Table 1.

New Bone-Modifying Agent

Recommendation Category	2003 Recommendations	2011 Recommendations	Change
Indications and time of initiation	For breast cancer patients who have evidence of bone destruction on plain radiographs, IV pamidronate 90 mg delivered over 2 h or zoledronic acid 4 mg over 15 min every 3 to 4 wk are recommended. Starting bisphosphonates in women with an abnormal bone scan and an abnormal CT or MRI scan showing bone destruction, but normal plain radiographs, is considered reasonable by Panel consensus based on the findings in women with lytic or mixed lytic/blastic changes on plain radiographs. There is insufficient evidence relating to efficacy to support one bisphosphonate over the other. For each of the guidelines, clinical judgment should also take into consideration the patient's general performance status and overall prognosis.	For patients with breast cancer who have evidence of bone metastases, denosumab 120 mg subcutaneously every 4 wk, or IV pamidronate 90 mg delivered over no less than 2 h, or zoledronic acid 4 mg over no less than 15 min every 3 to 4 wk is recommended. Starting bone-modifying agents in women with an abnormal bone scan and an abnormal CT scan or MRI showing bone destruction, but normal plain radiographs, is considered reasonable by Panel consensus based on the findings in women with lytic or mixed lytic/blastic changes on plain radiographs. Starting bone-modifying agents in women with only an abnormal bone scan but without evidence of bone destruction on radiographs, CT scans, or MRI is not recommended outside of a clinical trial. There is insufficient evidence relating to efficacy to support one bone-modifying agent over another.	Addition of new bone-modifying agent. Term changed from bisphosphonates to bone-modifying agents.

Note: Bolded text indicates substantive changes. Italicized text indicates minor changes.

Abbreviations: IV, intravenous; CT, computed tomography; MRI, magnetic resonance imaging; h, hours; min, minutes; wk, weeks.