Practical consensus recommendaton for adjuvant bone-modifying agents in breast cancer

Abstract

Bone-modifying therapy is a primary research interest in breast cancer. Several features contribute to the importance of the bone environment in the management of breast cancer. Firstly, bone metastases represent the most common site of breast cancer metastases and secondly, the emergence of cancer treatment-induced bone loss (CTIBL) among breast cancer survivors and patients is of increasing concern. In the adjuvant setting, bisphosphonates can be given to prevent and treat tumor therapy-induced bone loss in premenopausal and postmenopausal women and, owing to their beneficial effect on bone turnover, have also been evaluated for prevention of bone metastases occurrence. Expert oncologists discusses on the update on the approaches of Bone-modifying Agents and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Adoption of adjuvant bisphosphonates for early breast cancer into standard clinical practice: Challenges and lessons learnt from comparison of the UK and Australian experience

“…As a result of published international data, the sub-analysis of the AZURE trial and the subsequent confirmed results of the large 2015 meta -analysis [5] , [6] , [7] , [8] , [9] , [10] , [11] , adjuvant BPs have now become standard of care to reduce BC mortality in post-menopausal EBC patients in the UK as well as the rest of Europe and America, supported by published guidelines on drug choice, duration and patient selection [17] , [18] , [19] , [20] , [21] . Interestingly, a very recent study reported that extending adjuvant zoledronic acid treatment beyond 2 years did not improve the prognosis of high-risk patients with EBC receiving chemotherapy and that current recommendations for 3 – 5 years of treatment could be relaxed [25] .…”

“…Following publication of the 2015 meta -analysis [11] , many international guidelines now recommend adjuvant BPs (usually intravenous zoledronic acid every six months for three years or oral clodronate) for post-menopausal women with EBC to reduce recurrence and mortality, particularly for those considered at high risk of BC recurrence [17] , [18] , [19] , [20] , [21] . Women with high risk of disease recurrence are deemed those who warrant standard adjuvant systemic chemotherapy/HER-2 targeted therapy and/or have greater that 10% 10-year risk of disease relapse.…”

“…For women with BC, BPs are available on the PBS for treating osteoporosis, reducing the risk of skeletal related events in patients with BC metastatic to the bone and managing hypercalcemia of malignancy [22] . However, despite the evidence and recommendation in international guidelines [17] , [18] , [19] , [20] , [21] , adjuvant BPs are not PBS listed for preventing CTIBL, reducing BC recurrence or improving survival for patients with EBC. On a private script in Australia, the most commonly used BP (zoledronic acid 4 mg) costs between AUD $50 - $200 per dose [23] .…”