British Association of Surgical Oncology Guidelines. The management of metastatic bone disease in the United Kingdom. The Breast Specialty Group of the British Association of Surgical Oncology.

Abstract

Bone metastases can present to a number of different specialties and their successful management requires a coordinated approach with good liaison between the specialists. Patients who respond to systemic therapy for their metastases have a good chance of being alive at 3 years, and 20% will be alive at 5 years. This means that it is worth palliating these patients properly. With this in mind, the intention of this document is to try and improve the process of care for women with metastatic bone disease from breast cancer. These guidelines consider all aspects of care from diagnosis to assessment of response to treatment, and describe the Quality Objectives that should be addressed at each stage. The level of available evidence is indicated throughout the document where possible. In considering diagnosis, the guidelines emphasize the value of having a dedicated orthopaedic surgeon specifically linked to each Cancer Unit. The attachment of a dedicated orthopaedic surgeon will ensure that mechanical problems are correctly identified, and that actual or imminent fracture is correctly managed. The latter is particularly important as the management of pathological fractures is not the same as that of traumatic fractures. The orthopaedic surgeon should also act as the liaison between his/her own Unit and the tertiary spinal or neurosurgical centres as necessary. In addition, empowering the radiologist means that the diagnostic process can be accelerated and refined. The place of different investigations in diagnosis, including tumour markers, is discussed. The guidelines emphasize the need for a definitive diagnosis before treatment in the (rare) case of a solitary metastasis. The treatment section discusses orthopaedic management, radiotherapy and systemic treatments (endocrine therapy, chemotherapy and bisphosphonates). The guidelines emphasize the emergency nature of spinal cord compression, describing the need for fast access to assessment and for good liaison between specialists. It is essential that these are available and widely publicized to ensure effective management. The role of radiotherapy in both local pain relief and spinal cord compression is discussed, and various techniques are described. Endocrine therapy and chemotherapy are discussed in relation to the disease-free interval, performance status, extent and site of metastatic disease, and oestrogen receptor status. Specific chemotherapy regimes are not discussed as these are subject to change and local protocols should be followed. The increasing evidence behind the role of bisphosphonates is reviewed. With many unanswered questions about the long-term use of this group of drugs, the guidelines offer a scoring system for deciding which patients might benefit most from long-term bisphosphonate therapy. The guidelines describe the possible ways of assessing response to treatment and the difficulties that may be encountered, including a discussion of the role of tumour markers in assessment of response. A final section looks at palliative care principles in bone pain management, acknowledging the need for continuation of good care throughout the patient's journey, from diagnosis onwards. We very much hope these guidelines will stimulate individuals and institutions to improve the process of delivering care to this group of patients.