Expected survival of cancer patients and myeloma undergoing bisphosphonates or denosumab. Potential impact on diagnosis and management of Osteonecrosis of Jaws (ONJ)

TLDR: Data support careful evaluation of short and long-term actuarial ONJ risk (versus short-term absolute risk) in the choice of antiresorptive treatment duration for bone metastatic cancer and myeloma patients and exclusion of jawbone surgery due to expected short survival in most of ONJ patients seems not warranted.

Abstract: Survival of cancer and myeloma patients after diagnosis of bone lesions is largely variable. Appropriate medical therapy together with antiresorptive treatment (bisphosphonates or denosumab) can obtain prolonged survival with adequate quality of life. Osteonecrosis of Jaws (ONJ) is not rare in patients with bone metastatic cancer and myeloma patients, occurring mostly after prolonged antiresorptive treatment. Expected survival can influence the choice of antiresorptive treatment, the perception of ONJ risk, and even the ONJ management. We reviewed survival data after start of antiresorptive treatment of 509 ONJ patients registered in a cancer network database (Rete Oncologica Piemonte-Valle d’Aosta, North-Western Italy).  Main characteristics: 196 males, 313 females; median age: 68 (39-89) years. Underlying disease: breast cancer: 42.9%; myeloma: 25.3%; prostate cancer: 17.2%; lung cancer: 6.7%; renal cancer: 2.5%; other cancer types: 4.3%. Main antiresorptive treatment: zoledronic acid: 79.4%; denosumab: 5.3%; other drugs/sequences: 15.3%. Actuarial median survival (range) after the start of antiresorptive treatment was 66.0 (95% CI 57-77) months for breast cancer patients, 77.3 (95% CI 61.9-86.8) months for myeloma patients, 47.3. (95% CI 37.8-51.9) months for prostate cancer patients, 29.4 (95% CI 20.4-40.1) months for lung cancer patients, 39.4 (95% CI 20-107.3) months for renal cancer patients, 82.4 (95% CI 51.9-150.9) months for other cancer patients. Two-, three- and four-year actuarial survival rates were respectively 91.7%%, 80.2%, 67.4% for breast cancer patients, 91.4%, 83.7%, 68.9% for myeloma patients, 78.4%, 61.2%, 41.9% for prostate cancer patients; 55.8%, 32.3%, 23.5% for lung cancer patients; 61.5%, 53.8%, 46.1% for renal cancer patients; 81.8%, 77.3%, 68.1% for others cancer types. Our data support careful evaluation of short and long-term actuarial ONJ risk (versus short-term absolute risk) in the choice of antiresorptive treatment duration for bone metastatic cancer and myeloma patients. Furthermore, exclusion of jawbone surgery due to expected short survival in most of ONJ patients seems not warranted.