Q&A: Ghada El-Hajj Fuleihan, MD, MPH, and Matthew T. Drake, MD, PhD

Endocrine News talks with Ghada El-Hajj Fuleihan, MD, MPH, and Matthew T. Drake, MD, PhD, co–chairs of the guideline development panel that created the latest Endocrine Society Clinical Practice Guideline on treating hypercalcemia of malignancy.

Hypercalcemia of malignancy (HCM) is the most common metabolic complication of cancer, but its incidence may be declining due to potent chemotherapeutic agents. The high mortality associated with HCM has declined markedly due to the introduction of increasingly effective chemotherapeutic drugs. Despite the widespread availability of efficacious medications to treat HCM, evidence-based recommendations to manage this debilitating condition are lacking.

The new guideline, “Treatment of Hypercalcemia of Malignancy in Adults: An Endocrine Society Clinical Practice Guideline,” will be published online Wednesday December 21, and will appear in the March 2023 print issue of The Journal of Clinical Endocrinology & Metabolism.

The co-chairs of the guideline development panel are Ghada El-Hajj Fuleihan, MD, MPH, at the Department of Internal Medicine, American University of Beirut, Beirut, Lebanon, and Matthew T. Drake, MD, PhD, at the Department of Internal Medicine, Mayo Clinic, Rochester, Minn. They share their thoughts with Endocrine News about how this guideline will provide the latest in evidence-based recommendations for treatment, and how it should be a valuable tool for primary care physicians and other practitioners.

Endocrine News: What was the main reason for the publication of the hypercalcemia of malignancy guideline – what drove the decision and why now?

Ghada El-Hajj Fuleihan: Hypercalcemia of malignancy (HCM) is the most common metabolic complication of malignancies. Its presence carries a poor prognosis, and if left untreated it can be life threatening. While several published clinical practice guidelines (CPGs) target the treatment of cancer patients with bone metastases, multiple myeloma, and parathyroid carcinoma, we are unaware of any guidelines that are specific for the treatment of HCM. HCM treatment substantially and rapidly alleviates symptoms, improves quality of life, and importantly provides an opportunity to administer therapies targeting the primary malignancy.

“We hope these guidelines will provide a structured framework to guide care pathways in various clinical HCM scenarios. The guidelines illustrate common presentations of HCM, with regards to etiology of HCM, severity of hypercalcemia, and presence of symptoms.”

Matthew T. Drake, MD, PhD, Department of Internal Medicine, Mayo Clinic, Rochester, Minn.

EN: What are your hopes for the impact of the guideline on endocrine standards of care for adults with hypercalcemia of malignancy?

Matthew T. Drake: We hope these guidelines will provide a structured framework to guide care pathways in various clinical HCM scenarios. The guidelines illustrate common presentations of HCM, with regards to etiology of HCM, severity of hypercalcemia, and presence of symptoms. They are based on a systematic approach using the GRADE method which was used to scrutinize the evidence available to-date, its quality as well as its limitations.

EN: How do you expect other medical specialties to be affected by the Guideline Development Panel’s recommendations?

GEF: We anticipate these CPGs and the related workflow/care pathways to streamline the clinical care of patients with HCM across medical specialties. They may provide opportunities for data pooling of case series from various disciplines and will hopefully stimulate the development of clinical trial protocols aiming at closing knowledge/care gaps identified during the development of these guidelines.  

“Hypercalcemia of malignancy (HCM) is the most common metabolic complication of malignancies. Its presence carries a poor prognosis, and if left untreated it can be life threatening. While several published clinical practice guidelines target the treatment of cancer patients with bone metastases, multiple myeloma, and parathyroid carcinoma, we are unaware of any guidelines that are specific for the treatment of HCM.”

Ghada El-Hajj Fuleihan, MD, MPH, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon

EN: What are the key take home messages for patients in this guideline?

MTD: The key messages to patients are that the guideline’s recommendations are driven by disease etiology, severity, clinical manifestations, and resources/health care systems available. In addition to the universal use of potent anti-resorptive medications such as intravenous zoledronic acid and subcutaneous denosumab, regardless of HCM disease etiology, the utilization of disease-specific drugs such as calcimimetics for parathyroid carcinoma and glucocorticoids for some tumors such as lymphoma, are useful adjuncts that can be added in sequential or combination protocols.