The data also revealed notable differences in practice
The data also revealed notable differences in practice patterns across the countries. In France, Italy, Spain and the UK, patients were most likely to have multiple disseminated sites of metastases at the time of initial bone squalene epoxidase detection; however, patients in Germany were most likely to have a solitary bone metastasis. This suggests that bone metastases were more likely to be detected at an earlier stage in Germany than in other countries, meaning patients potentially received bisphosphonate treatment for longer than those in the other countries. Data from the audit on the circumstances surrounding bone metastasis detection supported this theory, with routine screening for metastases being much more common in Germany (38% of metastases were discovered this way) than in the other four countries (6–24%). Germany may offer a good example in this area as bone-targeted agents are beneficial even when initiated early in metastatic disease . Thus, prompt diagnosis may result in patients experiencing fewer SREs overall.
The results of this audit suggest that the clinical management of bone metastases is at times suboptimal in these major European countries. Data from a study of a US claims database conducted by Hagiwara et al.  suggest that this issue is not confined to Europe. In their analysis, only 58.5% of patients with breast cancer received intravenous bisphosphonates in the first year after bone metastasis detection, and this proportion was even lower for those with prostate or lung cancer. Although it is some years since these studies were carried out, we believe that these data still have relevant implications for clinical practice. The recent introduction of denosumab may have improved access to treatment for patients with renal impairment, but other perceived barriers such as short life expectancy and short planned treatment duration are likely to persist in the clinic.
Encouragingly, the Skeletal Care Academy steering committee (composed of international experts in the field of cancer-related bone disease; oncologists, urologists, surgeons, nurses and patient advocacy groups) has put together a Patient Charter, setting out the basic requirements for standards of patient care in cancer-related bone disease . This charter emphasizes the need for a multidisciplinary team who should understand the various management strategies available for patients with bone metastases. Increasing physicians׳ and nurses׳ awareness of different treatment strategies, together with improved clinical practice guidelines on optimal treatment duration and treatment of patients with short life expectancies, may help to improve patient access to effective therapies. Furthermore, prompt detection of bone metastases, as seen in Germany, may allow patients early access to bone-targeted agents, thereby delaying or avoiding debilitating bone complications and pain.
Conflict of interest statement
Acknowledgments Writing and editorial support was provided by Oxford PharmaGenesis™ Ltd. Funding for this support was provided by Amgen (Europe) GmbH.
Introduction Bone is a common site for metastasis in advanced cancer; reports suggest that approximately 65–75% of patients with advanced breast and prostate cancer, and 30–40% of patients with advanced lung, kidney or thyroid cancer, will develop bone metastasis. Almost all patients with multiple myeloma develop lytic bone disease [1,2]. Owing to the inherent nature of their manifestation, osteolytic lesions (commonly seen in patients who have lung or breast cancer or multiple myeloma) can be related to severe pain, pathologic fractures, life-threatening hypercalcemia, spinal cord compression and other nerve-compression syndromes . In contrast, patients with prostate cancer have predominantly osteoblastic lesions that can also be frequently associated with bone pain, as well as pathologic fractures and spinal cord compression owing to the poor quality of bone formed during the remodeling process  and the often osteoporotic state induced by prolonged castration. These skeletal complications are commonly categorized as skeletal-related events (SREs) and defined as pathologic fracture, radiation to bone, spinal cord compression and surgery to bone. History of previous SREs is associated with an increased risk for subsequent events and a poorer prognosis. Previous studies have demonstrated decreased survival rates in those patients who have bone metastases and prior SREs [4,5]. Although bone metastases/lesions and their associated SREs are predictors for increased mortality [4,6–8], patients with advanced cancer today are generally surviving longer as new and more effective treatment options are introduced into the therapeutic armamentarium. Thus, prevention of SREs becomes even more important as patient life-span is extended.