November 2003
Dear Readers: Here's the Article for this Month:
Name of article:
American Society of Clinical Oncology 2003 Update on the Role of Bisphosphonates and Bone Health Issues in Women With Breast Cancer
Author(s): Hillner BE et al.
J Clinical Oncology 2003; 21 (Novembre 1): 4042-57
Abstract:
The American Society of Clinical Oncology (ASCO) has just published an update of the 2000 guidelines for the use of bisphosphonates in breast cancer. After these guidelines, a new potent intravenous bisphosphonate, zoledronic acid, was approved for use in women with breast cancer.
For the 2003 update, the Expert Panel reviewed the published data since 2000. The vast majority of reports were reviews whereas no major RCTs in the metastatic setting have been initiated. There are no new reports of clodronate in the metastatic disease setting.
A summary of the clinical recommendations for the breast cancer patients with bone metastases will be provided.
The Authors underline that for each of the guidelines, clinical judgment should also take into consideration the patient's performance status and overall prognosis.
1. for patients with evidence of bone destruction on plain radiographs, intravenous pamidronate 90 mg delivered over 2 hours or zoledronic acid 4 mg over 15 minutes every 3 to 4 weeks are recommended. At present, there does not exist any published data showing the superiority of one bisphosphonate over the other.
2. It is considered reasonable to start bisphosphonates in the presence of normal plain radiographs, but with an abnormal bone scan and with an abnormal CT or MRI showing bone destruction,
3. whereas it is not recommended starting bisphosphonates only in the presence of an abnormal bone scan, having normal radiographs and no evidence of bone destruction on CT or MRI
4. A new interesting point is the emphasis given to renal function. Short-term use of bisphosphonates, when appropriately administered, is associated with a low risk of renal dysfunction. In an uncontrolled study on long term administration (more than 2 years) of pamidronate or zoledronate, a significant increase of serum creatinine level was observed with respect to baseline. Many data are available regarding the renal toxicity secondary to prolonged pamidronate use and a speedy infusion (less than 1 hour). The Panel recommends that serum creatinine should be monitored prior to each dose of pamidronate or zoledronate. Other evaluations (serum calcium, electrolytes, phosphate, magnesium, Hb) should be performed regularly
5. in patients with pre-existing renal disease and a serum creatinine level less than 3.0 mg/dL, no change in dosage, infusion time, or interval of pamidronate/zoledronate administration is required
6. the safety and frequency of nonrenal adverse events with pamidronate and zoledronate overlaps
7. the administration of bisphosphonates should be continued until a decline in the patient's performance status
8. the Panel recommends that in patients with painful bone metastases, the administration of bisphosphonates should not substitute, but to be added to the standard therapy of analgesics, corticosteroids, NSAIDs, interventional procedures, systemic radiopharmaceutical, local RT.
Why I chose this article.
Bone pain has a complex pathogenesis, and treatment should be individualized for patients and managed by means of a multidisciplinary approach.
Bisphosphonates represent a further valid therapy to add to an already consolidated list of treatments such as radio-chemo-hormone therapy, analgesics and orthopaedic intervention in the pain management of patients with bone metastases. The performance status of the patient, his life expectancy, and quality of life must guide the physician in the choice of the best possible therapy.
Further studies are necessary to better define the palliative role of bisphosphonates and the appropriate schedule of infusions in patients with advanced or terminal cancer who are no longer being treated with oncological therapies.
Regards,
Carla Ripamonti, MD
Member of the Board of Directors, IAHPC
