Skeletal-Related Events among Breast and Prostate Cancer Patients: Towards New Treatment Initiation in Malaysia's Hospital Setting

  • Ezat, Sharifa Wan Puteh (Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Junid, Syed Mohamed Aljunid Syed (United Nations University-International Institute for Global Health) ;
  • Khamis, Noraziani (Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Ahmed, Zafar (International Centre for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Sulong, Saperi (International Centre for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Nur, Amrizal Muhammad (International Centre for Casemix and Clinical Coding, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Aizuddin, Azimatun Noor (Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Ismail, Fuad (Department of Oncology and Radiotherapy, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Abdullah, Norlia (Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Zainuddin, Zulkifli Md (Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Kassim, Abdul Yazid Mohd (Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia Medical Centre) ;
  • Haflah, Nor Hazla Mohamed (Department of Orthopaedic and Traumatology, Universiti Kebangsaan Malaysia Medical Centre)
  • Published : 2013.05.30


The human skeleton is the most common organ to be affected by metastatic cancer and bone metastases are a major cause of cancer morbidity. The five most frequent cancers in Malaysia among males includes prostate whereas breast cancer is among those in females, both being associated with skeletal lesions. Bone metastases weaken bone structure, causing a range of symptoms and complications thus developing skeletal-related events (SRE). Patients with SRE may require palliative radiotherapy or surgery to bone for pain, having hypercalcaemia, pathologic fractures, and spinal cord compression. These complications contribute to a decline in patient healthrelated quality of life. The multidimensional assessment of health-related quality of life for those patients is important other than considering a beneficial treatment impact on patient survival, since the side effects of treatment and disease symptoms can significantly impact health-related quality of life. Cancer treatment could contribute to significant financial implications for the healthcare system. Therefore, it is essential to assess the health-related quality of life and treatment cost, among prostate and breast cancer patients in countries like Malaysia to rationalized cost-effective way for budget allocation or utilization of health care resources, hence helping in providing more personalized treatment for cancer patients.


  1. Aapro M, Abrahamsson PA, Body JJ, et al (2008). Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel. Ann Oncol, 19, 420-32.
  2. Aapro MS, Coleman RE (2012). Bone health management in patients with breast cancer: current standards and emerging strategies. Breast, 21, 8-19.
  3. Ariffin OZ, Nor Saleha IT (2011). National Cancer Report 2007, Ministry of Health, Malaysia.
  4. Bagi CM (2005). Targeting of therapeutic agents to bone to treat metastatic cancer. Advanced Drug Delivery Reviews, 57, 995-1010.
  5. Bernard DS, Farr SL, Fang Z (2011). National estimates of outof-pocket health care expenditure burdens among nonelderly adults with cancer: 2001 to 2008. J Clin Oncol, 29, 2821-6.
  6. Bradley C (2006). Feedback on the FDA's February 2006 draft guidance on patient reported outcome (PRO) measures from a developer of PRO measures. Health Qual Life Outcomes, 4, 78.
  7. Castellano D, Sepulveda JM, Garcia-Escobar I, et al (2011). The role of rank-ligand inhibition in cancer: the story of Denosumab. Oncologist, 16, 136-45.
  8. Cohen DJ, Reynolds MR (2008). Interpreting the results of cost-effectiveness studies. J Am Coll Cardiol, 52, 2119-26.
  9. Coleman RE (1997). Skeletal complications of malignancy. Cancer, 80, 1588-94.<1588::AID-CNCR9>3.0.CO;2-G
  10. Coleman RE (2001). Metastatic bone disease: clinical features, pathophysiology and treatment strategies. Cancer Treat Rev, 27, 165-76.
  11. Coleman RE (2004). Bisphosphonates: clinical experience. Oncologist, 9, 14-27.
  12. Coleman RE (2006). Clinical features of metastatic bone disease and risk of skeletal morbidity. Clin Cancer Res, 12, 6243-9.
  13. Colloca G, Colloca P (2011). Health-related quality of life assessment in prospective trials of systemic cytotoxic chemotherapy for metastatic castration - resistant prostate cancer: which instrument we need? Med Oncol, 28, 519-27.
  14. DePuy V, Anstrom KJ, Castel LD, et al (2007). Effects of skeletal morbidities on longitudinal patient-reported outcomes and survival in patients with metastatic prostate cancer. Support Care Cancer, 15, 869-76.
  15. Dhillon S, Lyseng-Williamson KA (2008). Zoledronic Acid: A review of its use in the management of bone metastases of malignancy. Drugs, 68, 507-34.
  16. Felix J, Andreozzi V, Soares M, et al (2011). Hospital resource utilization and treatment cost of skeletal-related events in patients with metastatic breast or prostate cancer: estimation for the Portuguese National Health System. Value in Health, 14, 499-505.
  17. Fidler IJ (2003). The pathogenesis of cancer metastasis: the 'seed and soil' hypothesis revisited. Natural Review of Cancer, 3, 453-8.
  18. Fong MK, Hare R, Jarkowski A (2012). A new era for castrate resistant prostate cancer: a treatment review and update. J Oncol Pharm Practice, 18, 343-54.
  19. Goh P, Harris K, Napolskikh J, et al (2007). New integrative therapies for oncology: multidisciplinary prostate bone metastases clinic: first of its kind in Canada. Current Oncology, 14, 9-12.
  20. Hagiwara M, Oglesby A, Chung K, Zilber S, Delea TE (2011). The impact of bone metastases and skeletal-related events on healthcare costs in prostate cancer patients receiving hormonal therapy. Commun Oncol, 8, 506-15.
  21. Hadji P (2011). Clinical considerations for the use of antiresorptive agents in the treatment of metastatic bone disease. Critical Reviews in Oncology/Hematology, 80, 301-13
  22. Hadji P, Aapro M, Costa L, Gnant M (2012). Antiresorptive treatment options and bone health in cancer patients-safety profiles and clinical considerations. Cancer Treatment Reviews, 38, 815-24.
  23. Jilani A, Garrett Z, Sutcliffe F, Stevens A (2012). NICE guidance on denosumab for prevention of skeletal-related events in adults with bone metastases from solid tumours. Lancet Oncol, l3, 1194-5.
  24. International Agency for Research on Cancer and Cancer Research UK (2012). World cancer factsheet. Cancer Research UK: London.
  25. Johnson JR, Williams G, Pazdur R (2003). End points and the food and drug administration. J Clin Oncol, 21, 1404-11.
  26. Kim A, Fall P, Wang D (2005). Palliative care: optimizing quality of life. J Am Osteopath Assoc, 105, 9-14.
  27. Konski A (2004). Radiotherapy is a cost-effective palliative treatment for patients with bone metastasis for prostate cancer. Int J Radiat Oncol Biol Phys, 60, 1373-8.
  28. Lage MJ, Barber BL, Harrison DJ, Jun S (2008). The cost of treating skeletal-related events in patients with prostate cancer. Am J Manag Care, 14, 317-22.
  29. Lamerato L, Havstad S, Gandhi S, Jones D, Nathanson D (2006). Economic burden associated with breast cancer recurrence: findings from a retrospective analysis of health system data. Cancer, 106, 1875-82.
  30. Meneses K, Azuero A, Hassey L, McNees P, Pisu M (2012). Does economic burden influence quality of life in breast cancer survivors? Gynecologic Oncol, 124, 437-43.
  31. Ministry of Health Malaysia (2010). Malaysian Clinical Practice Guideline of Cancer Pain Management.
  32. Ministry of Health Malaysia, Ministry of Higher Education Malaysia (2011). Protocol for Systemic Therapy of Cancer. Second edition. Malaysia.
  33. Ministry of Health Malaysia (2012). MOH Health facts 2012. Health Informatics Centre Planning and Development Division, MOH.
  34. Mundy GR (1997). Mechanisms of bone metastasis. Cancer, 80, 1546-56<1546::AID-CNCR4>3.0.CO;2-I
  35. Namiki M, Akaza H, Lee SE, et al (2010). Prostate cancer working group report. Jpn J Clin Oncol, 40, 70-5
  36. Ng CH, Pathy NB, Taib NA, et al (2011). Comparison of breast cancer in Indonesia and Malaysia ? a clinico-pathological study between Dharmais Cancer Centre Jakarta and University Malaya Medical Centre, Kuala Lumpur. Asian Pac J Cancer Prev, 12, 2943-6.
  37. Ogce F, Ozkan S (2008). Changes in functional status and physical and psychological symptoms in women receiving chemotherapy for breast cancer. Asian Pac J Cancer Prev, 9, 449-52.
  38. Osanto S, Van Poppel H (2012). Emerging novel therapies for advanced prostate cancer. Ther Adv Urol, 4, 3-12.
  39. Osoba D (2011). Health-related quality of life and cancer clinical trials. Ther Adv Med Oncol, 3, 57-71.
  40. Payne H, Pearcy R (2012). Symptoms and health-related quality of life in castration-resistant prostate cancer: the patient's perspective. J Men's Health, 9, 9-16.
  41. Penson DF, Moul JW, Evans CP, et al (2004). The economic burden of metastatic and prostate specific antigen progression in patients with prostate cancer: findings from a retrospective analysis of health plan data. J Urol, 171, 2250-4.
  42. Saad F, Lipton A, Cook R, et al (2007). Pathologic fractures correlate with reduced survival in patients with malignant bone disease. Cancer, 110, 1860-7.
  43. Schulman KL, Kohles J (2007). Economic burden of metastatic bone disease in the U.S. Cancer, 109, 2334-42.
  44. Shahmoradi N, Kandiah M, Loh SP (2010). Quality of life and functional status in patients with advanced cancer admitted to hospice home care in Malaysia: a cross-sectional study. Eur J Cancer Care, 21, 661-6.
  45. Shih YC, Xu Y, Cormier JN, et al (2009). Incidence, treatment costs, and complications of lymphedema after breast cancer among women of working age: a 2-year follow-up study. J Clin Oncol, 27, 2007-14.
  46. Taib NA, Yip CH, Low WY (2011). Recognising symptoms of breast cancer as a reason for delayed presentation in Asian Women-the psycho-socio-cultural model for breast symptom appraisal: opportunities for intervention. Asian Pac J Cancer Prev, 12, 1601-8.
  47. Tamura K (2012), Medical oncology in Asia. Chin Clin Oncol, 1, 2.
  48. Testa MA, Simonson DC (1996). Assessment of quality-of life outcomes. N Engl J Med, 334, 835-40.
  49. World Health Organisation (2011). Cancer Fact Sheet No 297. The World Health Organisation: Geneva
  50. Yoo KY (2010). Cancer prevention in the Asia Pacific Region. Asian Pac J Cancer Prev, 11, 839-44

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