Zoledronic acid or denosumab are commonly added to upfront treatment for the management of skeletal-related events (SREs) in patients with advanced lung cancer, notes Corey J. Langer, MD. In some patients, the administration of denosumab or zoledronic acid can be delayed, if only a single bone metastasis is present. In general, the decision to begin therapy should be based on the volume of metastases, since these treatments can result in adverse events.

The intravenous bisphosphonate zoledronic acid and the RANK ligand inhibitor denosumab are both effective for the prevention of SREs, making a decision challenging, Heather A. Wakelee, MD, notes. Zoledronic acid has been approved longer and can be quite easy to administered; however, denosumab may have advantages over zoledronic acid, in terms of the administration route and toxicity profile, Wakelee believes. The management of SREs is becoming even more of a concern as patients begin to live longer, as a result of novel targeted therapies. For long-term survivors, new dosing strategies may be required, Wakelee suggests.

Approximately 40% of patients with advanced lung cancer will develop bone metastases, notes Benjamin P. Levy, MD. In addition to the administration route and tolerability, Levy points out that the treatments can be selected based on creatinine levels and the risk of hypocalcaemia. In general, Levy feels that denosumab is better tolerated. Additionally, a retrospective analysis showed a survival advantage with denosumab; although this still requires confirmation, Levy notes.

In general, Mark A. Socinski, MD, does not believe lung cancer is predominantly a bone disease. However, he does utilized denosumab and zoledronic acid in select scenarios. Mark G. Kris, MD, utilizes treatments geared toward bone health more selectively. Kris feels that an effective systemic therapy should also heal the bone, making additional treatment unwarranted. In general, when one of these treatments is utilized, both Socinski and Kris prefer zoledronic acid, due to their experience with the drug.

In some situations, a bone flare may suggest new metastases when none are present. These flares stress the importance of collaboration with radiology in order to provide clinical data on patient performance, Langer suggests. In general, the delay or potential prevention of SREs provides ancillary care for patients with lung cancer that has made a significant difference, Langer believes.