Risks and benefits of bisphosphonates

Bone is the most common site for metastasis in cancer and is of particular clinical importance in breast and prostate cancers due to the prevalence of these diseases. Bone metastases result in considerable morbidity and complex demands on health care resources, affecting quality of life and independence over years rather than months. The bisphosphonates have been shown to reduce skeletal morbidity in multiple myeloma as well as a wide range of solid tumours affecting bone by 30-50%. Quite appropriately, these agents are increasingly used alongside anticancer treatments to prevent skeletal complications and relieve bone pain. The use of bisphosphonates in early cancer is also increasingly important to prevent the adverse effects of cancer treatments on bone health. These include ovarian suppression and the use of aromatase inhibitors in breast cancer patients and androgen deprivation therapy in those with prostate cancer. Bisphosphonate strategies, similar to those used to treat postmenopausal osteoporosis, have suggested that bisphosphonates are a safe and effective treatment for the prevention of treatment-induced bone loss. When compared to other cancer therapies, the frequency and severity of adverse events related to bisphosphonate therapy are generally mild and infrequent; thus, the benefits of treatment with any bisphosphonate almost always outweigh the risks. However, renal dysfunction may occasionally occur and over recent years, a new entity, bisphosphonate-associated osteonecrosis of the jaw (ONJ), has been described. The incidence, clinical importance and prevention strategies to minimise the impact of this problem on patients requiring bisphosphonates is discussed.