Personalized (tailored) treatment with antiresorptive drugs (bisphosphonates, denosumab) in patients with bone metastases from solid tumors – A “Pico” document by Rete Oncologica Piemonte-Valle D’Aosta Bone Metastatic Disease Study Group

BACKGROUND. The optimal use of antiresorptive agents (bisphosphonates; denosumab) in patients with bone metastases from solid tumors is uncertain in several aspects, including the initial drug choice and the planned treatment duration, till the long-term therapy. Drug costs, logistics and facilities, patients’ preferences, renal toxicity, and expected risk of Medication-Related Osteonecrosis of the Jaw (MRONJ), as well as other side effects, may conditionate the oncologists’ choice. MATERIAL AND METHODS. Italian oncologists from a study group on bone metastatic disease within the “Rete Oncologica Piemonte-Valle d’Aosta” (a cancer network in North-Western Italy) evaluated scientific literature and current guidelines and recommendations, to answer a PICO (Patient/population; Intervention; Comparison; Outcome) question. The question was: in patients with bone metastases from solid tumors, is treatment with antiresorptive drugs (bisphosphonates or denosumab) amenable to personalized use (for choice of drug and duration of treatment) based on the type of disease, the expected risk of side effects, and patient compliance, as an alternative to “one-fit-for-all” therapy (monthly zoledronic acid or denosumab, indefinitely), in order to: reduce the commitment to the patient and to the oncological structure; reduce economic costs; reduce the risk of medium/long-term side effects (e.g., MRONJ)? RESULTS. The study group analysed the cost of drugs; the engagement of the oncology unit; the patient commitment/compliance; the risk of side effects (renal toxicity, hypocalcaemia, MRONJ); the options of the planned initial duration of treatment; the timing of administration (monthly versus quarterly). Early antiresorptive treatment was recommended (at the diagnosis of bone metastases, after pre-therapy dental evaluation). Four types of tailored treatment options were recommended, in four main different metastatic cancer scenarios. CONCLUSION. A tailored antiresorptive treatment might reduce the number of accesses to oncological structures by the patient, the costs for the structure and for the healthcare system (both in terms of work and cost of drugs), and the risk of medium/long-term side effects (renal failure; MRONJ), potentially without reducing the expected benefits of the treatment.