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The Role of Bisphosphonates in Malignant Bone Pain: A Review

Some malignancies, such as those originating in the breast, prostate, and endometrium are, to varying degrees, responsive to hormonal therapy (17). Referral of patients with these cancers to oncologists should be considered, since hormonal therapy can lead to some sustained symptom relief in selected patients (17,18). An oncology consult is generally indicated to determine the appropriateness of antineoplastic therapy, since this modality can provide, under certain circumstances, good palliation for prolonged periods of time. However, significant toxicity coupled with poor effectiveness has limited the general use of chemotherapeutic drugs in the management of malignant bone pain in patients with very advanced cancer (19). Corticosteroids as adjuvant analgesics may provide dramatic short-term pain relief, and their analgesic effect is often accompanied by other benefits such as improved appetite and general sense of well-being (20). Orthopedic, neurosurgical, and anesthetic procedures may be helpful in a very small select group of patients (21,22). It is a sine qua non that patients with cancer-related pain require psychological support concurrent with any pharmacological or physical therapy. Significant advances have been made in our knowledge of the pathophysiology of malignant bone destruction and bone pain. It is now considered that metastatic bone destruction is essentially mediated by osteoclast activation rather than by the direct osteolytic effects of metastatic cancer cells. Bone destruction involves the release of paracrine factors produced by an interaction between the tumor cells, neighboring osteoclasts, the immune system, and other systemic factors. The net result is an increase in osteoclast activity, bone resorption, and the release of various nociceptive chemicals (23,24). Given the central role of osteolysis in malignant hypercalcemia, bone destruction, and malignant bone pain, it is logical to use inhibitors of osteoclasts to modify the process (25-28). A variety of agents have been shown to do this, including plicamycin and mithramycin, the calcitonins, gallium nitrate, and the INTRODUCTION