Table 2.

Existing guideline recommendations for bisphosphonate use in metastatic breast cancer patients with bone metastases. Additional abbreviations: CT, computed tomography; MR, magnetic resonance; ZOL, zoledronic acid; IBA, ibandronate; PAM, pamidronate; CLO, clodronate; DMB, denosumab. Reproduced with permission from the Journal of Breast Cancer: Targets and Therapy [18].

	When to start?	Which bisphosphonate?	When to stop?
ASCO Guidelines 2011 [30]	Breast cancer + radiographic evidence of bone destruction: Lytic disease on X-ray Abnormal bone scan with CT/MR showing bone destruction	IV PAM 90 mg every 3–4 weeks OR IV ZOL 4 mg every 3–4 weeks OR SC DMB 120 mg every 4 weeks	Until evidence of substantial decline in patient’s general performance status
International Expert Panel Guidelines 2008 [32]	Breast cancer + first sign of radiographic evidence of bone metastases, even if patient is asymptomatic	Nitrogen-Bisphosphonate IV preferable (ZOL, IBA, PAM) PO for patients who cannot or need not attend hospital care (CLO, IBA)	Continue beyond 2 years but always based on individual risk assessment; should not discontinue treatment once SRE occurs