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Bone Health in Oncology: Closing Gaps, Reducing Costs, and Unlocking Biosimilar Value

This recap article is supported by Sandoz.

Introduction and MASCC Session Overview

Experts convened at the Multinational Association of Supportive Care in Cancer (MASCC)/International Society of Oral Oncology 2025 Annual Meeting in Seattle, Washington, from June 26 to 28, 2025. The meeting included a panel session titled “Osteoporosis and Bone Metastasis in Oncology: Addressing Bone Health Treatment Gaps and the Role of Biosimilars.”1 Moderator Nicole Kuderer, MD, outlined the non-CME format, reviewed disclosures, and framed the panel discussion around the persistent clinical and economic burden of skeletal complications in cancer care.

Kuderer introduced a panel featuring internationally recognized leaders in supportive oncology. Matti Aapro, MD, a Swiss medical oncologist and past president of both the European Cancer Organisation and MASCC, highlighted the global relevance of bone health management. Gary Lyman, MD, of Duke University, an oncologist and leading expert in supportive cancer care, reviewed the clinical and economic burden of skeletal complications and the value of biosimilars. The panel also included patient advocate Darrell Wilson, a prostate cancer survivor and board member of the National Alliance of State Prostate Cancer Coalitions, who described the lived experience of treatment gaps and their impact on quality of life (QOL).

Across the discussion, panelists reinforced that supportive care research, toxicity management, and evidence-based guidelines remain the foundation of high-quality oncology practice (panel transcript, unpublished, June 2025). Bone health and associated pain are an urgent and costly challenge, especially for patients with breast cancer and prostate cancer, where skeletal complications, including osteoporosis, are common and often preventable (panel transcript, unpublished, June 2025).2,3 Treatment delays and underuse of bone-modifying agents (BMAs) contribute to avoidable fractures, diminished QOL, and substantial downstream costs.3-5 As Aapro noted, “We know that these bone-modifying agents need at least 2 to 3 months to become really effective, so we shouldn’t be waiting (panel transcript, unpublished, June 2025).”

The panel also examined biosimilars as a practical, payer-aligned strategy to expand access to BMAs. By lowering costs through price competition, biosimilars may enable earlier initiation of therapy, reduce skeletal-related events (SREs), and alleviate financial burden for patients and health systems (panel transcript, unpublished, June 2025). Wilson said that for members of his prostate cancer support group who may struggle with the cost of original bisphosphonates, knowing that more affordable options exist can make a difference (Wilson email communication; January 14, 2026). Lyman emphasized that broader adoption of biosimilars is a meaningful opportunity to close persistent treatment gaps and improve outcomes in oncology bone health (panel transcript, unpublished, June 2025).

Background and Prevalence: Baseline Bone Health Burden in the General Population

Bone metastases and SREs are common in breast cancer and prostate cancer.6,7 With about 50% of patients living at least 1 year and 10% surviving 5 years, many are at risk for fractures over extended periods (panel transcript, unpublished, June 2025).

Fragility fractures are also widespread in the general population. Osteoporosis-related hip fractures have a global survival rate of between 17% to 27%, and patients can face irreversible decline (panel transcript, unpublished, June 2025). Hip fracture mortality in the US is also high at about 21% after 1 year, and survivors often experience early declines in independence and QOL.8,9 In oncology, SREs add significant morbidity and mortality, with only about 30% of patients surviving 12 months after a pathologic fracture.10 Fractures increase mortality by 30% to 50% beyond metastasis alone; in prostate cancer, the risk of death rises 29%, and in breast cancer, 52% (Figure 1; panel transcript, unpublished, June 2025).1,11 Other high-risk oncology settings have similar patterns. In multiple myeloma, for example, real-world evidence shows that fractures are associated with a 44% increased risk of death (panel transcript, unpublished, June 2025).1,11

Despite these risks, treatment gaps persist. BMAs remain underutilized, and many high-risk patients are not identified early enough to prevent avoidable fractures (panel transcript, unpublished, June 2025).3 Patient experience reflects this gap. For example, Wilson described that men receiving androgen deprivation therapy (ADT) report missed DEXA scans and limited discussion of bone health unless they raise the issue themselves (panel transcript, unpublished, June 2025). Given the scale of this burden, the panel emphasized the importance of guideline-driven approaches to early detection and prevention.

Current Guideline Landscape and Foundational Concepts

Major oncology guidelines provide a structured framework for bone health management, with recommendations spanning proactive assessment, pain management, pharmacologic therapy, and radiation-based interventions.

The European Society for Medical Oncology, MASCC, and the National Comprehensive Cancer Network emphasize early assessment and intervention to reduce fracture risk and skeletal complications in patients with cancer.1,7,12

Pain control is a key component of supportive care. Guidelines support the appropriate use of analgesics, including opioids when necessary, even though clinicians and patients hesitate to use them.1,13

BMAs such as denosumab and bisphosphonates can help reduce skeletal complications, and the evidence supporting their use is extensive. Pivotal randomized trials demonstrated that BMAs decrease fractures, pain, and other skeletal-related complications, forming the foundation for current guideline recommendations (panel transcript, unpublished, June 2025).1,14-17

Aapro noted that clinicians should be aware of the specific risks that can occur when a patient stops taking denosumab (panel transcript, unpublished, June 2025).1,18 “If you stop denosumab, you should introduce another bone-modifying agent or at least follow them very carefully to see if they [develop] a rebound effect and intervene immediately,” he said (panel transcript, unpublished, June 2025).

Radiation therapy also remains essential in managing bone metastases. Aapro said guidelines call for prompt external beam radiation as a first-line treatment for low-class pain from bone metastases to avoid unnecessary delays in symptom relief (panel transcript, unpublished, June 2025).1,7,12,19-21

Guidelines further define the broad clinical impact of SREs, which include fractures, spinal cord compression, bone surgery, and radiation therapy. These events are associated with reduced QOL, loss of mobility and independence, increased mortality risk, and substantial health care resource utilization (panel transcript, unpublished, June 2025). Wilson said that making guideline information easier to access could help patients feel more informed and supported (Wilson email communication, January 14, 2026). With this framework in mind, the panel revisited the clinical reality of bone metastases, emphasizing why guideline-directed care is important in daily oncology practice.

Clinical Impact of Bone Metastases

Bone metastases have profound clinical consequences that extend beyond pain. Certain bone events can directly contribute to mortality, while others reflect the presence of advanced systemic disease, underscoring the seriousness of skeletal involvement in cancer (panel transcript, unpublished, June 2025).1

The burden of SREs amplifies this impact. SREs—including fractures, spinal cord compression, and the need for bone surgery or radiation—lead to loss of independence, reduced QOL, and greater reliance on caregivers and health care resources (panel transcript, unpublished, June 2025).1,22 While metastatic bone disease is the most severe end of the spectrum, the panel also highlighted that skeletal risks extend well beyond active cancer treatment, affecting long-term survivors as well.

Osteoporosis Risk in Cancer Survivors

Bone metastases represent one of the most serious skeletal complications in cancer; however, survivors without metastatic disease also face significant long-term risks to bone health.7 Many patients experience treatment-related bone loss that can progress to osteoporosis.3

Osteoporosis is a frequent long-term complication among cancer survivors, particularly those treated with hormone deprivation therapies such as ADT for prostate cancer or aromatase inhibitors for breast cancer (panel transcript, unpublished, June 2025).3 These treatments reduce sex hormone levels, leading to hypogonadism and accelerated bone loss, which further increase the risk of osteoporosis and fracture (panel transcript, unpublished, June 2025).23

Because many survivors live for years after completing treatment, maintaining bone health becomes an important part of long-term care. Aapro described recommended strategies that include obtaining baseline and follow-up DEXA scans to monitor bone density changes over time, optimizing vitamin D and calcium intake, and using BMAs when clinically indicated (panel transcript, unpublished, June 2025).1,3 Together, these measures help reduce fracture risk and support functional independence as patients transition into long-term follow up.

Economic Burden

The economic burden of skeletal complications in cancer is substantial, encompassing both direct medical costs and broader indirect impacts on patients and the health system. Direct costs arise from hospitalizations, orthopedic surgeries, radiation therapy, and pharmacologic interventions, all of which impact overall spending on SREs.1,5,24-27 Indirect costs add more strain, including long-term care needs, loss of productivity, disability hours, caregiver burden, and the functional decline that often accompanies SREs.1,2,28

These financial pressures extend to the broader health system. As Lyman explained, inpatient management of SREs can be nearly 5 times more expensive than ambulatory care, placing a disproportionate burden on payer budgets and health system resources (panel transcript, unpublished, June 2025).1,29 “When episodes are managed in the hospital, the cost is much greater…than when they can be managed in the ambulatory setting,” he said (panel transcript, unpublished, June 2025). High out-of-pocket (OOP) costs also influence patient behavior. For example, Wilson described how per-dose charges of $1600 to $3000 for BMAs lead some patients to delay therapy until insurance changes or to avoid treatment altogether (panel transcript, unpublished, June 2025).

Against this backdrop of rising costs and preventable complications, the panel turned to biosimilars as a practical strategy to expand access to bone-protective treatments while easing financial pressure on patients and the health system.

The Role of Biosimilars in Expanding Access and Reducing Costs

Biosimilars can reduce the economic burden of cancer care and expand access to essential supportive therapies. By introducing price competition, biosimilars have helped lower oncology drug spending, which is expected to exceed $150 billion by 2027.30 New biosimilars—along with generics—have saved patients with cancer more than $22 billion, enabling earlier and broader use of BMAs without compromising outcomes (panel transcript, unpublished, June 2025).1,31,32 Recent modeling of biosimilar denosumab shows $23 to $56 million in payer savings over 5 years for a 1-million-member health plan. Reinvestment with those savings could help about 20% more patients receive denosumab and prevent additional SREs at the same efficacy (Figure 2).33 As Lyman noted, “Biosimilars do offer opportunities…to expand access to bone-modifying agents like denosumab without necessarily compromising clinical outcomes (panel transcript, unpublished, June 2025).” Wilson shared that this expansion is important since financial toxicity often forces patients to delay or avoid bone-protective biologics (panel transcript, unpublished, June 2025).“The period in between care if you are delaying because of insurance is frightening,” he said (panel transcript, unpublished, June 2025).

Beyond BMAs such as denosumab and zoledronic acid, biosimilars of filgrastim and pegfilgrastim also address broader supportive care needs while helping reduce patient OOP costs compared with reference products.1,34,35 Optimizing coverage strategies further enhances access, for example:

  • Starting BMAs at the time of bone metastasis diagnosis helps avoid treatment delays (panel transcript, unpublished, June 2025).7
  • Maintaining denosumab every 4 weeks and stepping zoledronic acid down to every 12 weeks after disease control balances efficacy with resource use (panel transcript, unpublished, June 2025).7
  • Careful monitoring during denosumab discontinuation helps prevent rebound fractures (panel transcript, unpublished, June 2025).7
  • Ensuring timely access to radiation therapy reduces emergency department utilization and hospital admissions for uncontrolled bone pain.1,7

At the system level, Lyman also explained that favorable tiering of biosimilars can maximize savings and expand access across oncology populations (panel transcript, unpublished, June 2025).These strategies are consistent with pathways that treat bone health as a core element of high-quality oncology care (panel transcript, unpublished, June 2025).

Bringing these themes together, the panel emphasized several priorities for improving bone health in oncology and reducing the long-term burden of skeletal complications.

Key Takeaways and Future Directions

Fractures and other SREs are deadly, costly, largely preventable, and contribute to clinical deterioration, reduced QOL, and excess mortality. Timely screening, guideline-based prevention, and consistent use of BMAs can mitigate these risks (panel transcript, unpublished, June 2025).Despite this, bone health in oncology—particularly in breast cancer and prostate cancer—is undermanaged. Skeletal complications remain a major driver of cost and patient burden, demonstrating the importance of early detection and consistent risk evaluation, including routine DEXA scanning (panel transcript, unpublished, June 2025).3

Improving outcomes requires strong multidisciplinary coordination. Oncology, primary care, dentistry, and supportive care teams must work together to deliver timely interventions and avoid missed opportunities for prevention and management (panel transcript, unpublished, June 2025). Biosimilars strengthen this effort by expanding access while reducing costs. This impact is greatest when biosimilars are favorably tiered and integrated into modern care pathways that help payers and the health system lower spending without compromising outcomes (panel transcript, unpublished, June 2025).1,31

Elevating bone health within oncology care is both clinically necessary and economically sound, reducing hospitalizations, mitigating downstream costs, and improving survival outcomes (panel transcript, unpublished, June 2025).

REFERENCES

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