PracticeUpdate: Haematology & Oncology

EDITOR’S PICKS 7

ARTICLE OF THEMONTH Longer-interval dosing of zoledronic acid effective in patients with bone metastases Introducing Editor’s Picks, a new section featuring the most recent top clinical trials in oncology and haematology specially selected by the PracticeUpdate Oncology Editorial and Advisory Board members. T he use of zoledronic acid in patients with metastatic breast cancer (MBC) with bony metastases is crucial to prevent skeletal-related events, which have been shown to occur in up to 50% of patients when untreated. Skeletal-related events are defined as fractures, spinal cord compression, need for surgery or radiation to relieve symptomatic disease, and hypercalcemia of malignancy. Bone metastases disrupt the normal homeostasis between bone formation and resorption by promoting osteoclast maturation and activity and increased bone resorption. Bone is a common site of recurrence in breast cancer. Bony metastases significantly impact quality of life; therefore, MBC patients should be offered bisphosphonate (or RANK ligand inhibitor) therapy at diagnosis with bone metastases. However, these therapies are not without potential side effects. A rare and serious complication is oste- onecrosis of the jaw. Therapies are also associated with the need for monthly visits to the infusion suite, which can be disruptive especially to a patient who would otherwise not require these visits as she is not on chemotherapy. The option to dose zoledronic acid less frequently without compromising efficacy is therefore an attractive alternative for patients. JAMA 2017;317(1):48-58. AL Himelstein, JC Foster, JL Khatcheressian, et al. Impact on metastatic breast cancer By Reshma L. Mahtani DO

Radiation with or without antian- drogen therapy in recurrent prostate cancer N Engl J Med 2017;376:417-428, Shipley WU, Seif- erheld W, Lukka HR, et al, for the NRG Oncology RTOG. Take-home message • In this double-blind, placebo-controlled trial involving 760 patients who had undergone primary prostatectomy with a lymphadenectomy and had disease with a tumour stage T2 or T3, no nodal involvement, and a detectable PSA level of 0.2–4.0 ng/mL, overall survival at 12 years was 76.3% in the bicalutamide group vs 71.3% in the placebo group; death from prostate cancer was 5.8% vs 13.4% in the bicalutamide and placebo groups, respectively. • The addition of 24months of antiandrogen therapy with daily bicalutamide to salvage radiation therapy resulted in significantly higher rates of long-term overall survival and lower incidences of metastatic prostate cancer and death from prostate cancer than radiation therapy plus placebo.

also await the results of the RADICALs and GETUG-16 (salvage radiation trials) to assess if practice should change.

For patients who expressed <1% of PD-L1, response was 16.1%. Grade 3–4 treatment-re- lated adverse events occurred in 18%, with three treatment-related deaths. This is a novel study; once again it mirrors response rates observed in previous studies involving checkpoint inhibitors. Of particu- lar interest, monotherapy with nivolumab is beneficial regardless of whether PD-L1 is expressed. However, perhaps most excitingly, it heralds an era where individualised therapy in bladder cancer can be based on molecular marker expression. Much like oestrogen and Herceptin receptor expression can influence treatment paradigms in breast cancer, personal- ised care is a reality for bladder cancer. Patients can be directly counselled regarding potential response rates and therapeutic strategies based on PD-L1 expression. It remains to be seen whether routine, efficient and cost-effective PD-L1 expression is clinically applicable.

Dr Mahtani is a haematologist/medical oncologist and Assistant Clinical Professor of haematology/oncology at the Sylvester Comprehensive Cancer Center, Miami.

Take-home message • This was a randomised, open-label phase III trial designed to assess whether 12-week dosing of zoledronic acid was noninferior to every 4-week dosing in 1822 patients with bone metastatic breast cancer, prostate cancer, and multiple myeloma. There was no significant difference between the rate of skeletal-related events among patients who received zoledronate every 12 weeks and those who received it every 4 weeks. • The authors concluded that longer-interval treatment with zoledronic acid may be an acceptable treatment modality among patients with bone metastases.

VOL. 2 • NO. 2 • 2017