ASCO GUIDELINES Bundle

Bone-Modifying Agents in Breast Cancer

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106 Commerce Street, Suite 105 Lake Mary, FL 32746 TEL: 407.878.7606 • FAX: 407.878.7611 For additional copies, order at GuidelineCentral.com Copyright © 2017 All rights reserved ASCOBON1733 Disclaimer is pocket card is derived om recommendations in the American Society of Clinical Oncology Guideline. is resource is a practice tool based on ASCO ® practice guidelines and is not intended to substitute for the independent professional judgment of the treating physician. Practice guidelines do not account for individual variation among patients. is pocket card does not purport to suggest any particular course of medical treatment. Use of the practice guidelines and this resource are voluntary. e practice guidelines and additional information are available atwww.asco.org/breast- cancer-adjuvant-bisphosphonates-guideline. Copyright © 2017 by American Society of Clinical Oncology. All rights reserved. Abbreviations CCO, Cancer Care Ontario; ONJ, osteonecrosis of the jaw Source Dhesy-ind et al. Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: A Cancer Care Ontario and American Society of Clinical Oncolog y Clinical Practice Guideline. Journal of Clinical Oncolog y 2017 March 6. doi: 10.1200/JCO.2016.70.7257 [epub ahead of print]. ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care and that all patients should have the opportunity to participate. Additional information, including a data supplement, a methodolog y supplement, slide set, and other clinical tools and resources, is available at www.asco.org/breast-cancer- adjuvant-bisphosphonates-guideline and www.asco.org/guidelineswiki • It is desirable to have multiple agents with different modes of administration (see Recommendation 2) • As with any novel therapy or new indication for existing medications, cost, access, funding, and drug approval need to be considered in the implementation of treatment recommendations. As mentioned in the preamble to the Practice Guideline, several health care settings currently may have access only to bone-modifying agents to improve bone- density or for the treatment of metastatic cancer. As such, drug formularies and governing bodies may need to revise approved dose and scheduling parameters for these relevant medications before clinicians may be able to utilize them. As examples in North America: ▶ Zoledronic acid has recently been added to the Cancer Care Ontario (CCO) Drug Formulary (April 2016) for the adjuvant treatment of breast cancer in postmenopausal women. Clodronate thus far only has Health Canada Approval for the management of hypercalcemia of malignancy and for treatment of bone metastases and is included in the CCO Formulary and British Columbia Cancer Agency Cancer Drug Manual for these purposes. ▶ Zoledronic acid is approved in the United States for treatment of low bone mass and metastatic disease, and clodronate is not available. ▶ Ibandronate is not currently approved for use in Canada. It is approved by the US FDA for the prevention or treatment of postmenopausal osteoporosis. ▶ Direct patient cost and health system resource impact should be considered in implementing such recommendations. Other Considerations

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