ESMO Guidelines on the Management of Bone Health in Patients With Cancer

European Society for Medical Oncology

August 24, 2020

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.

 

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