A conversation with osteoporosis researcher Felicia Cosman, MD
Her own early osteoporosis led endocrinologist Felicia Cosman, MD, to her groundbreaking work with anabolic medications and other important breakthroughs in osteoporosis treatments.
For that work, she received the American College of Endocrinology (ACE) Distinction in Endocrinology Award by the American Association of Clinical Endocrinologists.
Cosman, who serves as a professor of medicine at Columbia University in New York, spoke with Endocrine Today about her personal connection to osteoporosis research, the virtues of perseverance and her passion for travel.
What was the defining moment that led you to your field?
Cosman: To some extent, I fell into it because I always had an interest in the skeletal system, and bone was the focus of my research during my endocrinology fellowship at Columbia. Then an opportunity came up to work in the osteoporosis field and pursue clinical research, particularly osteoporosis pathophysiology and osteoporosis therapeutics at Columbia’s affiliated rehabilitation hospital in Rockland County. That was appealing to me and turned out to be my lifelong career.
I have a particular interest in anabolic therapies for osteoporosis. This evolved from my early research where we were testing the effects of parathyroid hormone, or PTH, before it was an approved osteoporosis medication, on stimulating bone formation and building bone mass. A lot of my research evaluated in vivo studies exploring mechanisms of action of PTH, using bone biopsies and biochemical assays, as well as bone density testing. We also attempted to determine how to best utilize PTH in combination or in sequence with other (antiresorptive) medications for osteoporosis.
As other anabolic medications became potentially available, I shifted my interest to work in the clinical development of these other compounds, namely abaloparatide (Tymlos, Radius Health) and romosozumab (Evenity, Amgen). These studies helped toward the FDA approval of abaloparatide in April 2017 and romosozumab in April 2019.
Some of my interest in the anabolic therapies stems from the fact that I personally had extremely low bone mass, something I found out as a young woman. I was still premenopausal, healthy and just 40 years old. I had ready access to bone density testing because I worked in the bone density area every day, and I found out that my bone mass was already in the osteoporosis range at that point. In combination with the fact that my mother had suffered vertebral fractures that were discovered incidentally when she was getting evaluated for another medical issue, I knew that I was in the very high-risk category for fractures, long term. That was a defining moment, and perhaps is what swayed me to become particularly interested in the utilization and applicability of anabolic therapies. This idea that you could rebuild the skeleton with these types of medications to shift the person off her high-risk curve and protect her from disabling and deforming fractures became both a personal as well as professional interest for me.
What advice would you offer a student in medical school today?
Cosman: Anything that’s worth something requires a lot of hard work. There’s no single path for success. Often that path is not straight and is filled with ups and downs. This is certainly true in the area of clinical science. If you get one grant rejected or one paper rejected, you have to persevere. If you are confident that your ideas are good, don’t give up.
Have you ever been fortunate enough to witness medical history in the making?
Cosman: I’ve been on the front lines of the research studies that have gotten drugs approved. Most recently, I was at the FDA advisory committee for the discussion of romosozumab, and I participated in that advisory committee.
The osteoporosis field is not really that old, so just being part of the development of all of these compounds and participating in the research from diagnostic testing — including, bone density and vertebral imaging, biochemical markers and bone biopsies — as well as evaluating therapeutic agents for bone, is really witnessing history.
I’ve also participated in guideline committees, task forces and advisory committees. I headed the National Osteoporosis Foundation’s 2014 clinicians guide committee, and we made some progress in advocating for appropriate use of medical therapy as well as diagnostic testing to include not just bone density, but also spine imaging. Trying to identify patients who have subclinical vertebral fractures is another one of my big interests in the last 10 years or so.
What do you think will have the greatest influence on your field in the next 10 years?
Cosman: The field needs to evolve to think about the best way to utilize our armamentarium over a long period of time. A lot of our guidelines talk about treating or not treating for a duration of 3 to 5 years. Fortunately, postmenopausal women and middle-aged men have a life expectancy that may be 40 years after the diagnosis of osteoporosis is made in their 50s. We need to think about strategies to maintain skeletal integrity for all of this time. The same choices may not be appropriate in a 55-year-old woman compared with an 86-year-old woman.
The use of anabolic medication has been undervalued and underappreciated by most of our societies, and I would say that AACE is perhaps the one exception. AACE guidelines have recommended a consideration of initial use of anabolic therapies for people at high risk. I firmly believe that is the right approach and that the field will evolve toward that approach. One of the limiting features right now is not effectiveness or safety, but cost, and I hope that as the costs come down with these medications, that doctors and patients will take advantage because they offer much more than just antiresorptive therapies.
What are your hobbies/interests outside of your field?
Cosman: My biggest interest outside my field is my family. I have a husband of 32 years and three children in their 20s. One daughter is about to start a doctorate program in public health from Johns Hopkins and another is working for an immigrant rights organization called Cosecha. My son is working for IBM as a technical solutions specialist. So they all are doing extremely well.
I love to cook enriched dishes that highlight vegetables and enjoy sorting through recipes and planning meals with my daughter. I’m a big outdoors person; I love to walk and hike with my husband and dog. I participate in seasonal activities — biking, tennis, swimming and skiing. I love classical music and some popular music, art and traveling. I recently got back from trips to Japan, Amsterdam and Paris. This year I’ll be going to South Korea and Cartagena, Colombia, and will be going back to Japan and stopping in Hawaii on the way back. – by Phil Neuffer