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The current NCCN Guidelines recommend the addition of zoledronic acid or denosumab to upfront treatment for the management of skeletal-related events (SREs) in patients with advanced lung cancer, notes Corey J. Langer, MD. The intravenous bisphosphonate zoledronic acid was the primary drug used for the management of SREs in patients with lung cancer for several years. However, in 2010 the RANK ligand inhibitor denosumab was approved for the prevention of SREs in patients with solid tumors.
Both approved therapies effectively treat SREs, making a decision challenging, Heather A. Wakelee, MD, notes. In general, denosumab may have advantages over zoledronic acid, in terms of the administration route and toxicity profile, and might improve survival, Wakelee believes.
The administration of denosumab or zoledronic acid can be delayed for patients with a single bone metastasis, Wakelee believes. In general, the decision to begin therapy should be based on the volume of metastases, since these treatments can result in adverse events. Managing these side effects is more of a concern as patients begin to live longer as a result of novel targeted therapies. For long-term survivors, new dosing strategies may be required, Wakelee suggests.
Approximately 40% of patients with advanced lung cancer will develop bone metastases, notes Benjamin P. Levy, MD. In addition to the administration route and tolerability, Levy points out that the treatments can be selected based on creatinine levels and the risk of hypocalcaemia. In general, Levy feels that denosumab is better tolerated.
Mark A. Socinski, MD, and Mark G. Kris, MD, both utilize treatments geared toward bone health more selectively. Kris feels that an effective systemic therapy should also heal the bone, making additional treatment unwarranted. In general, when one of these treatments is utilized, both Socinski and Kris prefer zoledronic acid, due to their experience with the drug.
In some situations, a bone flare may suggest new metastases when none are present. These flares stress the importance of collaboration with radiology in order to provide clinical data on patient performance, Langer suggests. In general, the delay or potential prevention of SREs provides ancillary care for patients with lung cancer that has made a significant difference, Langer believes.