Use of Adjuvant Bisphosphonates and Other Bone-Modifying Agents in Breast Cancer: ASCO-OH (CCO) Guideline Update.

Purpose: To update recommendations of the American Society of Clinical Oncology (ASCO)-Ontario Health (Cancer Care Ontario [CCO]) adjuvant bone-modifying agents in breast cancer guideline.
Methods: An Expert Panel conducted a systematic review to identify new, potentially practice-changing data.
Results: Four articles met eligibility criteria and form the evidentiary basis for revision of the previous recommendations.
Recommendations: Adjuvant bisphosphonate therapy should be discussed with all postmenopausal patients (natural or therapy-induced) with primary breast cancer, irrespective of hormone receptor status and human epidermal growth factor receptor 2 status, who are candidates to receive adjuvant systemic therapy. Adjuvant bisphosphonates, if used, are not substitutes for standard anticancer modalities. The benefit of adjuvant bisphosphonate therapy will vary depending on the underlying risk of recurrence and is associated with a modest improvement in overall survival. The NHS PREDICT tool provides estimates of the benefit of adjuvant bisphosphonate therapy and may aid in decision making. Factors influencing the decision to recommend adjuvant bisphosphonate use should include patients' risk of recurrence, risk of side effects, financial toxicity, drug availability, patient preferences, comorbidities, and life expectancy. When an adjuvant bisphosphonate is used to prevent breast cancer recurrence, the therapeutic options recommended by the Panel include oral clodronate, oral ibandronate, and intravenous zoledronic acid. The Panel supports starting bisphosphonate therapy early, consistent with the points outlined in the parent CCO-ASCO guideline; this is a consensus recommendation. The Panel does not recommend adjuvant denosumab to prevent breast cancer recurrence, because studies did not show a consistent reduction of breast cancer recurrence in any subset of those with early-stage breast cancer.Additional information can be found at www.asco.org/breast-cancer-guideline.
Competing Interests: Andrea EisenOther Relationship: Cancer Care Ontario Melissa K. AccordinoHonoraria: Sermo (I), M3 (I), Charter Oak Research, ExpertConnect, Medscape, Deerfield Management, Incrowd, Massive BioOther Relationship: Onclive Mark J. ClemonsHonoraria: PfizerConsulting or Advisory Role: Cornerstone Research Group, ApotexTravel, Accommodations, Expenses: Pfizer Sukhbinder Dhesy-ThindHonoraria: PfizerConsulting or Advisory Role: Novartis Canada Pharmaceuticals Inc, Seattle Genetics Melissa S. DillmonStock and Other Ownership Interests: Johnson & Johnson (I), Bristol Myers Squibb (I)Consulting or Advisory Role: Puma Biotechnology Elizabeth S. FrankHonoraria: AstraZenecaTravel, Accommodations, Expenses: Roche Sigrun HallmeyerLeadership: Association of Community Cancer Centers (ACCC)Honoraria: Cardinal HealthConsulting or Advisory Role: Bristol Myers Squibb, Cardinal Health, Array PharamceuticalSpeakers' Bureau: Bristol Myers SquibbTravel, Accommodations, Expenses: Cardinal Health, Bristol Mers SquibbUncompensated Relationships: Society for Immunotherapy of Cancer Beverly MoyConsulting or Advisory Role: MOTUS (I)Research Funding: Puma Biotechnology (Inst) Alia ThawerHonoraria: Knight Pharmaceuticals, Novartis Canada Pharmaceuticals Inc, Pfizer, GlaxoSmithKline Canada, AbbVie, AstraZeneca CanadaConsulting or Advisory Role: Ipsen, Amgen, Novartis, Lilly, Sandoz-Novartis, Pfizer, EisaiResearch Funding: Novartis, AstraZeneca Joy Y. WuResearch Funding: Radius Health Catherine H. Van PoznakResearch Funding: Bayer (Inst)Patents, Royalties, Other Intellectual Property: UpToDateNo other potential conflicts of interest were reported.