Jie Zi dispels phlegm lodged between the skin and the inner membranes. Gui Zhi warms the channels and frees the flow of the vessels. Qi makes the blood quicken. Therefore, the addition of Huang Qi is in order to boost the qi to quicken the blood, while the addition of processed Ru Xiang and Mo Yao is in order to dispel stasis and stop pain. Wu Gong and Quan Xie are both bug ingredients which free the flow of the network vessels and stop pain. They are also able to combat cancer toxins with their own toxicity. Because the kidneys govern the bones, the formula also includes Gou Ji, Xu Duan, and Bu Gu Zhi to supplement the kidneys and strengthen the bones, free the flow of the sinews and quicken the network vessels. Finally, Da Huang frees the flow of the stools and promotes the expulsion of toxins. Taken as a whole, this formula has the ability to warm yang and free the flow of the vessels, scatter cold and transform phlegm. When combined with chemotherapy for the treatment of metastatic bone cancer, it achieves a definite effect for stopping pain and a better effect than the chemotherapy alone. Based on the above outcomes, Dr. Wang thinks that this approach deserves to be progressively and widely adopted in clinical practice.

abstracted & translated by Bob Flaws, LicAc, Dipl Ac & CH, FNAAOM

Townsend Letter for Doctors and Patients, by Bob Flaws

Managing Bone Loss in Cancer Patients

Cancer patients are at a higher risk for developing osteoporosis due to accelerated loss in bone density associated with many anticancer treatments. There are a variety of hormonal and non-hormonal treatments that may promote bone loss by inducing hypogonadism, which increases bone resorption and bone turnover. Examples include endocrine therapies for breast cancer (e.g., selective estrogen-receptor modulators [SERMs] and aromatase inhibitors [AIs]), androgen deprivation therapy (ADT) for prostate cancer, various chemotherapeutics and glucocorticoids (Table 1).' Surgical gonadal ablation, such as bilateral orchiectomy in prostate cancer and oophorectomy in breast cancer, also results in hypogonadism and bone loss in patients with hormone-sensitive tumors.

The more pressing issue is that the bone loss which occurs with cancer therapy is generally more rapid and severe than postmenopausal bone loss in women or normal age-related osteoporosis in men. Rates of bone loss occurring with cancer therapy can be up to 10 times higher than normal.1"4 In normal men, bone mineral density (BMD) decreases at a rate of 0.5 percent to 1 percent per year starting in midlife.4 Women have higher rates of bone loss around menopause an average of 2 percent loss in bone mass per year for five to 10 years - which then declines over time.

Patients receiving cancer therapy experience significantly greater degrees of bone loss. For example, bone loss in men with prostate cancer on ADT can occur at a rate of 4 percent to 5 percent per year. Marked changes are detectable six months after initiation of hormonal therapy in men with prostate cancer.5 Significant bone loss can occur in women with breast cancer who are treated with AIs or other endocrine therapies. Results of recent trials found bone loss of 4 percent and 6.1 percent in the lumbar spine after two years and five years, respectively.6"8 This is on top of the "normal" bone loss associated with the aging process and menopause. Such bone loss leads to osteoporosis and, ultimately, fractures which diminish the quality of life and increase mortality.

I am not prepared to review all the countless studies done on the various therapies for cancer that are associated with bone loss. It is very clear that many of the drugs used in cancer treatment cause bone loss, some more than others. For the purpose of this article, we do not need to know the specific rates of bone loss associated with each specific treatment. It is my opinion that if a patient had or is having treatment for cancer, the matter of avoiding bone loss should, at the very least, be considered and a plan for intervention and management should be implemented.

We already know that nearly one-third of postmenopausal, Caucasian women suffer from osteoporosis, and 25 percent have at least one vertebral deformity. It isn't difficult to determine that most women who undergo therapy for breast, ovarian and uterine cancer should be treated and/or monitored for osteoporosis.9 Similar precautions should be performed for men with prostate and testicular cancer.

It is unfortunate that even with all the information available, osteoporosis often remains undetected in patients with cancer until a bone fracture occurs. Studies suggest that bone density testing is performed in only 3 percent to 32 percent of high-risk patients.10 These patients are literally falling through the cracks. Several organizations have developed clinical guidelines for screening cancer patients for bone loss. The U.S. Surgeon General's office, the American Society of Clinical Oncology and the U.S. Preventive Services Task Force all have guidelines for women with risk factors, but none for men. The National Comprehensive Cancer Network does have clinical practice guidelines for men with prostate cancer. To summarize these guidelines, it is recommended that patients undergo BMD screening at baseline and at annual intervals to monitor for further bone loss.23,33 Just based on my minimal experience within my film-reading practice, these guidelines are not being used with any regularity. It is my opinion that as health care professionals, chiropractors can and should monitor their own patient pool for possible accelerated bone loss.

Just as a review, the standard approach for measuring bone loss is with DXA (dual-energy absorptiometry). The T-score reflects the number of standard deviations a patient's bone mass varies from the mean value for sex-matched young adults. Professional guidelines recommend only high-risk breast cancer patients with T-scores between -1 and -2.5 undergo monitoring on an annual basis for changes in BMD. However, many professionals (including myself) are of the opinion that all patients receiving therapy which depletes estrogen and male patients with prostate cancer should be monitored on an annual basis. The same guideline also should be used for patients being treated for osteoporosis. All patients should receive guidance regarding lifestyle changes such as proper exercise, calcium and vitamin D supplementation and dietary modification. Also patients with existing osteopenia and osteoporosis should be evaluated for conditions that further insult skeletal health, such as vitamin D deficiency, hyperthyroidism, hyperparathyroidism and hypercalciuria. Table 2 summarizes the presently accepted recommendations for monitoring patients with below-normal T-scores.

The true incidence of bone fracture in older cancer patients (e.g., postmenopausal women) is likely underestimated as a result of the occurrence of undetected or "silent" fractures. It is estimated that up to two-thirds of all vertebral fractures may not be clinically diagnosed, since they are often caused by inconsequential trauma and often go unrecognized by patients and physicians.13 Routine BMD screening of at-risk patients can help identify bone loss and allows initiation of therapy as indicated, in order to avoid future fractures.

Existing treatment guidelines recommend that men and women who are osteoporotic should be strongly considered for bisphosphonate therapy.14-16 Bisphosphonates may even be used in conjunction with chemotherapy and endocrine therapy. Currently, bisphosphonatealendronate is approved in the U.S. for the treatment and prevention of osteoporosis in men and postmenopausal women. Other drugs including risedronate and ibandronate (oral and IV) also are approved for use in postmenopausal women, and alendronate and isedronate are approved for glucocorticoid-related osteoporosis in both men and women. Of course, these drugs do come with side effects, and the goal should be to preserve the patients' bone density so they might avoid developing osteoporosis without the need for interventional drugs. Unfortunately, for many patients with a low BMD at baseline, these drugs are often the only option for the prevention of further bone loss, along with lifestyle changes, exercise and nutritional support.

Chiropractors have been managing patients with osteoporosis for decades. They are in a unique position to monitor patients with osteoporosis, as they often treat these patients for musculoskeletal disorders. The health care community often is not aware of the service that most chiropractors provide their patients, such as nutrition counseling, exercise programs and lifestyle changes. In particular, cancer patients should be counseled on lifestyle changes that include proper nutrition, daily exercise and avoiding smoking and caffeine. Chiropractors can play a crucial role in helping to manage cancer patients at risk for osteoporosis.

It should be stressed that avoiding osteoporosis and future fractures is not just a matter of taking bisphosphonates regularly, but more importantly includes exercise, proper nutrition and lifestyle changes. Exercise is crucial; both weight-bearing aerobic exercise and muscle-strengthening exercise should be performed four to five times per week for at least 30 minutes a day.4 One of the better exercise programs that I've found is the "BEST Exercise Program," developed by an interdisciplinary research team from the University of Arizona and recommended by the National Osteoporosis Foundation (http://nof.confex.com/nof/2005/techprogram/P256.HTM).

Calcium and vitamin D are key for bone formation and maintenance. Patients should be counseled to eat foods rich in these nutrients and to get adequate sunlight exposure for vitamin D production.17 For patients unable to reach the daily target levels of calcium and vitamin D, bioavailable supplements are necessary. Total recommended calcium intake is 1,200 mg/day; any calcium should be taken in divided doses to improve absorption. Vitamin D recommended intake is 800 IU daily. New information regarding vitamin D emphasizes the great importance of this vitamin. So keep updated on the most recent information, as recommended dosages may be increased, especially for older patients.

Routine monitoring of serum levels of 25-hydroxyvitamin D will help identify vitamin D deficiencies.18 A 250HD concentration of 30 ng/ml or higher is desirable. All patients on bisphosphonate therapy should have routine assessment of their vitamin D status, along with BMD assessment. These patients are not being followed up. Chiropractors are seeing more and more cancer survivors, as these patients come in with musculoskeletal complaints. We need to make certain they are properly managed not only for the initial complaints, but also evaluated for possible bone loss, and that we continue to give them supportive care and counseling.

In summary, patients with cancer are at significant risk for bone loss and fracture, not only from their disease and age-related osteoporosis, but also from therapy for their malignancy. This loss of bone density has serious clinical consequences, increasing the risk for fracture and other morbidities that can decrease survival. Unfortunately, low awareness of this problem and infrequent screening result in many cancer patients with undiagnosed bone loss. Recognition of the magnitude of this problem and early identification of patients at risk for bone loss are key to effective management.

Dynamic Chiropractic, by Pate, Deborah

Fluoride linked to bone cancer, again

Newly available research out of Harvard University, links fluoride in tap water, at levels most Americans drink, to osteosarcoma, a rare form of bone cancer. (1)

The Environmental Working Group (EWG), a highly-regarded Washington DC-based organization, urges that fluoride in tap water be declared a known or probable cancer cause, (2) based on this and previous animal and human studies.

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Elise Bassin, PhD writes, in her April 2001 Harvard doctoral thesis, "... for males less than twenty years old, fluoride level in drinking water [about 1 part per million] during growth is associated with an increased risk of osteosarcoma." According to EWG, "Research dating back decades, much of it government funded, has long suggested that fluoride added to drinking water presents a unique cancer risk to the growing bones of young boys." (3)

Citing a strong body of peer-reviewed evidence, including the Bassin study, EWG urges an expedited review of fluoride for inclusion in a US government report of substances known or feared to be cancer-causing in humans. (2)

Richard Wiles, EWG's Sr. Vice President, told the British newspaper The Observer, "I've spent 20 years in public health trying to protect kids from toxic exposure. Even with DDT, you don't have the consistently strong data that the compound can cause cancer as you now have with fluoride." (4)

High-quality epidemiological studies show a strong association between fluoride in tap water and osteosarcoma in boys, reports EWG. EWG's Wiles writes, "The safety of fluoride in America's tap water is a pressing health concern .... the weight of the evidence strongly supports the conclusion that millions of boys in these [fluoridated] communities are at significantly increased risk of developing bone cancer as a result."

"The Harvard dissertation ... obviously had merit because Bassin was awarded her doctorate," writes The Observer.

Fluoride is added to water supplies in a questionable attempt to reduce tooth decay. Pro-fluoridation studies are outdated and flawed as revealed in British (5) and US reviews of the literature. (6)

More about fluoride and bone cancer here: http://www.fluoridealert.org/health/cancer/osteosarcoma.html http://www.ewg.org/issues/siteindex/issues.php?issueid=5030

References

1. "Association Between Fluoride in Drinking Water During Growth and Development and the Incidence of Osteosarcoma for Children and Adolescents," A Thesis Presented by Elise Beth Bassin, April 2001 http://www.fluoridealert.org/health/cancer/bassin2001.pdf

2. June 6, 2005 letter from Richard Wiles, Sr. Vice President, Environmental Working Group to Dr. C. W. Jameson, National Toxicology Program, Report on Carcinogens http://www.ewg.org/issues/fluoride/20050606/petition.php

3. Environmental Working Group News Release "Government Asked to Evaluate the Cancer Causing Potential of Fluoride in Tap Water," June 6, 2005 http://www.ewg.org/issues/fluoride/20050606/index.php

4. "Fluoride water 'causes cancer'," by Bob Woffinden, June 12, 2005, The Observer http://observer.guardian.co.uk/uk_news/story/0,6903,1504672,00.html

5. The University of York, Centre for Review and Dissemination "What the 'York Review' on the fluoridation of drinking water really found," Originally released: 28 October 2003 http://www.york.ac.uk/inst/crd/fluoridnew.htm

6. National Institutes of Health, News Release concerning Consensus statement regarding Diagnosis and Management of Dental Caries Throughout Life, March 26-28, 2001, Vol. 18, No. 1 http://consensus.nih.gov/news/releases/115_release.htm ("... the (NIH) panel was disappointed in the overall quality of the clinical data that it reviewed. According to the panel, far too many studies were small, poorly described, or otherwise methodologically flawed" (over 560 studies evaluated fluoride use).)

Contact: Paul Beeber, Esq

President & General Counsel

New York State Coalition Opposed to Fluoridation, Inc.

P.O. Box 263

Old Bethpage, New York 11804 USA 516-433-8882

http://www.orgsites.com/ny/nysocfnyscof@aol.com

Bone Cancer Survey