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.
Treatment
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.
Table 1. Route of Administration, Dose, and Schedule for Bone Modifying Agents
Agent | Route | Dose | Schedule |
|---|---|---|---|
Bisphosphonates | |||
Pamidronate | Intravenous | 90 mg | Delivered over no less than 2 hours every 3 or 4 weeks |
Zoledronic acid | Intravenous | 4 mg | Delivered over no less than 15 minutes every 12 weeks or every 3–4 weeks |
Monoclonal antibodies | |||
Denosumab | Subcutaneous injection | 120 mg | Every 4 weeks |