Treatment
Table 1. Complete List of Recommendations
a
New Recommendations from 2021 ASCO-OH Focused Guideline Update
Recommendation Evidence rating
e Panel does not recommend the use of adjuvant denosumab.
Key evidence:
Two Phase III studies of adjuvant denosumab did not show a consistent
reduction of breast cancer recurrence in any subset of patients with early-
stage breast cancer. e larger study, D-CARE, did not show improvement
in cancer outcomes with use of denosumab.
Moderate
recommendation;
EB-B-I
Recommendations Unchanged From 2017 CCO-ASCO Guideline
Recommendations
For purposes of adjuvant bisphosphonate use, the definition of menopause should include
both natural menopause (at least 12 months of amenorrhea prior to initiation of chemotherapy
or endocrine therapy) and menopause induced by ovarian ablation or suppression (but not
the cessation of menses due to chemotherapy alone). In people age ≤60 years with a previous
hysterectomy and ovaries le in place, luteinizing hormone, follicle-stimulating hormone, and
serum estradiol should be in the postmenopausal range and measured prior to initiation of any
systemic therapy to receive adjuvant bisphosphonates.
A dental assessment is recommended, where feasible, prior to commencement of
bisphosphonates, and any pending dental or oral health problems should be dealt with prior to
starting treatment, if possible. Patients should be informed of the risk of developing osteonecrosis
of the jaw (ONJ), especially with tooth extractions and other invasive dental procedures. Patients
should inform their dental practitioner of their treatment. Patients with suspected ONJ should
be referred to a dental practitioner with expertise in treating this condition. Recent guidelines or
position papers by groups such as the International Task Force on Osteonecrosis of the Jaw, the
American Association of Oral and Maxillofacial Surgeons, and the American Dental Association
should be consulted.
Patients should have serum calcium measured prior to starting treatment. Patients receiving
intravenous bisphosphonates (zoledronic acid) should be monitored for renal function prior to
starting this treatment, and for serum calcium and increase in serum creatinine throughout the
treatment period.
Calcium and vitamin D supplementation is recommended unless otherwise contraindicated.
Oral bisphosphonates and calcium should not be taken concurrently; several monographs suggest
an interval of at least 2 hours to allow for maximum absorption.
Symptoms such as ocular pain or loss of vision may be due to serious inflammatory conditions
such as uveitis or scleritis and should be promptly evaluated by an ophthalmologist.
a
From the 2017 CCO-ASCO Guideline and the ASCO-OH (CCO) 2021 Focused Guideline Update.
(cont'd)
