In elderly cancer patients with bone metastases, the use of bisphosphonates to prevent skeletal-related events (SREs) warrants special consideration. Elderly patients are at high risk of developing renal impairment due to reduced hydration, overuse of non-steroidal antiinflammatory drugs (NSAIDs) for analgesic purposes and concomitant treatment with antihypertensive, antidiabetic drugs and lipid-lowering agents. Furthermore, older patients with pre-existing renal impairment may be at an increased risk of renal toxicity associated with intravenous (IV) bisphosphonates. Elderly patients may also confuse the dosing with concomitant oral regimens, so ensuring compliance with oral bisphosphonate therapy can be difficult.
The American Society of Clinical Oncology (ASCO) issued an update on the guidelines for the use of bisphosphonates in 2003. They state that for patients with plain radiographic evidence of bone destruction, IV bisphoshonates are recommended. However, these guidelines were published some time ago and do not mention the use of bisphosphonates such as ibandronate that are not approved in the US. Furthermore, they do not take into consideration the particular needs of elderly patients. At the time of writing there were no randomised studies of elderly patients available on which to base these recommendations; therefore, data from the available phase III studies of commonly prescribed bisphosphonates were considered. Where available, subanalyses of phase III studies were used as a basis for recommendations. Clinical end-points taken into account included the prevention of SREs and the treatment of metastatic bone pain.
An International Society of Geriatric Oncology (SIOG) task force composed of Jean-Jacques Body, Rob Coleman, Philippe Clezardin, Carla Ripamonti, Rene Rizzoli and Matti Aapro from, respectively, Université Libre de Bruxelles, Institut Jules Bordet and CHU Brugmann, Brussels, Belgium; Weston Park Hospital, Sheffield, UK; INSERMU 664, Lyon, France; Rehabilitation and Palliative Care Unit, National Cancer Institute of Milan, Italy; University Hospital, Geneva, Switzerland; and Clinique de Genolier, Geneva, Switzerland has reviewed information from the literature on bisphosphonates in elderly patients with bone metastases and this work will be published in the European Journal of Cancer in 2007. This short manuscript highlights some of the matters discussed in the forthcoming paper.