Zometa - Zoledronic Acid geeft bij gebruik door kankerpatienten op langere termijn vergroot risico op botnecrose

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5 januari 2020: Bron: JAMA december 2020

Onder patiënten met solide tumoren, o.a. multiple myeloma - botkanker en borstkanker en andere vormen van kanker die werden behandeld met Zometa - zoledronic acid voor uitgezaaide kanker in de botten, blijkt de kans op botnecrose - botafbraak van de kaak elk jaar iets hoger te zijn.

Met percentages van 0,8% na 1 jaar en 2% na 2 jaar. en 2,8 procent na 3 jaar. Het percentage was het hoogst bij patiënten met multiple myeloma - botkanker (4,3%) en het laagst bij patiënten met borstkanker (2,4%).
Bijkomende factoren geassocieerd met hogere percentages osteonecrose van de kaak waren onder meer een hogere blootstelling aan zoledroninezuur, minder tanden, kunstgebitten, eerdere kaakchirurgie en huidig roken.

Omdat Zometa - Zoledronic acid wel kankerpatienten met botuitzaaiingen helpt stellen de onderzoekers voor om vooraf aan het starten met een botversterker dat de behandelaaars zouden kunnen beginnen met het verbeteren van de anamnese van kaakchirurgie, tandextractie of gebruik van een prothese bij patiënten, wetend dat dit bekende risicofactoren zijn. Het verkrijgen van een tandheelkundig onderzoek voorafgaand aan de start van BMA's kan erg nuttig zijn om lopende orale aandoeningen te behandelen.

Aangezien Zometa - Zoledronic acid vergelijkbare voordelen kan bieden bij het verminderen van skeletgerelateerde voorvallen met doseringsintervallen van 3 maanden, kunnen hoogrisicopatiënten met dit schema beginnen. Patiënten met een iets lager risico zouden na een jaar van maandelijkse infusies kunnen overschakelen op een dosering van 3 maanden.

De studie Association of Osteonecrosis of the Jaw With Zoledronic Acid Treatment for Bone Metastases in Patients With Cancer is gepubliceerd in JAMA en is tegen betaling of onder bepaalde voorwaarden in te zien:

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Key Points

Question What is the incidence of osteonecrosis of the jaw (ONJ) in patients treated with zoledronic acid for bone metastases from any cancer?

Findings In this cohort study of 3491 participants initiating zoledronic acid treatment for bone metastases, the cumulative incidence of ONJ was 0.8% at year 1, 2.0% at year 2, and 2.8% at year 3, with the highest incidence observed in multiple myeloma and the lowest in breast cancer. More frequent dosing of zoledronic acid and poor oral health were associated with higher rates of ONJ.

Meaning These findings suggest that cancer type, oral health, and frequency of dosing are associated with the risk of ONJ, which should help to guide stratification of risk for developing ONJ in patients receiving zoledronic acid.

Abstract

Importance Osteonecrosis of the jaw (ONJ) affects patients with cancer and metastatic bone disease (MBD) treated with bone-modifying agents (BMAs), yet the true incidence is unknown.

Objective To define the cumulative incidence of ONJ at 3 years in patients receiving zoledronic acid for MBD from any malignant neoplasm.

Design, Setting, and Participants This multicenter, prospective observational cohort study (SWOG Cancer Research Network S0702) included patients with MBD with either limited or no prior exposure to BMAs and a clinical care plan that included use of zoledronic acid within 30 days of registration. Medical, dental, and patient-reported outcome forms were submitted at baseline and every 6 months. Follow-up was 3 years. Osteonecrosis of the jaw was defined using established criteria. Data were collected from January 30, 2009, to December 13, 2013, and analyzed from August 24, 2018, to August 6, 2020.

Interventions/Exposures Cancer treatments, BMAs, and dental care were administered as clinically indicated.

Main Outcomes and Measures Cumulative incidence of confirmed ONJ, defined as an area of exposed bone in the maxillofacial region present for more than 8 weeks with no concurrent radiotherapy to the craniofacial region. Risk factors for ONJ were also examined.

Results The SWOG S0702 trial enrolled 3491 evaluable patients (1806 women [51.7%]; median age, 63.1 [range, 2.24-93.9] years), of whom 1120 had breast cancer; 580, myeloma; 702, prostate cancer; 666, lung cancer; and 423, other neoplasm. A baseline dental examination was performed in 2263 patients (64.8%). Overall, 90 patients developed confirmed ONJ, with cumulative incidence of 0.8% (95% CI, 0.5%-1.1%) at year 1, 2.0% (95% CI, 1.5%-2.5%) at year 2, and 2.8% (95% CI, 2.3%-3.5%) at year 3; 3-year cumulative incidence was highest in patients with myeloma (4.3%; 95% CI, 2.8%-6.4%). Patients with planned zoledronic acid dosing intervals of less than 5 weeks were more likely to experience ONJ than patients with planned dosing intervals of 5 weeks or more (hazard ratio , 4.65; 95% CI, 1.46-14.81; P = .009). A higher rate of ONJ was associated with fewer total number of teeth (HR, 0.51; 95% CI, 0.31-0.83; P = .006), the presence of dentures (HR, 1.83; 95% CI, 1.10-3.03; P = .02), and current smoking (HR, 2.12; 95% CI, 1.12-4.02; P = .02).

Conclusions and Relevance As the findings show, the cumulative incidence of ONJ after 3 years was 2.8% in patients receiving zoledronic acid for MBD. Cancer type, oral health, and frequency of dosing were associated with the risk of ONJ. These data provide information to guide stratification of risk for developing ONJ in patients with MBD receiving zoledronic acid.

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1 Comment for this article

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January 3, 2021

Suggest deeper review of oral and maxillofacial surgery literature

Kim Goldman, OMS | University

Although the prospective nature of this study is commendable, and the recommendation to establish baseline dental health before beginning therapy is excellent and already well circulated in the OMS literature as well as in basic dental training. There is little new information here and the suggestion that dosing zoledronic acid less frequently will alter the eventual development of MRONJ does not appear to be founded UNLESS such less frequent dosing is also associated with shorter treatment period (?) and lower total dose. A preponderance of clinical evidence reveals that the length of treatment (> 4 years vs < 4 years)and the route of treatment (IV > PO/IM) most influence the development of MRONJ. Research additionally suggests that total dosing affects the speed at which MRONJ might develop.

CONFLICT OF INTEREST: None Reported