. 2024 Mar 1;32(3):202. doi: 10.1007/s00520-024-08392-8

Table 2.

Summary of answers to the second part of the survey

Questions and options	Number (percentage)
You prescribe antiresorptive drugs (bisphosphonates, denosumab) for patients with bone metastases from breast cancer:
a) Always, at the time of diagnosis of bone metastases b) Almost always (except for a minority of patients) c) Only in symptomatic cases or in cases at high risk of skeletal-related events (SREs) d) Rarely e) Never f) I do not follow patients with breast cancer	60 (37.1%) 81 (50%) 20 (12.3%) 1 (0.6%) 0 (0%) 29
You prescribe antiresorptive drugs (bisphosphonates, denosumab) for patients with bone metastases from prostatic carcinoma:
a) Always, at the diagnosis of bone metastases, regardless of hormonal responsiveness b) Only in castration-resistant carcinoma, regardless of symptomatology c) Only in castration-resistant carcinoma, and only in symptomatic cases or which I consider to be at high risk of SRE d) In both hormone-dependent and castration-resistant carcinoma, if symptomatic e) Never f) I do not follow patients with prostate cancer	53 (37.9%) 46 (32.8%) 29 (20.7%) 12 (8.6%) 0 (0%) 51
You prescribe antiresorptive drugs (bisphosphonates and denosumab) for patients with bone metastases from other solid tumors (lung, renal cancer, etc.):
a) Always, at the time of diagnosis of bone metastases b) Almost always (except for a minority of patients) c) Only in cases of symptomatic cases or at high risk of skeletal events (SRE) d) Rarely e) Never f) I do not follow this type of patient, except occasionally	35 (19.9%) 79 (44.9%) 55 (31.2%) 7 (4%) 0 (0%) 15
You ask for dental evaluation before prescription of antiresorptive drugs (bisphosphonates, denosumab)
a) Always, systematically b) Almost always c) Only in case of poor oral hygiene of the patient d) Rarely e) Never	173 (90.6%) 17 (8.9%) 1 (0.5%) 0 (0%) 0 (0%)
The pre-therapy dental evaluation usually includes:
a) Dental panoramic X-rays and dental examination b) Only dental panoramic X-rays c) Only dental examination	183 (95.8%) 2 (1.1%) 6 (3.1%)
For most of your patients, pre-therapy dental evaluation takes place:
a) Entirely at my hospital b) Entirely in another structure (upon reservation/organization by my center staff) c) Partly internal, partly external (e.g., dental panoramic X-rays in a public structure and dental visit at a private practice) d) All delivered to individual choice and/or personal initiative of the single patient	90 (47.1%) 23 (12.1%) 54 (28.2%) 24 (12.6%)
If one or more dental extractions are programmed by the dentist:
a) You always start therapy immediately and delay the tooth/teeth extraction b) You always wait for extraction before starting the treatment c) You start the treatment in selected cases (e.g., aggressive disease) and wait for extraction in most cases d) You start immediately in most cases and wait for extraction only in selected cases (e.g., asymptomatic disease with a good prognosis)	2 (1.1%) 125 (65.4%) 58 (30.4%) 6 (3.1%)
In case of waiting after extraction, you usually start the treatment:
a) 2 weeks from extraction, and after dental check-up (closed cavity) b) After 4 weeks from extraction, and after dental check-up (closed cavity) c) 4 weeks after extraction, regardless of dental check-up d) After 6–8 weeks, regardless of dental check-up e) Other	34 (17.8%) 119 (62.3%) 11 (5.7%) 25 (13.1%) 2 (1.1%)
You prescribe for patients with bone metastases from solid tumors:
a) Always zoledronic acid b) Always bisphosphonates (zoledronic acid, ibandronate, or pamidronate, depending on the patient) c) Always denosumab d) Zoledronic acid or denosumab, depending on the patient e) Other	22 (11.5%) 5 (2.6%) 14 (7.3%) 150 (78.6%) 0 (0%)
Are there limitations to denosumab prescription (in addition to the need to fill out the AIFA – the Italian Medicine Agency—form) in your center?
a) No b) Yes, by hospital commitment or choice c) Yes, due to my workgroup indications d) Other	163 (85.3%) 9 (4.7%) 16 (8.4%) 3 (1.6%)
If you prescribe zoledronate or denosumab on the individual patient, the choice depends on:
Select maximum 3 possible answers Primary cancer type Prognosis of the cancer patient Symptomatology Age of the patient Risk of skeletal-related events (SREs) Blood creatinine level Calcium level Availability of venous access Patient oral health Other	57 29 18 37 24 135 37 66 5 9
During treatment with zoledronic acid and other bisphosphonates, you check:
a) Only creatinine level, periodically b) Only calcium level, periodically c) Creatinine and calcium level, periodically d) Only creatinine level, before each infusion e) Only calcium, before each infusion f) Creatinine and calcium, before each infusion e) Other	0 (0%) 0 (0%) 30 (15.7%) 3 (1.6%) 1 (0.5%) 155 (81.1%) 2 (1.1%)
During treatment with denosumab, you check:
a) Only creatinine level, periodically b) Only calcium level, periodically c) Creatinine and calcium level, periodically d) Only creatinine level, before each administration e) Only calcium, before each administration f) Creatinine and calcium, before each administration e) Other	0 (0%) 4 (2.0%) 27 (14.1%) 2 (1.1%) 26 (13.6%) 125 (65.5%) 7 (3.7%)
Did you find hypocalcemia after denosumab or bisphosphonates?
a) No b) Sporadically, and always asymptomatic c) Sporadically, with few symptomatic cases d) Quite frequently, but always asymptomatic e) Quite frequently, and with some symptomatic cases	0 (0%) 119 (62.3%) 54 (28.3%) 13 (6.8%) 5 (2.6%)
How do you usually treat asymptomatic hypocalcemia?
a) I temporarily interrupt the treatment and check the calcium later b) I prescribe oral calcium c) I prescribe calcium by intravenous infusion d) I prescribe high doses of vitamin D e) Other	32 (16.8%) 108 (56.6%) 16 (8.4%) 15 (7.8%) 20 (10.4%)
In case of treatment with bisphosphonates, as a supplementation you prescribe in most patients:
a) Only calcium b) Only vitamin D c) Calcium and vitamin D separately d) Calcium + vitamin D associations f) Nothing	2 (1.1%) 11 (5.7%) 60 (31.4%) 112 (58.6%) 6 (3.2%)
In case of treatment with denosumab, as a prophylaxis you prescribe in most of patients:
a) Only calcium b) Only vitamin D c) Calcium and vitamin D separately d) Calcium + vitamin D associations e) Nothing	4 (2.1%) 10 (5.2%) 57 (29.8%) 114 (59.7%) 6 (3.2%)
What do you think about a quarterly administration of zoledronic acid?
a) I am not convinced that it can be a reliable alternative to the monthly administration of zoledronic acid b) It can be a valid alternative to monthly administration, after one year of monthly infusions c) It is a valid “upfront” alternative (from the beginning of therapy) to monthly administration, in some patients (e.g., pauci-symptomatic patients, or with mildly aggressive disease, etc.) d) Other	9 (4.7%) 107 (56.0%) 72 (37.7%) 3 (1.6%)

Questions and options

Number (percentage)

You prescribe antiresorptive drugs (bisphosphonates, denosumab) for patients with bone metastases from breast cancer:

a) Always, at the time of diagnosis of bone metastases

b) Almost always (except for a minority of patients)

c) Only in symptomatic cases or in cases at high risk of skeletal-related events (SREs)

d) Rarely

e) Never

f) I do not follow patients with breast cancer

60 (37.1%)

81 (50%)

20 (12.3%)

1 (0.6%)

0 (0%)

You prescribe antiresorptive drugs (bisphosphonates, denosumab) for patients with bone metastases from prostatic carcinoma:

a) Always, at the diagnosis of bone metastases, regardless of hormonal responsiveness

b) Only in castration-resistant carcinoma, regardless of symptomatology

c) Only in castration-resistant carcinoma, and only in symptomatic cases or which I consider to be at high risk of SRE

d) In both hormone-dependent and castration-resistant carcinoma, if symptomatic

e) Never

f) I do not follow patients with prostate cancer

53 (37.9%)

46 (32.8%)

29 (20.7%)

12 (8.6%)

0 (0%)

You prescribe antiresorptive drugs (bisphosphonates and denosumab) for patients with bone metastases from other solid tumors (lung, renal cancer, etc.):

a) Always, at the time of diagnosis of bone metastases

b) Almost always (except for a minority of patients)

c) Only in cases of symptomatic cases or at high risk of skeletal events (SRE)

d) Rarely

e) Never

f) I do not follow this type of patient, except occasionally

35 (19.9%)

79 (44.9%)

55 (31.2%)

7 (4%)

0 (0%)

You ask for dental evaluation before prescription of antiresorptive drugs (bisphosphonates, denosumab)

a) Always, systematically

b) Almost always

c) Only in case of poor oral hygiene of the patient

d) Rarely

e) Never

173 (90.6%)

17 (8.9%)

1 (0.5%)

0 (0%)

The pre-therapy dental evaluation usually includes:

a) Dental panoramic X-rays and dental examination

b) Only dental panoramic X-rays

c) Only dental examination

183 (95.8%)

2 (1.1%)

6 (3.1%)

For most of your patients, pre-therapy dental evaluation takes place:

a) Entirely at my hospital

b) Entirely in another structure (upon reservation/organization by my center staff)

c) Partly internal, partly external (e.g., dental panoramic X-rays in a public structure and dental visit at a private practice)

d) All delivered to individual choice and/or personal initiative of the single patient

90 (47.1%)

23 (12.1%)

54 (28.2%)

24 (12.6%)

If one or more dental extractions are programmed by the dentist:

a) You always start therapy immediately and delay the tooth/teeth extraction

b) You always wait for extraction before starting the treatment

c) You start the treatment in selected cases (e.g., aggressive disease) and wait for extraction in most cases

d) You start immediately in most cases and wait for extraction only in selected cases (e.g., asymptomatic disease with a good prognosis)

2 (1.1%)

125 (65.4%)

58 (30.4%)

6 (3.1%)

In case of waiting after extraction, you usually start the treatment:

a) 2 weeks from extraction, and after dental check-up (closed cavity)

b) After 4 weeks from extraction, and after dental check-up (closed cavity)

c) 4 weeks after extraction, regardless of dental check-up

d) After 6–8 weeks, regardless of dental check-up

e) Other

34 (17.8%)

119 (62.3%)

11 (5.7%)

25 (13.1%)

2 (1.1%)

You prescribe for patients with bone metastases from solid tumors:

a) Always zoledronic acid

b) Always bisphosphonates (zoledronic acid, ibandronate, or pamidronate, depending on the patient)

c) Always denosumab

d) Zoledronic acid or denosumab, depending on the patient

e) Other

22 (11.5%)

5 (2.6%)

14 (7.3%)

150 (78.6%)

0 (0%)

Are there limitations to denosumab prescription (in addition to the need to fill out the AIFA – the Italian Medicine Agency—form) in your center?

a) No

b) Yes, by hospital commitment or choice

c) Yes, due to my workgroup indications

d) Other

163 (85.3%)

9 (4.7%)

16 (8.4%)

3 (1.6%)

If you prescribe zoledronate or denosumab on the individual patient, the choice depends on:

Select maximum 3 possible answers

Primary cancer type

Prognosis of the cancer patient

Symptomatology

Age of the patient

Risk of skeletal-related events (SREs)

Blood creatinine level

Calcium level

Availability of venous access

Patient oral health

Other

135

During treatment with zoledronic acid and other bisphosphonates, you check:

a) Only creatinine level, periodically

b) Only calcium level, periodically

c) Creatinine and calcium level, periodically

d) Only creatinine level, before each infusion

e) Only calcium, before each infusion

f) Creatinine and calcium, before each infusion

e) Other

0 (0%)

30 (15.7%)

3 (1.6%)

1 (0.5%)

155 (81.1%)

2 (1.1%)

During treatment with denosumab, you check:

a) Only creatinine level, periodically

b) Only calcium level, periodically

c) Creatinine and calcium level, periodically

d) Only creatinine level, before each administration

e) Only calcium, before each administration

f) Creatinine and calcium, before each administration

e) Other

0 (0%)

4 (2.0%)

27 (14.1%)

2 (1.1%)

26 (13.6%)

125 (65.5%)

7 (3.7%)

Did you find hypocalcemia after denosumab or bisphosphonates?

a) No

b) Sporadically, and always asymptomatic

c) Sporadically, with few symptomatic cases

d) Quite frequently, but always asymptomatic

e) Quite frequently, and with some symptomatic cases

0 (0%)

119 (62.3%)

54 (28.3%)

13 (6.8%)

5 (2.6%)

How do you usually treat asymptomatic hypocalcemia?

a) I temporarily interrupt the treatment and check the calcium later

b) I prescribe oral calcium

c) I prescribe calcium by intravenous infusion

d) I prescribe high doses of vitamin D

e) Other

32 (16.8%)

108 (56.6%)

16 (8.4%)

15 (7.8%)

20 (10.4%)

In case of treatment with bisphosphonates, as a supplementation you prescribe in most patients:

a) Only calcium

b) Only vitamin D

c) Calcium and vitamin D separately

d) Calcium + vitamin D associations

f) Nothing

2 (1.1%)

11 (5.7%)

60 (31.4%)

112 (58.6%)

6 (3.2%)

In case of treatment with denosumab, as a prophylaxis you prescribe in most of patients:

a) Only calcium

b) Only vitamin D

c) Calcium and vitamin D separately

d) Calcium + vitamin D associations

e) Nothing

4 (2.1%)

10 (5.2%)

57 (29.8%)

114 (59.7%)

6 (3.2%)

What do you think about a quarterly administration of zoledronic acid?

a) I am not convinced that it can be a reliable alternative to the monthly administration of zoledronic acid

b) It can be a valid alternative to monthly administration, after one year of monthly infusions

c) It is a valid “upfront” alternative (from the beginning of therapy) to monthly administration, in some patients (e.g., pauci-symptomatic patients, or with mildly aggressive disease, etc.)

d) Other

9 (4.7%)

107 (56.0%)

72 (37.7%)

3 (1.6%)