Key Points
ÎBone-modifying agents (BMAs) are recommended for patients with metastatic breast cancer with evidence of bone destruction.
> Denosumab 120 mg subcutaneously every 4 weeks > Pamidronate 90 mg IV over ≥ 2 hours every 3 to 4 weeks or > Zoledronic acid 4 mg IV over ≥ 15 minutes every 3 to 4 weeks
ÎOne BMA is not recommended over another.
ÎIn patients with creatinine clearance > 60 mL/min, no change in dosage, infusion time, or interval is required. Monitor creatinine level with each IV bisphosphonate dose.
ÎIn patients with creatinine clearance < 30 mL/min or on dialysis who may be treated with denosumab, monitoring for hypocalcemia is recommended.
ÎAll patients should have a dental examination and preventive dentistry before using a BMA.
ÎAt onset of cancer bone pain, provide standard of care for pain management.
ÎAdd a BMA for bone pain if there is tumor involving the bone with evidence of bone destruction.
ÎUse of biochemical markers of bone metabolism to monitor BMA use is NOT recommended for routine care.
Treatment Options Indications and Time of Initiation
ÎFor patients with breast cancer who have evidence of bone metastases, denosumab 120 mg subcutaneously every 4 weeks, IV pamidronate 90 mg delivered over no less than 2 hours, or zoledronic acid 4 mg over no less than 15 minutes every 3 to 4 weeks is recommended.
ÎIn women with an abnormal bone scan and an abnormal computed tomography (CT) scan or magnetic resonance imaging (MRI) showing bone destruction but normal plain radiographs, starting BMAs is considered reasonable by Panel consensus based on the findings in women with lytic or mixed lytic/blastic changes on plain radiographs.
ÎStarting BMAs in women with only an abnormal bone scan but without evidence of bone destruction on radiographs, CT scans, or MRI is NOT recommended outside of a clinical trial.
