Bone-Modifying Agents in Metastatic Breast Cancer

Publication Date: October 16, 2017
Last Updated: March 19, 2024


  • Patients with breast cancer who have evidence of bone metastases should be treated with BMAs. (Strong Recommendation: EB-H)
    • One BMA is not recommended over another.
    • Options include:
      • denosumab, 120 mg subcutaneously, every 4 weeks;
      • pamidronate, 90 mg intravenously, every 3–4 weeks; or
      • zoledronic acid, 4 mg intravenously, over no less than 15 minutes,
        every 12 weeks or every 3–4 weeks.
  • The analgesic effects of BMAs (denosumab, pamidronate, or zoledronic acid) are modest. They should not be used alone for bone pain.
    (Weak Recommendation: EB-L).
    • The current standard of care for supportive care and pain management should be applied. This can include analgesia, adjunct therapies, radiotherapy, surgery, systemic anti-cancer therapy, and referral to supportive care and pain management.
    • Evidence of a clinically meaningful benefit is insufficient to support the use of one bone-modifying agent over another.


Unchanged from 2011

  • BMAs are recommended for patients with metastatic breast cancer with evidence of bone destruction.
  • One BMA is not recommended over another.
  • Mechanism of action, as well as the potential benefits and harms, should be taken into account when considering long-term use of BMA.
  • In patients with creatinine clearance >60 mL/min, no change in dosage, infusion time, or interval is required.
  • Monitor creatinine level with each intravenous bisphosphonate dose.
  • In patients with creatinine clearance <30 mL/min or on dialysis who may be treated with denosumab, close monitoring for hypocalcemia is recommended.
  • All patients should have a dental examination and preventive dentistry
    before using a BMA.
  • Use of biochemical markers to monitor BMA use is NOT recommended for routine care.



Role of Bone-Modifying Agents in Metastatic Breast Cancer

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