The European Society for Medical Oncology (ESMO) has published new guidelines on the management of bone health in patients with cancer.
Key recommendations include the following:
- CT and MRI are modalities of choice for routine response assessment of bone metastases in multiple myeloma (MM) [II, A].
- FDG-PET/CT imaging is valuable for early evaluation of response [II, B].
- Bone biomarkers are not recommended for routine follow-up [III, B].
- 223Ra is valuable for patients with metastatic castration-resistant prostate cancer (mCRPC) and symptomatic skeletal metastases as the dominant site of disease [I, A].
- 223Ra should be given as a single agent (with luteinising hormone-releasing hormone [LHRH] analogues) following previous use and/or in combination with bone-targeted agents (BTAs) [III, A].
- EBRT remains the treatment of choice for localised moderate-severe bone pain [I, A].
- A single 8 Gy fraction is recommended for painful uncomplicated bone metastases [I, A].
- Prophylactic antiemetics and dexamethasone are recommended [II, B].
- Postoperative radiotherapy (RT) should follow orthopaedic fixation of a long bone or spinal decompression and/or stabilisation [III, B].
- Prophylactic surgery for impending fracture is preferred over fixation after fracture [III, B].
- Start zoledronate or denosumab in patients with breast cancer or CRPC and bone metastases, whether symptomatic or not [I, A].
- Start zoledronate or denosumab in patients with advanced lung cancer, renal cancer and other solid tumours with life expectancy of ≥3 months and significant bone metastases [I, B].
- Zoledronate, pamidronate or denosumab should be initiated at diagnosis of MM [I, A].
- Denosumab is the agent of choice in MM patients with renal impairment.
- Bisphosphonate can be interrupted after 2 years in patients in remission [II, B].
- Zoledronate can de-escalated to every 12 weeks, preferably after monthly treatment for 3-6 months [I, B].
- Denosumab intervals >4 weeks are not recommended.
- Patients should have a dental evaluation before initiating BTA [III, A].
- Correct vitamin D deficiency with adequate calcium intake [I, A].
- Bisphosphonates are recommended if denosumab is discontinued for >6 months [III, B].
- Adjuvant bisphosphonates (IV zoledronate, daily oral clodronate or ibandronate) are recommended for postmenopausal or premenopausal women with early breast cancer treated with gonadotropin-releasing hormone (GnRH) analogues at significant risk of recurrence [I, A].
- Initiate treatment alongside neo/adjuvant chemotherapy (where indicated) and continue for 2-5 years [I, A].
- Bisphosphonates are not recommended as disease-modifying agents for premenopausal women with early breast cancer (not on GnRH analogues) or patients with other solid tumours [I, A].
- Denosumab is not recommended for the prevention of metastasis [I, A].
- In at-risk patients, DEXA is recommended [V, A].
- Anti-resorptive therapy is recommended in women receiving either aromatase inhibitors or ovarian function suppression (OFS) and men on ADT for >6 months with a BMD T score of <-2 or ≥2 risk factors for fracture [I, A].
- Denosumab 60 mg every 6 months is the treatment of choice in men on ADT and postmenopausal women with early breast cancer at low risk for recurrence [I, B].
- Vertebroplasty and kyphoplasty should be discussed within the multidisciplinary team [I, B].
References: Coleman R, Hadji P, Body JJ, et al. Bone health in cancer: ESMO clinical practice guidelines. Ann Oncol. 2020;S0923-7534(20)39995-6. Published online ahead of print 2020 Aug 5. doi:10.1016/j.annonc.2020.07.019.
This article originally appeared on Univadis, part of the Medscape Professional Network.