DO PHYSICIANS FOLLOW SYSTEMIC TREATMENT AND FUNDING POLICY GUIDELINES? A REVIEW OF BISPHOSPHONATE USE IN PATIENTS WITH BONE METASTASES FROM BREAST CANCER
Main Article Content
Keywords
Bisphosphonates, guidelines, drug use evaluation, breast cancer
Abstract
Background
The use of bisphosphonates for the prevention of skeletal related events in women with bone metastases from breast cancer is well established. We undertook an evaluation of bisphosphonate use in clinical practice in three Canadian cancer centres. In addition we assessed whether or not physicians at these centres are following their local treatment guidelines and funding policies.
Methods
Charts and electronic files of patients who had received either clodronate or pamidronate at any time between January 2000 and December 2001 at three Canadian cancer centres were retrospectively reviewed.
Results
There has been a marked improvement in the time between the diagnosis of bone metastases and the commencement of bisphosphonates from a median of 155 days in 1998 to 24 days in 2001. However, despite a local funding policy requiring that oral clodronate be the first bisphosphonate used, this was the case in only 67% of patients. In addition, despite one centre’s guidelines recommending that bisphosphonates be stopped once the patient was progressing, 90% of their patients remained on bisphosphonates until they died.
Conclusions
A considerable amount of effort is spent on the creation of “evidence based” treatment guidelines. Funding agencies develop policies based on these treatment guidelines, but often funding is more restrictive than the treatment guideline would suggest. It is clear from this review that physicians still appear to manage a substantial proportion of patients outside of funding policies, but within evidence based recommendations. Therefore, a need exists for either the creation of guidelines and policies that physicians will follow or the implementation of methods to ensure that restrictive policies are actually followed.
References
2. Mundy G. Mechanisms of bone metastasis. Cancer 1997;80:1546-1556.
3. Rubens R. Bone metastases - the clinical problem. European Journal of Cancer 1998;34:210-213.
4. 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. Journal of Clinical Oncology 1999;17(3):846-854.
5. Coleman R, Rubens R. The clinical course of bone metastases from breast cancer. British Journal of Cancer 1987;55:61-66.
6. Hill M, Richards M, Gregory W, Smith P, Rubens R. Spinal cord compression in breast cancer: a review of 70 cases. British Journal of Cancer 1993;68:969-973.
7. Conte P, Latreille L, Mauriac L, et al. Delay in progression of bone metastases in breast cancer patients treated with intravenous pamidronate results from a multinational randomized controlled trial. Journal of Clinical Oncology 1996; 14:2552- 2559.
8. Diel I, Solomayer E, Costa S, et al. Reduction in new metastases in breast cancer with adjuvant clodronate treatment. New England Journal of Medicine 1998; 339:357-363.
9. Diel I. Continual PO versus IV interval therapy with bisphosphonates in patients with breast cancer and bone metastases. Proceedings of the American Society of Clinical Oncology Abstract #488 (1999).
10. Elomaa I, Blomqvist C, Porkka L, et al. Treatment of skeletal disease in breast cancer: a controlled clodronate trial. Bone 1987;8:S53-S56.
11. Elomaa I, Blomqvist C, Grohn P, et al. Longterm controlled trial with diphosphonate in patients with osteolytic bone metastases. Lancet 1983 1:146-149.
12. Hortobagyi G, Theriault R, Porter L, et al. Efficacy of pamidronate in reducing skeletal complications in patients with breast cancer and lytic bone metastases. New England Journal of Medicine 1996;335:1785-1791.
13. Hortobagyi G, Theriault R, Lipton A, et al. Long-term prevention of skeletal complications of metastatic breast cancer with pamidronate. Journal of Clinical Oncology 1998;16:2038-2044.
14. Lipton A, Theriault RL, Hortobagyi GN, et al. Pamidronate prevents skeletal complications and is effective palliative treatment in women with breast carcinoma and osteolytic bone metastases: longterm follow-up of two randomized, placebocontrolled trials. Cancer 2000;88(5):1082-90.
15. Martoni A, Guaraldi M, Camera P, et al. Controlled clinical study on the use of dichloromethylene disphosphate in patients with breast carcinoma metastasizing to the skeleton. Oncology 1991;48:97-101.
16. Paterson A, Powles T, Kanis J, et al. Doubleblind controlled trial of oral clodronate in patients with bone metastases from breast cancer. Journal of Clinical Oncology 1993;11:59-65.
17. van Holten-Verzantvoort A, Bijvoet O, Cleton F, et al. Reduced morbidity from skeletal metastases in breast cancer patients during longterm bisphosphonate (APD) treatment. Lancet 1987;2:983-985.
18. Rosen LS, Gordon DH, Dugan W Jr, et al. Zoledronic acid is superior to pamidronate for the treatment of bone metastases in breast carcinoma patients with at least one osteolytic lesion. Cancer 2004;100(1):36-43.
19. van Holten-Verzantvoort A, Kroon H, Bijvoet O, et al. Palliative pamidronate treatment in patients with bone metastases from breast cancer. Journal of Clinical Oncology 1993;11:491-498.
20. Bloomfield D, Warr D, Whelan T, et al. Use of bisphosphonates in patients with bone metastases from breast cancer. Current Oncology 1999;6:144- 154.
21. Breast Cancer Disease Site Group. Use of bisphosphonates in patients with bone metastases from breast cancer. CCO Practice Guideline Initiative. Available from URL:www.hiru.mcmaster.ca/ccopgi/guidelines/bre /cpg1_11.html. (2000).
22. Cancer Care Ontario New drug funding program. Available from: URL: www.cancercare.on.ca/treatment/newdrugs.html. (2000).
23. Hilner BE, Ingle JN, Chelbowski RT, et al. American Society of Clinical Oncology 2003 update on the role of bisphosphonates and bone health issues in women with breast cancer. J Clin Oncol 2003;21(21):4042-57.
24. Hillner BE, Ingle JN, Berenson JR, et al. American Society of Clinical Oncology guideline on the role of bisphosphonates in breast cancer. American Society of Clinical Oncology Bisphosphonates Expert Panel. J Clin Oncol 2000;18(6):1378-91.
25. Kruk D. The costs and consequences of using bisphosphonates as prophylaxix against the sequelae of bone metastases secondary to breast cancer. Master of Science Thesis, Graduate Department of Pharmaceutical Sciences, University of Toronto. 2001
26. Biermann W, Cantor R, Fellin F, et al. An evaluation of the potential cost reductions resulting from the use of clodronate in the treatment of metastatic carcinoma of the breast to bone. Bone 1991;12:S37-S42.
27. Major P, Cook R, Tozer R, Hirte H. Bisphosphonates for bone metastases in breast cancer patients: trial design issues and evaluation of published studies. Current Oncology 1998;5:181-187.
28. Dranitsaris G, Hsu T. Cost utility analysis of prophylactic pamidronate for the prevention of skeletal related events in patients with advanced breast cancer. Supportive Care in Cancer 1999;7:271-279.