Cáncer de Mama
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Transcript of Cáncer de Mama
CÁNCER DE MAMA
TERÁPIAS ÓSEAS
CA DE MAMA TEMPRANO: PREVENCIÓN DE FX
AUMENTO DE LA SLE CON TERAPIAS ADYUVANTES ÓSEAS
ENFERMEDAD METASTASICA
Predictors of Fracture Risk
• BMD (DXA), femoral neck T-score– Serial monitoring should be done on the same
equipment with the same reference standards at the same site
• Age• Drugs• History/presence of vertebral fracture
– Best predictor of a subsequent fracture is an existing one
• Risk of falls• Vitamin D levels
Tasa de Pérdida Ósea
1. Kanis JA. Osteoporosis. 1997:22-55. 2. Eastell R, et al. J Bone Miner Res. 2006;21:1215-1223. 3. Maillefert JF, et al. J Urol. 1999;161:1219-1222. 4. Gnant M, et al. Lancet Oncol. 2008;9:840-849. 5. Shapiro CL, et al. J Clin Oncol. 2001;19:3306-3311.
Bo
ne
Lo
ss a
t 1
Yr
(%)
Naturally Occurring Bone Loss CTIBL
0
2
4
6
8
10
Normal Men[1]
Postmenopausal Women[1]
Al Therapy inPostmenopausal
Women[2]
ADT[3]
Al Therapy+ GnRH
Agonist inPremenopausal
Women[4]
Premature Menopause
Secondary toChemotherapy[5]
0.51.0
2.6
4.6
7.07.7
Tamoxifen
LetrozoleAnastrozole
Fra
ctu
res
(%)
11.0
7.7
5.7
4.0
7.0
5.0
P < .0001
P < .001
0
2
4
6
8
10
12
14
P = .003
Exemestane
ATAC[1]
(68 mos)IES[2]
(58 mos)BIG 1-98[3]
(26 mos)
Riesgo de fx elevado de los IA esteroidales y noesteroidales vs Tamoxifeno
1. Howell A, et al. Lancet. 2005;365:60-62. 2. Coleman RE, et al. Lancet Oncol. 2007;8:119-127. 3. Thürlimann B, et al. N Engl J Med. 2005;353:2747-2757.
Oral Bisphosphonate Impact on BMD in Patients With Breast Cancer
• Clodronate in breast cancer patients with chemotherapy-induced premature ovarian failureSaarto T, et al. J Clin Oncol. 1997;15:1341-1347.
• Risedronate reduces bone loss in women with chemotherapy-induced ovarian failureDelmas PD, et al. J Clin Oncol. 1997;15:955-962.
• Alendronate in GnRH agonist-induced premature menopause (patients without cancer)Ripps BA, et al. J Reprod Med. 2003;48:761-766.
• Monthly ibandronate and anastrozole-induced bone lossLester JE, et al. Clin Cancer Res. 2008;14:6336-6342.
• SABRE trial: study of anastrozole with risedronate Van Poznak C, et al. J Clin Oncol. 2010;28:967-975.
Management of Bone Health Using BMD
T-Score: NCCN Task Force Report• T-score: > -1 (normal)
• T-score: -1.0 to -1.5
• T-score: -1.5 to -2.0
• T-score < -2.0 orFRAX 10-yr fracture risk: > 20% major fracture > 3% for hip fracture
• Repeat DXA every 2 yrs*
• Repeat DXA every 2 yrs*• Consider checking 25(OH) level
• Repeat DXA every 2 yrs*• Consider checking 25(OH) level• Consider pharmacologic
therapy• Repeat DXA every 2 yrs*• Consider checking 25(OH) level• Strongly consider
pharmacologic therapy
Gralow JR, et al. J Natl Compr Canc Netw. 2009;7:S1-S32.
*In selected cases, longer or shorter intervals may be considered. If a major change in patient risk factors or a major intervention occurs, then repeating DXA at 1 yr is reasonable.
Key endpoints:Primary: BMD at 12 mosSecondary: BMD at 36 and 60 mos, disease recurrence, fractures, safety
Letrozole + immediate Zoledronic Acid 4 mg every 6 mos
Breast cancerstage I to IIIa(N = 1065)Postmenopausal or amenorrheic due to cancer treatmentER+ and/or PgR+
T-score ≥ -2.0
Letrozole +
Treatment duration: 5 yrs
RDelayed Zoledronic Acid
If 1 of the following occurs:BMD T-score < -2 Clinical fractureAsymptomatic fracture at 36 mos
Coleman R, et al. Ann Oncol. 2012. Oct 9.
ZO-FAST: A Phase III Study of the Use of Zoledronic Acid With Adjuvant Letrozole
Coleman R, et al. Ann Oncol. 2012. Oct 9. [Epub ahead of print]
ZO-FAST (Primary Endpoint): Median Change in LS BMD With Zoledronic Acid
Immediate zoledronic acidDelayed zoledronic acid
P < .0001 for each
Ch
ang
e in
LS
(L
S-L
4) B
MD
(%
)
12 Mos 24 Mos 36 Mos 48 Mos 60 Mos-6
-4
-2
0
2
4
6
+4.3
-5.4
Δ 5.9 Δ 8.2 Δ 8.8 Δ 9.2 Δ 10.0
Modalidades de tratamiento
Bifosfonatos orales
• Buena adherencia a sus meds
• Rechazan meds IV• No quieren o pueden ir a
la clínica• Menos costosos• Menos efectos 2os• < riesgo de osteonecrosis
o de fx subtrocantéricas
Bifosfonatos IV
• Mayor adherencia en pacientes conintolerancia GI (RGE) uotros síntomas.
ABCSG-12: Phase III Study of Adjuvant Endocrine Therapy ± Zoledronic Acid
• Key endpoints– Primary: DFS at 5 yrs
– Secondary: recurrence-free survival, OS, BMD, safety
TAM 20 mg/day
ANA 1 mg/day
Treatment 3 yrs(median follow-up: 48 mos)
TAM + ZA 4 mg q6m
ANA + ZA 4 mg q6m
R
Long-term monitoring for 5 yrs for recurrence
and survival(DFS, OS)
3-yrBMD
5-yrBMD
Premenopausal patients with stage I/II breast cancer
(goserelin 3.6 mg/28 days)stratified by: ER+ and/or PgR+ Age Stage Grade Lymph nodes
(N = 1803)
Gnant M, et al. N Engl J Med. 2009;360:679-691.
Gnant M, et al. Lancet Oncol. 2008;9:840-849.
ABCSG-12 Bone Substudy: Change in BMD at Yrs 3 and 5
10
5
0
-5
-10
-15
Per
cen
t C
han
ge
in L
S
BM
D (
g/c
m2 )
Fro
m B
asel
ine
Mos
Mos
No Zoledronic Acid
Tamoxifen Anastrozole
36 60
-9.0P < .0001
-4.5NS
-13.6P < .0001
-7.8P = .003
36 60
36 60 36 60
Zoledronic Acid
Tamoxifen Anastrozole
+1.0NS
+5.2P = .04
-0.1NS
+3.1NS
*
*
*
Ellis GK, et al. J Clin Oncol. 2008;26:4875-4882.
Denosumab in Patients With Breast Cancer Receiving Adjuvant AIs
Per
cen
t C
han
ge
in B
MD
Fro
m
Bas
elin
e at
LS
8
7
6
5
4
3
2
1
0
-1
-2
-31 3 6 12 24
Mos
5.5% difference at 12 mos
7.6% difference at 24 mos
*P < .0001 vs placebo
Placebo (n = 122)Denosumab 60 mg q6m (n = 123) *
*
Toxicity: no significant difference in AEs between denosumab and placebo arm
Checklist for Bone Health in Patients With Breast Cancer
Item Description
Determine osteoporosis risk factors
•T-score < -1.5?•Older than 65 yrs?•Low BMI (< 20)?
Other factors
•Family history of hip fracture?•Personal history of fragility after 50 yrs of age?•Oral corticosteroid use of > 6 mos?•Smoking (current or past history)?•10-yr probability for hip fracture (by FRAX)?
Cancer treatment–related factors
•AIs?•Ovarian ablation?
Assays•DXA to assess BMD (every 2 yrs)•25(OH)D level•Serum calcium level
Treat the following with bone-directed therapy
•Hip or vertebral fracture•T-score < -2.0•10-yr probability for hip fracture ≥ 3%•10-yr probability of a major osteoporotic event ≥ 20%
Hadji P, et al. Ann Oncol. 2011;22:2546-2555. National Osteoporosis Foundation.
T-score < -2.0Any 2 of the following risk factors
T-score < -1.5
Aged younger than 65 yrs
Low BMI (< 20)
Family history of hip fracture
Personal history of fragility fracture after 50 yrs of age
Oral corticosteroid use of > 6 mos
Smoking (current or history of)
T-score > -2.0, no risk factors
Monitor risk status and BMD q12m*
Monitor BMD on case by case basis for IV bisphosphonates;
q12-24m for oral bisphosphonates
ExerciseCalcium and vitamin D
supplements
*If ≥ 10% decrease in BMD (≥ 4% to 5% if osteopenic at baseline), investigate secondary causes and begin antiresorptive treatment. Use lowest T-score from 3 sites.
ExerciseTreatment including bisphosphonates,
denosumab,Calcium, and vitamin D
supplements
Guidance for Women With Breast Cancer Initiating AI Therapy: European
Guidelines
Hadji P, et al. Ann Oncol. 2011;22:2546-2555.
¿AUMENTAR LA SOBREVIDALIBRE DE ENFERMEDAD?
Y/OSOBREVIDA GLOBAL?
DFS
ABCSG-12 (84 Mos): Efficacy
100
80
60
40
20
0
DF
S (
%)
0 12 24 36 48 60 72 84 96 108
Mos Since RandomizationPatients at Risk, nNo ZAZA
903900
858862
833841
807822
758788
653674
521544
405419
191208
Events, n
Univariate Multiple CoxRegression
HR(95% CI)
P Value
HR(95% CI)
P Value
vs no ZA
vs no ZA
(Log-rank)
No ZA
132/903
0.72 (0.56-0.94)
.014 0.71(0.55-0.92)
.01198/900ZA
OS
100
80
60
40
20
0
DF
S (
%)
0 12 24 36 48 60 72 84 96 108
Mos Since RandomizationPatients at Risk, nNo ZAZA
903900
864868
856858
839849
811818
706708
576587
456454
215232
Events, n
Univariate Multiple CoxRegression
HR(95% CI)
P Value
HR(95% CI)
P Value
vs no ZA
vs no ZA
(Log-rank)
No ZA
49/903
0.63 (0.40-0.99)
.049 0.61(0.39-0.96)
.03333/900ZA
Gnant M, et al. SABCS 2011. Abstract S1-2.
ZA treatment duration: 5 yrs
AZURE: Study DesignAccrual September 2003 - February 2006
Country Centers, n
Patients, n
United Kingdom
123 2710
Ireland 10 247
Australia 28 226
Spain 8 107
Portugal 1 32
Thailand 2 25
Taiwan 2 13
Coleman RE, et al. N Engl J Med. 2011;365:1396-1405.
Standard therapy
Standard therapy +ZA 4 mg
Mos 6 30 60
3360 patients with stage II/III breast cancer
R
6 dosesq3-4w
8 dosesq3m
5 dosesq6m
Primary endpoint: DFS, with recurrence defined as date first suspected
AZURE: DFS and IDFS
Patients at Risk, n 1681 1591 1465 1354 1241 580 83 1678 1583 1445 1344 1252 561 71
DFS
0
ZAControl
0
Patients at Risk, n1681 1578 1443 1337 1222 570 821678 1574 1426 1316 1221 544 68
IDFS
0
ZAControl
DFS IDFS
1 2 3 4 5 6 7
20
40
60
80
Yrs
Control (n = 1678)
Adjusted HR: 0.98 (95% CI: 0.85-1.13;P = .79)
Su
rviv
ing
(%
)
00
ZA (n = 1681)
0
100100
00 1 2 3 4 5 6 7
20
40
60
80
Yrs
Su
rviv
ing
(%
)
00
100
00
Control (n = 1678)
Adjusted HR: 0.98 (95% CI: 0.85-1.12;P = .73)
ZA (n = 1681)
Coleman RE, et al. N Engl J Med. 2011;365:1396-1405.
AZURE: IDFS and OS by Menopausal Status
0
Mos Since Randomization
1.0
6 12 18 24 30 36 42 48 54 60 66 72 78 84
0.8
0.6
0.4
0.2
0
Pro
po
rtio
n A
live
and
in
vasi
ve D
isea
se F
ree
IDFS: Pre, Peri, and Unknown Menopausal Status
Adjusted HR: 1.15(95% CI: 0.97-1.36; P = .11)288 vs 256 events
Patients at Risk, nZA:
No ZA:1162 1088 996 919 829 393 57 0
1156 1092 995 920 853 388 47 0
0
Mos Since Randomization
1.0
6 12 18 24 30 36 42 48 54 60 66 72 78 84
0.8
0.6
0.4
0.2
0
Pro
po
rtio
n A
live
OS: Pre, Peri, and Unknown Menopausal Status
Adjusted HR: 0.97(95% CI: 0.78-1.21; P = .81)161 vs 165 events
Patients at Risk, nZA:
No ZA:1162 1131 1078 1020 955 466 71 0
1156 1123 1076 1032 963 446 60 0
0
Mos Since Randomization
1.0
6 12 18 24 30 36 42 48 54 60 66 72 78 84
0.8
0.6
0.4
0.2
0
Pro
po
rtio
n A
live
and
in
vasi
ve D
isea
se F
ree
IDFS: > 5 Yrs Postmenopausal
Adjusted HR: 0.75(95% CI: 0.59-0.96; P = .02)116 vs 147 events
Patients at Risk, nZA:
No ZA:519 490 447 418 393 177 25 0
522 482 431 396 368 156 21 0
0
Mos Since Randomization
1.0
6 12 18 24 30 36 42 48 54 60 66 72 78 84
0.8
0.6
0.4
0.2
0
Pro
po
rtio
n A
live
OS: > 5 Yrs Postmenopausal
Adjusted HR: 0.74(95% CI: 0.55-0.98; P = .04)82 vs 111 events
Patients at Risk, nZA:
No ZA:519 502 482 448 422 190 29 0
522 509 475 441 401 177 26 0
Coleman RE, et al. N Engl J Med. 2011;365:1396-1405.
Typical ORMenopausal Group
Description
Total: -1% ± 7%Z = .13; P = .9
21 (heterogeneity) = 7.91; P = .005
Odds Reduction (± SD)
n = 1041263 events
n = 2318544 events
HR: 0.75 (95% CI: 0.59-0.96)
HR: 1.15 (95% CI: 0.97-1.36)
Pre + < 5 yrs post+ unknown status
> 5 yrs postmenopausal
High estrogen environment
Low estrogen environment
1.0 1.2 1.4 1.6 1.8 2.00.2 0.4 0.6 0.8
AZURE: Treatment Effect on IDFS by Menopausal Status
Coleman RE, et al. N Engl J Med. 2011;365:1396-1405.
Niveles de Vit D 25 OHD > 30 ng/ml (suficientes) predicen beneficio del Ac Zoledrónico en las
tasas de recidiva a distancia en pacientes posmenopausicas
Marshall H, et al. ASCO 2012. Abstract 502.
Adjuvant Zoledronic Acid in Early Breast Cancer: Expert Perspectives
• No benefit in overall unselected population• Significant benefit in postmenopausal women seen in
multiple studies– Effect of menopause on DFS driven by influences on
nonbone recurrence• Potential for harm in pre- and perimenopausal women• These subset analyses do not justify the routine use of
adjuvant zoledronic acid in postmenopausal women
Letrozole + ZA 4 mg q6m
Letrozole + Delayed* ZA 4 mg q6m
*If 1 of the following occurs:BMD T-score < -2 SD Clinical fracture Asymptomatic fracture at 36 mos
Stage I-IIIa breast cancer Postmenopausal or
amenorrheic due to cancer treatment
ER+ and/or PgR+ T-score ≥ -2 SD
N = 1060
Treatment duration: 5 yrs
De Boer R, et al. SABCS 2011. Abstract S1-3.
ZO-FAST: 5-yr Final Analysis
*Censored patients at initiation of D-ZA (n = 144).
Time on Study (mos)
532533
518511
500491
488475
475463
376368
IM-ZAD-ZA
Patients at Risk, nTime on Study (mos)
532533
518459
500402
488376
475350
376267
IM-ZAD-ZA
Patients at Risk, n
ITT Population
100
90
80
70
60
50
40
30
20
10
0
DF
S (
%)
0 6 12 18 24 30 36 42 48 54 60 66
HR: 0.66; log-rank P value = .0375
IM-ZA 4 mg (42 events)D-ZA 4 mg (62 events)
Censored Analysis*
100
90
80
70
60
50
40
30
20
10
0D
FS
(%
)0 6 12 18 24 30 36 42 48 54 60 66
HR: 0.62; log-rank P value = .024
IM-ZA 4 mg (42 events)D-ZA 4 mg (53 events)
De Boer R, et al. SABCS 2011. Abstract S1-3.
27% of patients (n = 144) in the delayed arm initiated ZA on-study DFS HR: 0.46; P = .033
ZO-FAST: Final 5-yr DFS
HR
ZO-FAST[1]
104 events
ABCSG-12[3]
230 events
0.2 0.4 0.6 0.8 1 1.2 1.4
N = 1803
1. De Boer R, et al. SABCS 2011. Abstract S1-3. 2. Coleman RE, et al. N Engl J Med. 2011;365:1396-1405. 3. Gnant M, et al. SABCS 2011. Abstract S1-2.
N = 1065
n = 1041AZURE - > 5 yrs postmenopausal[2]
263 events
P Value
.02
.0375
.011
0.75
0.66
0.71
ZA Studies: DFS Comparison
NSABP B-34: Phase III Study of Adjuvant Clodronate in Breast Cancer
• Primary endpoint: DFS• Secondary endpoints: incidence of metastases, OS,
SREs, adverse events, and prognostic serum markers
Clodronate 1600 mg qd
Placebo
3323 patients withstage I-II breast cancer
receiving adjuvant standard therapy
Treatment duration: 3 yrs
R
Median follow-up: 8.4 yrsTwo thirds aged > 50 yrs; 25% N positive
NSABP B-34: DFS
Paterson A, et al. SABCS 2011. Abstract S2-3.
Dis
ease
Fre
e (%
)
100
80
60
40
20
00 2 4 6 8
Yrs After Randomization
Treatment
Placebo
Clodronate
N
1656
1655
Events, n
312
286
HR: 0.91; P = .27
NSABP B-34: Analysis of Specified Endpoints and Safety
• Adverse events comparable in clodronate and placebo arms– 1 case of ONJ observed in clodronate arm vs no cases in placebo
arm
Endpoint Events, n HR (95% CI) P Value
Clodronate(n = 1662)
Placebo (n = 1661)
DFS 286 312 0.913 (0.778-1.072) .266
OS 140 167 0.842 (0.672-1.054) .131
RFI 148 177 0.834 (0.671-1.038) .101
BMFI 61 80 0.765 (0.548-1.068) .114
NBMFI 78 105 0.743 (0.554-0.996) .046
Paterson A, et al. SABCS 2011. Abstract S2-3.
NSABP B-34 Subset Analysis: DMFI, RFI, BMFI, and NBMFI in Patients ≥ 50
Yrs
Endpoint for Patients 50 Yrs of Age or Older
HR P Value
DMFI 0.62 .003
RFI 0.76 .05
BMFI 0.61 .024
NBMFI 0.63 .015
Paterson A, et al. SABCS 2011. Abstract S2-3.
DMFI: distant metastasis-free interval
RFI: relapse-free interval
BMFI: bone-metastasis-free interval
NBMFI: non-bone metastasis-free interval
GAIN Trial: Study Design
Möbus V, et al. SABCS 2011. Abstract S2-4.
Arm A1: Arm B1:
Epirubicin150 mg/m2
q2w
Ibandronate50 mg PO QD 2 yrs
Paclitaxel225 mg/m2
q2w
Cyclophosphamide2000 mg/m2
q2w
Arm B2:Observation
Arm A2:Paclitaxel67.5 mg/m2 qwCapecitabine2000 mg/m2 Days 1-14 q3w
Epirubicin112.5 mg/m2
Cyclophosphamide600 mg/m2 q2w
PegfilgrastimCiprofloxacin
Darbepoetin alfa or Epoetin beta
CiprofloxacinPegfilgrastim
Darbepoetin alfa or Epoetin beta
GAIN: DFS and OS (ITT)
1.0
0.8
0.6
0.4
0.2
0
Su
rviv
al P
rob
abil
ity
(%)
DFS (Mos)0 12 24 36 48 60
12
1996998
1814871
1590727
1057483
555264
210105
3-Yr DFSIbandronate: 87.6%Observation: 87.2%
Cox RegressionHR: 0.945 (95% CI: 0.768-1.16; P = .59)
Ibandronate Observation
Product-Limit Survival EstimatesWith Number of Patients at Risk
+ Censored1.0
0.8
0.6
0.4
0.2
0.0
OS (Mos)0 12 24 36 48 60
12
1996998
1836886
1653756
1121506
586277
219112
3-Yr OSIbandronate: 94.7%Observation: 94.1%
Cox RegressionHR: 1.04 (95% CI: 0.763-1.42; P = .80)
Product-Limit Survival EstimatesWith Number of Patients at Risk
+ Censored
Möbus V, et al. SABCS 2011. Abstract S2-4.
GAIN: Subgroup AnalysesDFS for Ibandronate in Subgroups
HR0.5 1.0 1.5
Better With Ibandronate Worse With Ibandronate
pN1
pN2
pN3
ER and/or PgR positive
ER and PgR negative
Pre- and perimenopausal
Postmenopausal
< 60 yrs
≥ 60 yrs
HR: 1.04 (95% CI: 0.652-1.65; P = .877)
HR: 0.875 (95% CI: 0.599-1.28; P = .490)
HR: 0.951 (95% CI: 0.710-1.27; P = .734)
HR: 0.952 (95% CI: 0.736-1.23; P = .706)
HR: 0.856 (95% CI: 0.604-1.21; P = .383)
HR: 1.02 (95% CI: 0.756-1.37; P = .912)
HR: 0.897 (95% CI: 0.671-1.20; P = .462)
HR: 1.02 (95% CI: 0.807-1.30; P = .842)
HR: 0.746 (95% CI: 0.490-1.14; P = .172)
Möbus V, et al. SABCS 2011. Abstract S2-4.
Variable Efficacy in an Unselected Population
*Analysis relates to bone metastasis-free survival.
1. Coleman RE, et al. N Engl J Med. 2011;365:1396-1405. 2. Gnant M, et al. SABCS 2011. Abstract S1-2.3. De Boer R, et al. SABCS 2011. Abstract S1-3. 4. Paterson A, et al. SABCS 2011. Abstract S2-3. 5. Powles T, et al. Breast Cancer Res. 2006;8:R13. 6. Mobus V, et al. SABCS 2011. Abstract S2-4.
Consistent Efficacy in “Postmenopausal” Women
*Includes patients > 40 yrs on goserelin; no significant effect for patients < 40 yrs.†Analysis relates to OS. ‡≥ 60 yrs at study entry.
1. Coleman RE, et al. N Engl J Med. 2011;365:1396-1405. 2. Gnant M, et al. SABCS 2011. Abstract S1-2. 3. De Boer R, et al. SABCS 2011. Abstract S1-3. 4. Paterson A, et al. SABCS 2011. Abstract S2-3. 5. Powles T, et al. Breast Cancer Res. 2006;8:R13. 6. Mobus V, et al. SABCS 2011. Abstract S2-4.
Conclusions
• Targeting the host environment may complement activity of direct anticancer treatments
• Adjuvant benefit from bone-targeted treatment appears to be dependent on a low reproductive hormone environment– Biologic mechanisms need further evaluation
• Inhibiting the vicious cycle may not always be beneficial• Adjuvant ZA should be considered in women with a low
estrogen environment– Prevent bone loss and fragility fracture– Potentially improve disease outcomes
Shepherd LE, et al. ASCO 2012. Abstract 501. Used with permission.
Exemestane vs Anastrozole in Early Breast Cancer (MA.27): EFS Analysis
• EFS significantly improved with vs without osteoporosis therapy (HR: 0.70; P < .00001)
Patient-Reported Outcome, n (%)
Osteoporosis
Yes(n =
1294)
No(n =
6282)
Osteoporosis therapy (n = 2711)
1101 (85)
1610 (25.6)
No osteoporosis therapy (n = 4865)
193 (15)
4672 (74.4)
100
80
0Pat
ien
ts W
ith
ou
t E
ven
t (%
)
0 1 2 3 4 5 0
Yrs
P = .0003
Osteoporosis/no osteoporosis therapyOsteoporosis/osteoporosis therapyNo osteoporosis/no osteoporosis therapyNo osteoporosis/osteoporosis therapy
FDA-Approved Antiosteoclast Agents for Reduction of SREs in MBC
• Both ASCO and NCCN recommend all 3 agents• No agent recommended over another
Agent Drug ClassRecommended Dose and
Schedule
Zoledronic acid
Bisphosphonate 4 mg IV q3-4w
Pamidronate Bisphosphonate 90 mg IV q3-4w
Denosumab RANKL-targeted MAb 120 mg SQ q4w
1. Van Poznak CH, et al. J Clin Oncol. 2011;29:1221-1227. 2. National Comprehensive Cancer Network. Clinical practice guidelines in oncology: breast cancer. v.1.2012.
Denosumab vs Zoledronic Acid: Time to First On-Study SRE
Zoledronic acid 1020 829 676 584 498 427 296 191 94 29
Denosumab 1026 839 697 602 514 437 306 189 99 26
Patients at Risk, n
KM Estimate ofMedian Mos
DenosumabZoledronic acid
Not reached26.4
HR: 0.82 (95% CI: 0.71-0.95; P < .001 noninferiority; P = .01 superiority*)
Mos
0
1.00
Pro
po
rtio
n o
f S
ub
ject
s W
ith
ou
t S
RE
0 3 6 9 12 15 18 21 24 27 30
0.25
0.50
0.75
Stopeck AT, et al. J Clin Oncol. 2010;28:5132-5139.
40
20
0 Mo 12 Mo 18 At Time of Analysis
Denosumab (n = 1026)Zoledronic acid (n = 1020)
Per
cen
t o
f S
ub
ject
s W
ith
SR
Es
(95%
CI)
4.5%relative reduction
11.4%relative reduction
15.4%relative reduction
10
30
28.8%32.5% 32.9%38.9%25.4%26.6%
Stopeck A, et al. SABCS 2010. Abstract P6-14-01.
Denosumab vs Zoledronic Acid: Proportion Experiencing ≥ 1 SRE
GRACIAS