Should all myeloma patients take bone strengthening therapy?

Should all myeloma patients take bone strengthening therapy?

So that's a great question. And I think there's probably some difference of opinion in the field about that.

I would just say that in my feeling is that all patients would derive benefit from a bone strengthening treatment like Zoledronic acid or Denosumab.

And I think there is a very large clinical trial that has demonstrated to us that, for example, Zoledronic acid versus another treatment in that study resulted in a significantly decreased incidence of skeletal-related events.

So new lytic lesions, fractures, those kinds of things, regardless of what therapy is administered and regardless of preexisting lytic bone disease.

I think that study, which included over 1800 patients, was actually good evidence that the majority of patients should receive these treatments.

Bone strengthening therapy is really key and important. And we forget, you know, what used to really take the lives of our myeloma patients with skeletal-related events.

If you look back to the 1970s and before, the number one cause of mortality was skeletal-related events, things like hip fractures and bony fractures. And thanks to wonderful bone strengthening medicines and drugs that better control the disease, people tend not to die of that nearly in the ways they used to before.

So the question is, should we give it to everyone? Do they need it for everyone? We really only give it to people who have bony manifestations of myeloma.

So for the most part that's going to be lytic bone lesions, holes in the bones caused by the myeloma.

But there's one other group that really needs it. And if we all talk about the CRAB criteria from the 1970s, "B" stands for bony lesions.

There was a little asterisk in that paper and it said if you had osteoporosis and more than 30% plasma cells in your marrow and no other reason for the osteoporosis, you should get bone strengthening medicine because your manifestation of bony problems was not little holes, it was just a general demineralization.

So it's really important. If you have no evidence of bony lesions, make sure you get a bone density test to be sure that you're not having just systemic loss of bone mineralization.

And the answer is most patients over time will need some type of bone strengthening medication. The frequency is always a matter of debate.

We initially give it once every month and then we know that when you achieve deeper responses, you can start stretching that out to every three months and maybe even beyond.

So I think first, when we think of bone disease in myeloma, we need to think that we really need to be able to have better ways of detecting it.

And we know, in fact, that when we use some of the more advanced imaging, that a vast majority of patients will, in fact, have bone disease.

So the first thing is probably to think about, have I done my more advanced tests to detect bone damage, such as either an MRI, a CAT scan, or potentially a PET scan.

With that, in fact, the vast majority of patients will have some evidence of bone disease.

Now, if you happen to be one that does not have that at all, we would still recommend bone strengthening medications first. They're actually relatively safe and effective with not a lot of side effects.

And in the long term, they can still prevent future bone damage from happening. And that's important because bone damage is one of the leading causes of pain.

So for an improved quality of life for all, with a potential therapy that doesn't have a lot of toxicity, we would recommend bone strengthening medication in all patients.