Managing patients with bone and Distant Metastasis: Doctor Interview by Dr Ibrahim Husni Mohd Abugheida

Sonam: Good morning everyone. Today we have with us Doctor Ibrahim abugida. He’ll be discussing with us about managing patients with bone and Distant metal status. Welcome onboard Doctor Who. Hello, how are you all, good Sir? How are you

Dr. Ibrahim Husni Mohd Abugheida: good? Thank you.

Sonam: Doctor Ibrahim is head of radiation oncology at Burjeel Medical City, Abu Dhabi. He is trained from world-renowned cancer institutions including the American University of Beirut, Cleveland Clinic, Ohio, and the University of Texas MD Anderson Cancer Center. Dr. Ibrahim has a special interest in treating breast cancers, gastrointestinal, intestinal cancers, genitourinary cancers, karacic, and central nervous system diseases. As well as benign and functional diseases enabled to radiotherapy, he’s a member of the American Society for radiation and clinical oncology, so we look to ask from you what is basically bone and distant metastasis and what is the main cause of these metal status.

Dr. Ibrahim Husni Mohd Abugheida: Thank you so much for your question and for this very nice and kind introduction, so there are different types of cancer and there are some cancers. Are you likely to spread out rather than being in a certain location? And usually, when cancer spreads to a distant site, meaning away from its original side, this is called distant metastasis. The spreading usually happens through the bloodstream or to the lymphatic drainage of the primary site where the cancer is originating from, so this is in general about this metastasis. When the cancer cells go through the blood and find a certain bone where it’s kind of sets and start formulating a colony. Off cancer cells or hence forming a tumor. This is when cancer spreads into the bone. So there is some cancer that goes to the bone. There are some cancers that go to the brain, some cancer goes to the liver, but in terms of they are all called distant metastasis. Because cancer has spread out from its original site and found different cases where it’s metastasized.

Sonam:  What are the medical complications we face? Or the patient with bone, metastatis, face,

Dr. Ibrahim Husni Mohd Abugheida: So the complications range is actually some bone metastasis. The patients have and are completely asymptomatic, meaning that they don’t have any symptoms and it’s just found on scanning. There are some. Sometimes when you have a bone metastasis that is causing some pain, meaning that the tumor is formulating in the bone. Has displaced a lot of normal bone and has of course some compression or small nerves and causing some pain. There are some areas where the tumor is so extensive that it actually causes the bone to break. Calling what we call a pathological fracture, which is it, You know it fractures from the tumor and there are some areas where the tumor compresses other organs next to the bone that causes pain as well, like the spinal cord. If you have a tumor that goes to the spinal or vertebral column. And starts growing inwards, compressing the spinal cord can cause some neurological symptoms and so on and so forth. So it really depends on which bone, but I would say the most common symptom of bone metastasis is pain. If it shows a patient reports with so.

Sonam:  So basically what are the kinds of types? What are the types of cancer most likely in which normally bone metastatic is seen?

Dr. Ibrahim Husni Mohd Abugheida: That’s a very good question, so it depends. So let us have a lot of cancers. I would say they like to go to bones, but that doesn’t mean that other cancers can’t go to bones actually. So because it’s just like you know, the mechanism of action. How does cancer spread? I would say breast cancer because it’s the most common cancer that we see, so hence the number one reason where we patients we have with bonuses are usually from breast, primary, or breast cancer. Primary lung cancer also has a tendency to spread to bones, prostate cancer in men also has a high tendency to spread to bones. And so on. Many other cancers, like head and neck cancer, gynecological malignancies, so really don’t matter. You know what type of disease it originates from. It matters on finding the Nice medium to grow and cause symptoms inside the body.

Sonam: So if we talk about diagnosing the set metastasis, So what is the basic Test or what basic evaluation is required or used for the diagnosis.

Dr. Ibrahim Husni Mohd Abugheida: So the first of all is the most important test is the history and physical exam, so we need to take a detailed history from the patient. Discuss this pain, try to and that’s what type of pain it is. It is suggestive of metastasis or not. A physical exam is extremely important and then we go to them for further testing and imaging. Sometimes plain X-rays can show us you know extensive disease. Sometimes we see the bone metastasis on cross-sectional imaging like CT scans or CAT scans or PET scans as well. And sometimes we use bone-specific scans like bone scans that can also help us to see bone disease as well, so there are multiple imaging and the ultimate way of diagnosing bone metastasis is actually by having a biopsy of this to prove that this is actually cancer-related, the growth, not something else so so it ranges from history. Physical exam all the way to the biopsy. Which is always the gold standard, if of course, it has to be a safe biopsy, which is always the gold standard in diagnosing.

Diagnosis for bone and distance Metastasis

Sonam: So if we talk about the prognosis, how it takes place basically in the bone as well as in distant metastasis of different parts of the body. So how is the process of this?

Dr. Abu:  Well, you know if you ask me this question. 10 years ago I will have a different answer than the answer now. So usually when we have borne the taxes, this is automatically staged four, but we think you know stage four is a bad prognosis for the patients. However, you have to keep in mind that now Metastasis is not all the same. There is a new entity in oncology, what we call oligometastatic, which is metastasis that is limited metastasis and we believe that these patients have a different biology tumor than the ones that. Are diffusing into something and having a bone-only metastases as compared to bone, liver, and brain metastasis so completely different outcomes for the patients so so, so in general, we tell the patient this is stage four. This is most likely an incurable disease, but you know now, with the development of very good drugs and treatments like immunotherapy, that can give us long-term outcomes in these patients we might be able to actually give them a better quality of life, better control of the disease. By sometimes treating those metastatic sites if they are limited and they are, they are able to be treated easily and so so we cannot group them all in one group. So the outcome really differs between one patient. I’ll say a prostate cancer patient with one or two bone metastasis and lung cancer patients with five bone metastatic has to leave early brain growing lesion. So these are both metastatic but the outcomes are completely different.

Sonam: So now I’m coming to the most important part of you know, discussion. So what role does radiation therapy plays in such cases?

Dr. Ibrahim Husni Mohd Abugheida: Yeah, thank you so much for that. So radiation is actually a very powerful way of killing or controlling cancer cells. So radiotherapy in the form of metastasis sometimes we have a big role in the kind of. So as I mentioned, sometimes the bone attacks cause some pain and the patient are using a lot of pain Medications and we know that there’s a focal area of this chronic severe pain and the patient is having significant side effects from the pain medications, including you know, Constipation, dizziness, etc. Or he or she cannot tolerate the pain medication. Sometimes we resolved to radiotherapy to try to control the pain and the patients. So of course the degree of control varies between the patient and the other between the biology of the tumor between the top of the tumor and sometimes radiation. Is actually used more aggressively? I would say for patients who have limited Bone metastasis after we make sure that you know we have a good systemic control. They are giving good drugs and they are stable. Then we say, can we, you know, treat those with a slightly higher dose or with an ablative dose that could kind of give us local control and there are actually very encouraging phase two data that supports that for different ideologies. I would say the most important trial is the Sabre comments trial. That came out from Canada that has actually really shown that improved progression-free survival in these patients, meaning that these patients are left to progress when they are offered more aggressive local therapy with radiation, of course.

Medications for bone and distant Metastasis

Sonam: So if we talk about why Burjeel Medical City for treatment, So what are the advancements which are there because of which a patient should, you know, consider Burjeel as an option for treatment.

Dr. Abu: Well, thank you so much for this question again. That’s a, that’s a very I would say hard and an honest question like you know, so I will tell you why us. I would say everyone who practices oncology practices for a purpose and practices to try to give the best for their patients. But what I can tell everyone listening and seeing it. This is that he Burjeel medical city in Abu Dhabi. Actually, I tell every patient that I see that we are treating as if you’re one family. So we treat patients as if they are all. One family, we’ve put ourselves, our shoes in terms of the patients self shoes or their family issues. We respect the culture with respect, the identity of the patient, and most importantly is that a lot of times you know we tell patients no, you don’t need treatment. You need to go back home and you know, stay with your family. So so it’s a very fine balance between over-treating patients and even with the intention of doing the best for the patient. So so it’s. Always important that we balance this and we I will tell them every patient that gets seen at least in here. Look at them and not only for me. Also this the nurses to the therapist to the staff, to the physics team. You know if this is your own family member, what will be your treatment option for this patient? And this is how we minimize errors.

Sonam: So basically it is not a treatment, it is a personalized care experience.

Dr. Ibrahim Husni Mohd Abugheida: Absolutely so it’s individualized. It’s the treatment. And we have to integrate our treatment. You know, we have to leave it to the Burjeels for accuracy. And it’s all about you know. Precision medicine. It’s all about. How can we find something? How can we integrate, you know, a good radiation oncologist is not only a good division of the traditional college is a good medical oncologists a good surgeon. So how can we integrate the multidisciplinary approach for these patients? So you know, if I’m treating something and I know that there might be immunotherapy that might help me improve the patient’s outcome, you know, then you know we should definitely have  Medical oncologists input that. so so the good thing about this ecosystem and treating patients and a comprehensive cancer network is that you know you. It’s not a single person that’s taking care of a patient. It’s a team and it’s all about it. I always emphasize it’s. It’s the team that matters. So so so so. It’s individualized, a personalized tailored treatment that suits every single case.

Sonam: OK doctor, if we talk about the protocols and guidelines, what protocols and guidelines are you using? to provide them with the best treatment.

Dr. Ibrahim Husni Mohd Abugheida: Yes, thank you so much for this. So the currently accepted protocols and guidelines that is mostly adopted worldwide are the NCCN guidelines for the treatment of cancers. On top of that, so the NCCN guidelines are also some details about 3D therapy in terms of those constraints, etc. But to be very honest, I think we can do better, so the NCCN guidelines is placed for the entire world to look at it. But you know, coming from some centers that I know that we can deliver a better plan. And for example, I’ll tell you about a very common area of breast cancer. OK, so breast cancer when we’re treating breast cancer, you know the answers and I’ll give you or the RTOG guidelines give you a certain heart tolerance Dose, you know there’s a for the heart? You have a certain tolerance tools, and I think these can be really lower and with the techniques that we have at Burjeel Medical City. So that’s why, for example, we are doing gated treatment. So we are taking the patients are getting their treatment while having a deep breath. And this actually saves a lot of the heart decrease those. In the lungs as well. To decrease the potential. Late side effects of radiotherapy. This is extremely important, so so actually you know we sometimes I mean for an aim for a mean heart dose of less than two Gray or less than one Gray in some cases rather than 4 Gray, which is you know which is usually accepted. So we always try to do the extra step that like really save the patient long term consequences

Sonam: and that might help patients as well because they don’t have to go for the extensive. Treatment, which definitely brings on many side effects for the patients.

Dr. Ibrahim Husni Mohd Abugheida: You’re absolutely correct that so I was trying to do the most cost-effective patient driven. You know, if we can, we can. We know that if we can deliver treatment in a shorter course that has the same efficacy and even sometimes better than the long course, this will be. This will be our option and I’ve got to say you know these 5 old. It’s the bad side effects of COVID. And the problems with COVID that had created worldwide actually COVID have highlighted the importance of, you know, do we really need to get the patients six weeks for radiotherapy? Or can we get them in four weeks? Can we get them one week for radiotherapy? So that doesn’t mean that every patient has to come and spend three months of their time. You know, after the time that they want to spend with their families back home away, no, we can actually deliver the same treatment, sometimes even more effective in a shorter period of time. And all you need is the will. The experience the machine that does that, and very importantly the physics team who behind the scenes do all the quality assurance for the machine who is confident and experienced enough in in in commissioning this kind of treatments

Sonam: That brings out the best results for these patients as well.

Dr. Ibrahim Husni Mohd Abugheida: Yes, yes, that’s always are in.

Sonam: Yeah, all right doctor, this was the yet. So I think the discussion which we had built really help out many of the. Cancer patients who seek treatment for. Born and Distant meter setters and how they should, you know, follow the path of the treatment so this will really help them out and I’m really thankful for you for providing me with the valuable time from your busy schedule. So thanks a lot.

Dr. Ibrahim Husni Mohd Abugheida: So thank you so much for your time and again we are here to help. I mean we studied medicine to help people. I mean our job is to help people and and and our busy schedule is. ’cause we have people we’re trying to help so so our job is to convey this message and our numbers are contact details. Please feel free to share them with definitely and then and this is our job is, you know, even remotely virtually we can. We can try to assist and even collaborate with all the other facilities, hospitals, doctors and you know our job is to educate and learn at the same time because we are here. Learning is never-ending. The process I learned from patients way more than I learn from books and, and I want them to know that you know, we it’s mutual respect and mutual. Would say. Interest to try to get the patients the best outcome, right?

Sonam: So thank you very much, Doctor. Thanks for your time. Thank you bye-bye.

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