ASCO/CCO Role of Bone-Modifying Agents in Metastatic Breast Cancer Guideline Summary

Updates

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.

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