cancer and bone health webcast august 10, 2010 robert f. gagel, m.d

Cancer and Bone Health Webcast August 10, 2010 Robert F. Gagel, M.D. Dawn Born Please remember the opinions expressed on Patient Power are not necessarily the views of M. D. Anderson Cancer

Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care

from your own doctor. That’s how you’ll get care that’s most appropriate for you. Dawn’s Story Andrew Schorr: Bone loss is a natural part of the aging process. Unfortunately, cancer and some cancer treatments can also contribute to deterioration of bone health. Coming up you'll hear from an M. D. Anderson expert and a cancer survivor as they discuss prevention of bone loss and how to increase bone health. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by M. D. Anderson Cancer Center. I'm Andrew Schorr. Well, we talk so often about specific cancers and connect you with experts in the treatment of those illnesses, but there are some concerns that are overriding in cancer, and one is protecting the strength of your bones. You do not want to have fractures. So it sounds like we're talking about osteoporosis that affects millions of people, and that's true, and the risk of course is fracture, and fractures can be painful, debilitating, causing disability and in some cases leading to someone's demise. We don't want that. Well, if you're treated for cancer with powerful medicines to attack the cancer, and we're doing better with that, and radiation, even those have some effect, can have effect on the bone. So what do you do about it? Well, let's meet first someone who has dealt with that, and it started way before cancer. She is a cancer survivor and doing well, but we're going to talk about what happened first. So Dawn Boren joins us from Houston. Dawn, when you were pregnant with your first child, Matt, you found out that the fetus for its nourishment was stealing from your bone, right? Dawn: Yes, I did. Andrew Schorr: And so that led to what? What happened? What was the effect of that. Was it some fractures right then at your early age? Dawn: Yes. I was 30 years old and when Matt was two months old I found that I had four fractures in the thoracic region of my spine and two in the lumbar region.

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Andrew Schorr: Oh, my. So you're on one end of the scale where that was a very rare problem in pregnancy, but here you are, a woman, what, 30 at the time? Dawn: Yes, I was. Andrew Schorr: All right. And you had bone issues. Well, let's move forward--and you had treatment for that. Let's move forward many years, 1999, and then your gynecologist is suspicious about a lump, probably nothing but unfortunately it's one of those stories where it was something, and it turned out to be invasive ductal carcinoma, breast cancer, and you found out later that there had been some spread to your lymph nodes and you needed chemo and radiation. Was there any discussion then that that approach of fighting the cancer could also have an effect on your bones? And your breast cancer was estrogen receptor positive so I know the approach is stop the fuel for the cancer, the estrogen. So what about that? Dawn: Well, in those beginning days, no. No one was really focused at that time on by bones. Everyone was focused on the breast cancer. However, I met--in the breast center. However, I did have a relationship, a previous relationship with Dr. Gagel, and he and I did talking extensively about how the treatment for breast cancer and the menopause that I would go through would have an effect on my bones. Andrew Schorr: Well, let's mention this doctor you've had a relationship with and meet him as well, and that is a doctor you met many years ago because of these bone issues, an endocrinologist but also now head of the Division of Internal Medicine at M. D. Anderson and also co-director of the Bone Disease Program of Texas, which is a collaboration with Baylor College of Medicine, and that's Dr. Robert Gagel. Dr. Gagel, am I right that Dawn, starting with this bone and pregnancy issue but then later with cancer and where there can be effects on the bone from that, she was sort of at one end of the spectrum, am I right? Dr. Gagel: That's right. Dawn had a serious problem with her bones at age 30 with multiple vertebral fractures, and we nursed her along after her initial pregnancy through a couple more pregnancies and managed to increase her bone mass over the decade of--through the late 80s and into the 90s, and she was doing well, had no further fractures, and her bone mass had improved by at least 10 to 15 percent over the period of time up until 1999. Andrew Schorr: Now, I mentioned at the outset, though--and 1999 is a crucial year for Dawn, diagnosed with breast cancer--that the drugs we have that can fight breast cancer or even, as we'll discuss in this program, to help limit a recurrence like the class of

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medicines, the aromatase inhibitors, some of them are not kind to bone health. So she entered--there she was doing well, but then this was kind of a blow, wasn't it, in trying to fight the cancer but protect her bones. Am I right, Doctor? Dr. Gagel: Absolutely. Dawn's story is not so different from that of many other women with breast cancer, particularly in the earlier era. She had breast cancer considered serious enough that she received six months of standard chemotherapy for her breast cancer. Unfortunately, a common occurrence in women, certainly those over the age of 40 years, is that they, with the chemotherapy they may go through an early menopause. So Dawn in fact stopped having menstrual periods following the chemotherapy and developed just horrible fatigue related to estrogen deficiency, and this persisted for at least four to six months. She subsequently restarted periods but later went through a complete menopause at an earlier age than she would normally have gone through. Now, this is problematic because estrogen deficiency is one of the worst things that you can do for bone, and to have someone who already had borderline bone mass and a history of fractures at a relatively young age to go through an early menopause put a lot of pressure on us to come up with therapies that would prevent her bone loss. Protecting the Bones Andrew Schorr: Wow. So I mentioned that this affects a lot of us who have had treatment, so if the concern about bone health with Dawn had been going on for many years and you'd worked hard to get her back to a good place, but for any of us, if we walk in with healthier bones these treatments that are cancer-fighting or trying to prevent a recurrence we have to be mindful, I guess, in discussion with our doctors about, okay, let's beat the cancer, and I want to get through it, but let's protect my bones for reducing the long-term risk of fractures. Am I right about that, Dr. Gagel? Dr. Gagel: Yes. To put it in perspective, we define osteoporosis, and osteoporosis is a point at which you've lost or do not have bone to such a degree that you are at risk for a fracture, so it's the point at which we begin to see fractures, that is the loss of about 30 to 35 percent of bone mass. And many of these therapies, be it for breast cancer or for prostate cancer, where we block the effects of testosterone or the use of glucocorticoids in leukemia, lymphoma or bone marrow or stem cell transplant will cause significant amounts of bone loss. So if you're placed on, let's say, an aromatase inhibitor, as Dawn was, it's reasonable that if you're not treated with anything that you will lose anywhere from two to three percent of your bone mass per year. Now, the average woman continues on aromatase inhibitors for five years or more so that it's theoretically possible that she could lose as much as 15 percent of her bone mass in those five years related to aromatase therapy.

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Andrew Schorr: And she may have been losing it anyway just in the aging process. I know I'm telling my kids to drink milk and vitamin D and calcium and all that stuff as we're building when we're younger, but we're naturally losing bone usually as we get older, right? Dr. Gagel: That is correct. So it's important to think not only about estrogen deficiency but adequacy of vitamin D, adequacy of calcium intake and a robust amount of exercise to try to counter the effects of these drugs. Andrew Schorr: Dawn, from having had fractures this is no fun, right? I mean, you would advise people if there's anything they can do to avoid it, you want to, right? Dawn: It is no fun. Andrew Schorr: I should mention that Dawn has for many years been a corporate attorney, and so she's dealt with this for a long time. And now, Dawn, as you've struggled but still trying to deal with your bone health while you're taking a number of medications, you're on had some disability now, you're going on that just because it's tough, right? Dawn: It's tough, and the lack of estrogen does cause, as Dr. Gagel said, tremendous fatigue and on top of that the need, as he said, for a lot of exercise, eating healthy, vitamin D, calcium. There's just a lot to do. Andrew Schorr: Dr. Gagel, let's talk about what the strategy is now. Now, I kind of alluded to calcium, you know, getting that in your diet, and vitamin D I know is really important and maybe higher levels than just what might be in a multivitamin, and then there are medicines as well to--maybe a wider array now, too. So it will vary by patient, but what sort of a strategy. And you mentioned even exercise too, and I know I've heard about weight-bearing exercise. What sort of tools do you have now to try to help someone who is in therapy or a cancer survivor try to strengthen their bones and protect their bone health? Dr. Gagel: So we've already mentioned calcium, vitamin D and exercise, and those are important elements, but even with that unless one is on or a patient is placed on a drug to specifically prevent bone loss, bone loss will occur. So estrogen deficiency in women or androgen deficiency or testosterone deficiency in men are so--their functions are so important that both men and women lose bone if they're deprived of those hormones.

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So what we do in the case of breast cancer, for example, we know that the drugs are designed to lower the estrogen levels as low as possible and that that has benefit. It improves outcomes, improves survival, and there are fewer deaths from cancer in women who take aromatase inhibitors, so the challenge for the endocrinologist or the rheumatologist is to come up with an alternative strategy that will not interfere with their cancer treatment but at the same time protect their bones. And the drugs that we use at the present time in the context of breast cancer are bisphosphonates, and there are three oral and two intravenous bisphosphonates, each of which has their strengths and weaknesses. And we have one new agent, a monoclonal antibody that targets an important signaling molecule in the development of cells that break down bone, and the monoclonal antibody is called denosumab or its trade name is Prolia. And it was just approved within the last six weeks for treatment, and in fact Dawn will be starting on that within the next week or two when it becomes available. So we have a number of tools that we can use now to both treat osteoporosis and also to prevent it. Andrew Schorr: So it seems that now, I know M. D. Anderson, you have a program now, you've really made a commitment to it, this is part of the discussion that a cancer patient has with their doctor, and it goes along with a whole host of side effects, this really being a critical one, and that is help me fight the cancer, help me beat the cancer and help me remain otherwise as healthy as I can. Protect my heart, protect my bones and give me the best chance of living a full life after cancer, right? That's part of the dialogue. Dr. Gagel: That is absolutely a part of the dialogue, and we in internal medicine and endocrinology work as partners with the oncologists and our goal, be it endocrinology, cardiology, rheumatology or the other disciplines of internal medicine, is to come up with a strategy that will protect the bones, the heart and so forth so that a patient can receive treatment that we hope will be curative. Andrew Schorr: Dawn, it takes a proactive patient, too, right? You've been, over the years, a lot of these drugs and strategies have developed more recently. You speak up for yourself and have for years, right, and probably would recommend that for others? Dawn: Yes. I think it does take a proactive patient, and it takes a patient that's curious enough to ask the questions and to start a dialogue with a doctor. Andrew Schorr: We're going to talk more about bone health, and for those of you listening, whether you're the cancer patient or a family member, a loved one or a friend, we're going give you some strategies to help understand first of all the need for this and how

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you can advocate for yourself and also a little more about the tools and how they work to help strengthen your bones. It's all coming up as we continue our discussion on Patient Power. The Effect of Treatment on Bone Health Andrew Schorr: Welcome back to Patient Power. Andrew Schorr here with Dr. Robert Gagel who is head of the Division of Internal Medicine at M. D. Anderson. He's an endocrinologist very concerned about the health of your bones, and as you can imagine at M. D. Anderson really trying to help people who are in treatment or have been treated for cancer to have the best bone health and avoid fractures. Also with us is a patient of his who has been with him for many years, Dawn Boren from Houston, who actually had fractures after the first of three pregnancies many years ago, a rare condition, but it caused fractures. She got into a relationship with Dr. Gagel and then, guess what, she was diagnosed with breast cancer, and the treatments for breast cancer and some other cancers unfortunately do fight the cancer but they can have negative effects on your bone. I understand, Dr. Gagel, that's not universal. Like one of the drugs that's been used for many years to help women fight a recurrence, lower their risk of a recurrence of breast cancer, tamoxifen, that's been around for many years, that's not so unkind to bones. Is that right? Dr. Gagel: Well, it depends on where you stand in the spectrum of estrogenization or having or not having estrogen. So premenopausal women who are treated with tamoxifen will actually lose bone, but the majority of women who develop breast cancer are postmenopausal, and in those women tamoxifen actually prevents bone loss. So it actually has beneficial effects or acts more like an agonist or a stimulator of the beneficial effects of estrogen in bone. It's a bit paradoxical that something can be both an inhibitor of estrogen effect and a stimulator of effects in other tissues, but that's how these drugs were designed. Andrew Schorr: Of course, many women today either start right off the bat on aromatase inhibitors or then switch from tamoxifen to aromatase inhibitors. Those are not kind typically, though, right? You probably need some medication to counteract those effects. Dr. Gagel: Absolutely. Let me just go over the risk. In the average woman who starts on aromatase she can expect to lose anywhere between three and four percent of her bone mass per year if there is no other therapy initiated. So if you look at the average current treatment schedule, over the course of five years a woman could lose anywhere from 15 to 20 percent of her bone mass. Again, to put that in

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perspective, we start to see fractures or define it as osteoporosis when a normal individual has lost about 30 percent of bone mass or 30 to 35 percent of bone mass. Complications of Bone Loss Andrew Schorr: All right. So there's let's say a woman is 60, diagnosed with breast cancer, and get through treatment. Now she's on aromatase inhibitor and over five years maybe there's going to be that 15 percent loss. How deficient was the typical 60-year-old woman to begin with? Dr. Gagel: Right. So the average 60-year-old woman is probably going to be somewhere--if she has not received any specific therapy to prevent osteoporosis will probably have lost seven to ten percent of her bone mass already. So when you add 15 to 20 percent on top of the conservative estimate of seven percent you're getting very close to being at risk for fracture. Andrew Schorr: Just so we understand osteoporosis, so is it just less bone or is it porous bones or is it both? What makes them so fragile? Dr. Gagel: There are a couple of elements to it, and the most important is that there's just less bone. Now, nature gives us--we're not all alike. In other words, we have an average amount of bone that the average person in the population has, but there are wide variations with some individuals having more bone, probably related to genetics, what you inherited from your parents, and other people having less bone. And, for example, men and women in Scandinavian or northern European populations tend to have less bones than individuals certainly of African descent or even Mediterranean descent, so there are genetic differences in the amount of bone that you have. Yet the realty is if you lose 30 to 40 percent of your bone mass you are going to fracture, or if you don't have it you will fracture. Andrew Schorr: And I mentioned that that can not only be a tremendous cause of disability and pain but in some cases it can lead to your demise, right? Dr. Gagel: Correct. A common cause of death in older individuals is a hip fracture, so somewhere in the range of a quarter of women who develop a hip fracture after the age of 70 and a third of men who develop a hip fracture after the age of 70 will actually die within a year or two after such a fracture. Andrew Schorr: Oh, my. All right. Serious problems. So you said you have an array of medications layered on top of calcium and vitamin D and exercise that can help. So

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you talked about those percentages. How many percentage points can we get back? I know it's going to vary, but if something is being depleted how much can you replenish? Dr. Gagel: Let's just break that down into two components, the first component being prevention, the second component what we'll call treatment, that is to try to gain back something you've lost. So in terms of prevention, and bringing this back to breast cancer where we started, the goal would be if a patient is placed on aromatase inhibitors to look very carefully at that patient to see if she is at risk for fracture to begin with or heading toward a risk, and if so to initiate drug therapy that would prevent or slow the loss of bone. Now, the drug agents that we have available that are approved for prevention in this particular situation are largely bisphosphonates. They include alendronate or Fosamax, risedronate or Actonel, ibandronate or Boniva. Or we have other intravenous versions of ibandronate or Boniva and another compound which is zoledronic acid or Reclast. Reclast is the same as Zometa but it's packaged for use in osteoporosis. So in the breast cancer context those are the agents that we have to prevent bone loss, and by and large they're very effective and will prevent at least 90 percent of the estrogen deficiency-associated bone loss. In the treatment category we have the same group of drugs but in addition we have a newcomer and that's a drug called denosumab, d-e-n for dense, os, the Latin word for bone, and umab, which is the monoclonal antibody connecter. So this is a drug that actually is very effective in blocking signaling that leads to formation of the cells that cause bone breakdown, and it's very effective as a treatment for osteoporosis. Now, there are other compounds that are effective in osteoporosis, but we don't use them in the context of breast cancer. The first is a drug called raloxifene, which is similar but different than tamoxifen, but it is actually approved for prevention of breast cancer but has never been approved for treatment, and therefore we don't use it. A second drug that is very--is the only bone-building, truly bone-building drug that we have is a drug called teriparatide. It's trade name is Forteo. Again, there are some hypothetical concerns about the use of Forteo in the context of active breast cancer, and therefore we don't use it at the present time. There may be studies that prove its safety in the future, but for now we just avoid it. Supplementation Andrew Schorr: Dr. Gagel, just a word about calcium and vitamin D diet overall and supplements. Where do they come in?

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Dr. Gagel: Well, they're a very important component of overall bone health. We did a survey a couple of years ago, looked at vitamin D levels or 25-hydroxyvitamin D3, to be specific, in our patient population at M. D. Anderson Cancer Center, and somewhere between 55 and 60 percent of our patients had frank vitamin D deficiency. It is so common in our bone marrow transplant or stem cell transplant patients or in our leukemic patients that they are now just routinely measuring and then starting therapy with vitamin D, and it's very common in others. And it's not surprising. Our patients tend to be receiving therapy. They tend not to be getting adequate amounts of sunlight, and so it is particularly important in the cancer setting to take at least 1,000 units of vitamin D per day, or what I tend to give is 50,000 units once a month. In some patients we actually have to give 50,000 units twice a month to get their vitamin to normalize or maintain vitamin D levels or 25-hydroxy D3 levels in the normal range. Andrew Schorr: Just one basic question, the importance of vitamin D when it comes to bone health. Dr. Gagel: Vitamin D is very important because it has two functions. First, it is necessary for normal absorption of calcium. So if you have an inadequate vitamin D level you will not absorb calcium. Second, there is a direct effect of vitamin D to stimulate bone formation, so you cannot make normal bone nor mineralize it if you don't have an adequate amount of vitamin D. Andrew Schorr: And, Dawn, is it something that somebody can easily do on their own or getting some outside help makes a difference? Dawn: I think you need both. I think that every cancer patient needs to take a holistic approach to health. Part of it is sleeping regularly and sleeping long enough hours. We tend not to do that. Eating properly and getting as many of your vitamins as you can from food but then also supplementing where you're deficient. I think that it does require a very proactive dialogue with your doctor and a nutritionist and be sure that your body is getting what it needs to be healthy and to fight the cancer itself as opposed to fighting against the cancer because you're not healthy. Andrew Schorr: Dr. Gagel, what about calcium? A word about that. Dr. Gagel: Yes, calcium is very important. Vitamin D of course is important to stimulate absorption of calcium from the gastrointestinal tract, but unless you present enough calcium to the gastrointestinal tract of course it won't be absorbed. You cannot mineralize bone or make bone without adequate amounts of calcium. In general, both patients without cancer and patients with cancer should be

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taking--should be receiving in their diet or with supplementation somewhere in the range of 1200 to 1500 milligrams of elemental calcium per day. Generally for most women it's difficult to get that in a diet because women tend to avoid dairy products because of the fat they contain, and so either skim milk or taking a pill and taking a calcium supplement of one or two 500-milligram calcium tablets per day in addition to what one gets in one's diet is generally adequate. Andrew Schorr: Dr. Gagel, so obviously everybody's situation is different, even women with breast cancer, and then I think of other bone complications. Obviously an illness like multiple myeloma has effects on the bone. There are other illnesses we mentioned, other blood cancers. People have sarcoma, and the list goes on and on, and then you mentioned prostate cancer, where somebody could have androgen deprivation therapy, and that can have an effect on their bones too. So it sounds like, when you get right down to it, you may have an array of approaches but what's right for you, that's a discussion between you and your doctor. At M. D. Anderson you have this bone health clinic where someone would come and that would be addressed in their case. Dr. Gagel: That's correct. So when we evaluate a patient we try to put it into the context of their malignancy, and there are different approaches for different types of cancer and for different clinical situations. While we can give broad overviews and generally follow an algorithm for treatment of bone loss in a specific type of cancer, there's no such thing as one size fits all. Hope for the Future Andrew Schorr: Right. Dawn, so let me ask you. So we talked about really the importance of this discussion, how do you view bone health? Obviously you wanted to beat the cancer--and I understand you had a party, right, a big party, as a ten-year survivor. Dawn: I did. Andrew Schorr: 250 people there, something like that? Dawn: Yes. I had a great big party to thank all the people who helped me through those very difficult first couple of years with the treatment.

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Andrew Schorr: Right. It really takes a whole community of people and congratulations on that. I'm a survivor, too, over a decade now, so I know how you feel. But how do you view bone health in the mix of your overall health now? Because a lot of times people don't think about that. It's not top of mind. Dawn: Well, I think it's very important and as I'm sitting here listening to Dr. Gagel and recalling the, what, 15 years or so that I have been a patient of his I recollect that when I first met Dr. Gagel the doctors that had seen me for the bone condition told me I couldn't ever walk again, and in fact I was not walking very well. I couldn't open a refrigerator door. I couldn't hold my son. I couldn't push a door open. I couldn't do very much at all. And by actively discussing my bones and taking a very active role with Dr. Gagel's guidance and support, I go skiing, I do all kinds of things now. And I think that it's very important for anyone who has either bone loss for any reason or as a result of taking drugs for cancer to pay a lot of attention to bone and to know that if you pay attention to your bones and if you're actively involved and you're proactive, it's a great result. I don't seem to be concerned with the things I was concerned about 15 years ago. I just do everything I want and I'm strong. Andrew Schorr: That's terrific. Now, do you have any grandchildren yet? Dawn: No, I don't want them yet. Andrew Schorr: No, no, but you're going to have to be active to chase after them, right? Dawn: I will have to be active. I sure will. I have--one is out of college, one is in college and one is in high school, and I'm constantly on the go. Andrew Schorr: I'm there. I know that. Dr. Gagel, one other thing I just wanted to be sure we cover, and that is I mentioned at the beginning that it's not just drug therapy but it could even be radiation. I'm not sure I understand that. So am I right that radiation can affect bone health too in a cancer patient? Dr. Gagel: Yes, and there is a mixed effect of radiation. Paradoxically, radiation in younger individuals can actually affect the growth of the bone, and so you can see stunted growth of vertebral bodies or the spine as well as long bones that affect the growth plates in these structures.

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In an adult life or after the development of either androgenization or estrogenization there are different effects, and we can actually see situations where when a spine is irradiated the bone actually becomes denser. We don't really understand why that occurs, but we also see some individuals and particularly those treated with high doses of radiation where the bone stops growing completely and actually fractures start to develop as a result of the radiation. So there's no consistency to the response, and fortunately serious problems are uncommon and most commonly seen in patients who have had larger than usual doses of radiation. Andrew Schorr: All right. I think that's just, for our audience, one more reason, whether you've had radiation or chemotherapy, other targeted drug therapies, whatever it may be, you need to have this be part of the discussion. One last question for you, Dr. Gagel. So Dawn kind of alluded to this as how much help you've been to her over the years, and I know she's very grateful. With you and your colleagues do you feel encouraged now that you have the tools to help people to try to keep them out of the danger zone of fractures? Dr. Gagel: For the most part, yes. There's been a sea-change in our ability to treat osteoporosis over the last 15 years. Prior to 1995 we had estrogen as a treatment for osteoporosis and another hormone that is the least effective of our therapies called calcitonin, and it is still available and is approved. It's just the least effective of the therapies. In 1995 we added alendronate or Fosamax and shortly thereafter risedronate or Actonel and later still ibandronate or Boniva. And then later still we added Forteo and Evista, and the most recent addition just a few weeks ago is denosumab. And there are more in the pipeline. So this is our--our ability to prevent bone loss now has improved measurably over the last 15 years and is going to get better over the next five to ten years. There are drugs in the pipeline that will add to our abilities. Andrew Schorr: What an encouraging story. That's terrific. So, Dawn, skiing. Looking forward to grandchildren, and a great doctor who seems like he's helped you a tremendous amount. That's a good story. Dawn: It is. I'm very grateful. Andrew Schorr: Well, we're grateful for you to be with us and congratulations again on that ten-year survivor story, and let's talk again in another 10 or 20 years, okay, and then you'll show me pictures of the grandkids.

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Dawn: Right. Andrew Schorr: Dawn Boren, thank you so much for telling your story here. Dr. Robert Gagel, thank you so much for being with us. And also your dedication and your whom team there and then the collaboration with Baylor College of Medicine as well to understand bone issues and also help us prevent them and us as individuals and your dedication in helping people who have been treated for cancer so we can do better. Thanks so much for being with us. Dr. Gagel: You're very welcome. Andrew Schorr: All right. This is what we do on Patient Power. I just want to mention there's a vast library including our interviews with nutritionists at M. D. Anderson of course who look at diet related to your needs and that includes helping you with the vitamin D and the calcium you can get from your diet and all the nutrition to help you with your overall health also included in that, your bones. I'm Andrew Schorr. Thanks for joining us. Remember, knowledge can be the best medicine of all.

Please remember the opinions expressed on Patient Power are not necessarily the views of M. D. Anderson Cancer

Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care

from your own doctor. That’s how you’ll get care that’s most appropriate for you.

cancer and bone health webcast august 10, 2010 robert f. gagel, m.d

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