Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer...
-
Upload
hubert-hines -
Category
Documents
-
view
220 -
download
0
Transcript of Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer...
![Page 1: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/1.jpg)
Current Approaches and New Directions in Treating Bone
Metastases from Breast Cancer
Erica L. Mayer MD MPH
Dana-Farber Cancer Institute
May 16, 2009
![Page 2: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/2.jpg)
Outline
• Biology
• Symptoms/Imaging
• Treatment
• New Directions
![Page 3: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/3.jpg)
Bone Metastases in Breast Cancer• Up to 70% of women with advanced breast
cancer may develop bone metastases– Early site of spread– 20% of women have “bone only” disease– More common if tumor is hormone receptor positive
• Cancer cells target bones with an extensive blood supply: arms, legs, ribs, spine, pelvis. Tend not to travel to hands and feet.
• Breast cancer growth in bone is typically slow; therefore optimizing treatment is crucial
![Page 4: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/4.jpg)
Normal Bone BiologyBone is always in an active state of
remodeling (build up/break down)
• Resorption: stimulated osteoclasts erode bone, creating a cavity
• Reversal: bone surface is prepared for osteoblasts to begin forming bone
• Formation: osteoblasts replace resorbed bone and fill the cavity with new bone
• Resting: bone surface rests until a new remodeling cycle begins
Adapted from Novert's Pharmaceuticals
![Page 5: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/5.jpg)
Bone Metastases: General Mechanism
Adapted from Guise and Mundy. Endocr Rev. 1998;19:18.
Primary cancerAngiogenesis Invasion Embolism
Multicell aggregates(lymphocytes, platelets)
Response tomicroenvironment
Tumor cellproliferation Bone
metastases
Extravasation Adherence Arrest in distantcapillary bed in bone
Tra
ns
po
rt
![Page 6: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/6.jpg)
Osteolytic metastases
• Tumor cells produce growth factors that stimulate bone destruction• i.e. RANK ligand
• Osteoclasts are activated and break down bone
• Osteoblasts cannot build bone back fast enough
• Decreased bone density and strength; high risk for fracture
Patel, B. and DeGroot, H. Orthopedics Journal. 2001;24:612-7.
![Page 7: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/7.jpg)
Osteoblastic Metastasis
• Osteoblasts are stimulated by tumors to lay down new bone
• Bone becomes abnormally dense and stiff
• Paradoxically bones are also at risk of breaking
![Page 8: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/8.jpg)
Radiology: How to Evaluate
• Imaging tests– X-ray– Bone scan
• Sensitive, not specific. • False positives: trauma, arthritis,
infection– CT (“CAT” scan)– PET scan– MRI scan
• Bone biopsy – for confirmation
• Blood tests– Calcium, alkaline phosphatase
Bone Scan
![Page 9: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/9.jpg)
MRI imaging
T1 T2
![Page 10: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/10.jpg)
Symptoms/Complications Related to Bone Metastases
• Pain
• “Pathologic” fracture – broken bone after minimal trauma
• Bone marrow (“blood factory”) involvement -> low blood counts
• High calcium levels: confusion, drowsiness
• Nerve compression– Pain– Spinal cord compression
Goal is to use multidisciplinary management to reduce/eliminate all symptoms!
![Page 11: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/11.jpg)
Treatment Options
• Goals:– Attack the cancer– Strengthen the bone– Reduce symptoms
• Includes:– Systemic therapy– Local therapy
![Page 12: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/12.jpg)
Systemic Therapies
Anti-cancer therapy– Endocrine therapy
• Tamoxifen, aromatase inhibitors, ovarian suppression
– Chemotherapy• Many choices
– Biologic therapies• Herceptin, Tykerb, Avastin
![Page 13: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/13.jpg)
Systemic Therapies
Pain control– Pain medication
• Tylenol, NSAIDs (ibuprofen), narcotics, steroids• Success can be limited by side effects
– Radiopharmaceuticals• Strontium-89 and samarium-153: radioactive
particles travel directly to tumor in bone• Can reduce pain refractory to other measures• Infrequently used
![Page 14: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/14.jpg)
Systemic Therapies: Bisphosphonates
• Bind to and inhibit osteoclast action – Inhibit bone breakdown– Prevent bone damage– Improve bone density and strength
• Recommended for almost everyone with breast cancer bone metastases
![Page 15: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/15.jpg)
Evidence Supporting Bisphosphonates in Breast Cancer
• Multiple clinical trials have demonstrated treatment with bisphosphonates can reduce:– Bone pain– Fractures– High calcium levels– Radiation therapy to bone– Surgery to bone
• May also significantly improve quality of life in women with breast cancer
Lipton. Clin Breast Cancer 2007
![Page 16: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/16.jpg)
Oral Bisphosphonates: Clodronate
• Generally well tolerated
• Demonstrated benefits in clinical trials
• Issues for consideration– Not absorbed well from GI tract – may be less
effective than IV– Adherence to oral therapy a concern
• Not commercially available in US
Solomon et al. Arch Intern Med. 2005;165:2414.
![Page 17: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/17.jpg)
IV Bisphosphonates
• More potent than oral bisphosphonates
• Improved adherence in clinic setting; given once every 4 weeks
• Side events– Flu-like symptoms– Injection-site reactions– Renal toxicity – need to check kidney function before giving– Long-term use
• Osteonecrosis of the jaw• Electrolyte abnormalities (low calcium)
Conte et al. Oncologist. 2004;9(suppl 4):28.
![Page 18: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/18.jpg)
Theriault, R. L. et al. J Clin Oncol; 17:846 1999
Available IV bisphosphonates
Pamidronate (Aredia™) • In placebo-controlled trials
significantly reduced fracture, radiation, pain
Zoledronic Acid (Zometa™)• More potent agent; equally
effective in trials• Shorter infusion time (15
min vs 3 hours)
![Page 19: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/19.jpg)
Newest Bisphosphonate: Ibandronate
• Both oral and IV forms
• Prevents bone events (fractures, radiation, surgery ) compared with placebo
• Can relieve bone pain when given with a loading dose (but takes up to 12 weeks)
• May have less kidney toxicity
• Ongoing comparisons to zoledronic acid are underway
Cameron et al, The Oncologist, 2006
![Page 20: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/20.jpg)
Osteonecrosis of the jaw (ONJ)• What is ONJ?
– Exposed jawbone that does not heal
– Treated with surgery, antibiotics– Rare side effect: about 5% in
breast cancer population
• Who could get ONJ?– Risk related to cumulative
exposure – Recent invasive dental procedure
or poor oral health are risk factors• Tooth extraction
• Dental implant
![Page 21: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/21.jpg)
ONJ Prevention
• Potential benefits of bisphosphonates typically outweigh small risks of ONJ
• How to prevent:– See dentist before beginning
bisphosphonate– Pursue optimal preventative dental care– Practice good oral hygiene
• In those with stable disease after prolonged therapy, can consider reducing frequency of treatment
![Page 22: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/22.jpg)
New Systemic Therapy: Denosumab
• Denosumab: antibody against RANK ligand, the stimulator for osteoclasts
• Once-a-month subcutaneous injection
• Promising results as osteoporosis treatment in clinical trials
• Emerging role in the treatment of bone metastases
Ellis SABCS 2007; Lipton ASCO breast 2008; McClung et al, NEJM 2006
![Page 23: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/23.jpg)
Blocking RANK ligand in a mouse can fill in a mouse bone metastases
OPG
Control Treated
Morony et al. Cancer Res. 2001;61:4432.
![Page 24: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/24.jpg)
Ellis, G. K. et al. J Clin Oncol; 26:4875-4882 2008
Denosumab prevents osteoporosis in women receiving aromatase inhibitors
• 250 patients receiving placebo or denosumab• Results: increased bone density with
denosumab• Side effects: joint pain, body ache, fatigue
![Page 25: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/25.jpg)
Denosumab vs Zoledronic Acid
• Phase 2 trial of first-line denosumab vs zoledronic acid– 255 women enrolled– Equivalent reduction in bone breakdown– Equivalent prevention of bone events (fracture, radiation,
surgery)
• Phase 3 trials underway comparing denosumab and zoledronic acid head to head
Lipton et al, CCR 2008
![Page 26: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/26.jpg)
Denosumab after Zoledronic Acid
• Phase 2 trial of denosumab vs zoledronic acid after prior bisphosphonate therapy
• 111 patients enrolled with bone breakdown despite zoledronic acid
– Denosumab reduced markers of bone breakdown
– Less fracture, radiation, surgery in those receiving denosumab
Fizazi, JCO 2009
A future role may exist for denosumab for bisphosphonate-refractory disease
![Page 27: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/27.jpg)
Systemic Agents in Development
• Cathepsin K inhibitors– Cathepsin K degrades the bone– An oral inhibitor reduced bone turnover from breast
cancer bone metastases (ASCO 2009 poster)
• SRC kinase inhibitors (dasatinib)– SRC necessary for osteoclast bone breakdown– Dasatinib is oral, approved for chronic leukemia, may
have activity against breast cancer as well
• Ongoing trials are using these drugs after, with, or instead of zoledronic acid
![Page 28: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/28.jpg)
Local Therapies• Local therapies treat a limited number of
locations; do not treat the whole body
• Types:– Radiotherapy– Interventional Radiology– Surgery
• Goals:– Relieve pain– Prevent fracture– Enhance mobility and function– Preserve quality of life
![Page 29: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/29.jpg)
Radiation Therapy
• Radiation therapy can be used to treat painful bone metastases refractory to systemic therapies
– 80-90% of breast cancer patients experience relief of symptoms
– 40-46% experience full relief
– 70% never have pain in that region again
– May take months before full pain relief is realizedTong et al, Cancer 1982
![Page 30: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/30.jpg)
Radiation Therapy: Specifics
• Can take 1-4 weeks; 2 weeks is most common
• Chemotherapy is usually on hold during RT
• Side effects: nausea, diarrhea, low blood counts, fatigue
• Typically radiation is not used again in the same place
![Page 31: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/31.jpg)
Interventional Radiology
• What is it?– Minimally invasive procedures performed by
specialized radiologists to treat symptoms from bone metastases
• Indications:– To treat bone pain refractory to other
conservative pain control measures– Specialized technique for metastatic cancer to
spine bones• Stabilize broken bone
![Page 32: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/32.jpg)
Interventional Radiology: Techniques
• Vertebroplasty: – Injection of bone cement to
support weakened bones – Provides immediate and
substantial pain relief
• Kyphoplasty: – Balloon inflation of
compressed spine bone is performed before cement injection
– Used for compression fractures
![Page 33: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/33.jpg)
Positioning in Interventional Radiology
![Page 34: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/34.jpg)
Example: Vertebroplasty
![Page 35: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/35.jpg)
Example: Vertebroplasty
![Page 36: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/36.jpg)
Concept of kyphoplasty
![Page 37: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/37.jpg)
Concept of kyphoplasty
![Page 38: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/38.jpg)
Other Local Techniques• Radiofrequency Ablation (RFA) and
cryoablation– Minimally invasive procedures to “burn”
or “freeze” a tumor– Desensitizes by killing nerve endings
near the metastasis
• Most commonly used for cancer in the spine
• Techniques can achieve excellent pain control
• Use may expand with further data
![Page 39: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/39.jpg)
Surgical Joint Stabilization
• Indications for surgery for bone metastases:
– Prevention of bone fracture (“prophylactic”)• Risk depends on location of metastasis, type, size, and
presence of symptoms
– Alleviation of pain
– Maintain ability to walk (for hip metastases)
– Stabilize broken bone after pathologic fracture
Beals et al, Cancer 1971
![Page 40: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/40.jpg)
Surgical Joint Stabilization
• Benefits of surgery– Procedures designed for rapid recovery
• Simple pin placement to full hip replacement
– Most are walking again soon after hip surgery– Most have good to excellent pain relief– Can dramatically improve healing after fracture
• Typically performed in combination with radiotherapy
Ryan et al. J Bone Joint Surg Am, 1976
![Page 41: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/41.jpg)
Future Directions
• Can we prevent bone or other metastases by using bone medicines earlier on?
• Increasing evidence suggests bisphosphonates may have anti-cancer activity
![Page 42: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/42.jpg)
ABCSG 12ABCSG 12
Ovarian suppression +
tamoxifen
Ovarian suppression +
anastrozole
Zoledronic Acid (Zometa) 4 mg IV, Every 6 Months for 3 years
No Rx
All patients premenopausal, HR+
No adjuvant chemo
Stage I-II breast cancer- 30% with T2 tumors- 25% with positive nodes
N = 1803
![Page 43: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/43.jpg)
At 5 years, 36% reduction in risk of recurrence in those taking Zometa
![Page 44: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/44.jpg)
![Page 45: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/45.jpg)
![Page 46: Current Approaches and New Directions in Treating Bone Metastases from Breast Cancer Erica L. Mayer MD MPH Dana-Farber Cancer Institute May 16, 2009.](https://reader035.fdocuments.in/reader035/viewer/2022062313/56649d035503460f949d6753/html5/thumbnails/46.jpg)
Conclusions• Bone metastases are common in advanced breast cancer,
and can cause significant symptoms
• Multiple systemic and local therapies are available; standard therapy includes monthly zoledronic acid
• Better understanding of toxicities can improve the safety of treatment
• New agents take advantage of increased understanding of the biology of bone turnover
• Women with advanced breast cancer may live with bone metastases for many years, therefore optimizing therapy is crucial