The probability of detecting radiologically evident metastatic disease in asymptomatic women with newly diagnosed operable breast cancer is low. Despite the recommendations of most practice guidelines imaging is still frequently performed. Relatively little is known about what patients believe is important when it comes to radiologic staging. Patients with early stage breast cancer who had completed their definitive breast surgery were surveyed about their personal experiences, perceptions, and expectations on the issue of perioperative imaging for distant metastatic disease. Over a 3 month period, 245 women with primary operable breast cancer completed the questionnaire (87.0% response rate) and 80.8% indicated having had at least one imaging test for distant metastatic disease. These were either of the thorax (72.2%), abdomen (55.9%) or skeleton (65.3%) with a total of 701 imaging tests (average of 3.5 tests per patient imaged) performed. Overall, 57.1% indicated that they would want imaging done if the chance of detecting metastases was ≤10%. Although 80.0% of patients indicated that, “doing whatever their doctor recommended” was important to them, 70.4% also noted that they would be uncomfortable if their physician did not order imaging, even if this was in keeping with practice guidelines. Most patients with early stage breast cancer recall having imaging tests for distant metastases. Given the choice, most would prefer having imaging performed, even if this is not in line with current guidelines. If patient expectations are, in part, driving excessive imaging, new strategies addressing this are required.

Despite advances in adjuvant therapy for breast cancer, bone remains the most common site of recurrence. The goal of therapy for these patients is palliative and focused on maximizing the duration and quality of their life, while concurrently minimizing any disease or treatment-related complications. Bone metastases predispose patients to reduced survival, pain, impaired quality of life and the development of skeletal-related events. With an increased understanding of the pathophysiology of bone metastasis, effective treatments for their management have evolved and are now in widespread clinical use. This article will discuss the pathogenesis of bone metastases and review the key clinical evidence for the efficacy and safety of currently available systemic bone-targeted therapies in breast cancer patients with an emphasis on bisphosphonates and the receptor activator of nuclear factor kappa B ligand (RANKL) inhibitors. We will also discuss novel strategies and therapies currently in development.

155 Background: Questions remain around the optimal use of bone-targeted agents (BTA) in patients with bone metastases (BM) from breast cancer (BC). In Canada pamidronate (PAM) is the most commonly used BTA in BC.We explored whether a switch to a more potent BTA, like zoledronic acid (ZA), in patients who remain at high risk of skeletal related events (SREs) despite PAM use is associated with significant palliative benefit. Methods: BC patients with high risk BM (prior SRE, bone progression, bone pain or levels of bone turnover marker serum C-telopeptide (sCTX) >400ng/L) despite >3 months of PAM use were eligible. Patients were randomized in a double–blind manner to either switch to ZA or continue on PAM every 4 weeks for 12 weeks. Primary outcome was the proportion of patients achieving a fall in sCTX at 12 weeks. Secondary outcomes were pain control (BPI and FACT-BP) and toxicity. Results 73 patients completed the study. Median age 61 years (range 37 – 87), prior duration of PAM use 10 months (range 3 – 118). sCTX levels for all patients at baseline, 372+/- 471, week 12, 209 +/-290. Proportion of patients achieving a fall in sCTX from week 0 to week 12, 26/31 (84%) in ZA arm, 17/30 (57%) in PA arm, p=0.0262. Two patients were unable to complete the study due to deterioration in renal function (both receiving PAM), four due to progressive disease (two receiving ZA, two PAM), two patients chose to discontinue the study before completion (both receiving ZA). Four patients (5%) had SRE’s during the study, two receiving ZA, two receiving PAM. Quality of life and pain analysis shows no difference between week 0 and week 12 scores in either arm. Toxicity was predominantly grade 1 and 2, numerically there were more adverse effects in the ZA arm than PAM. Conclusion Switching patients with high risk BM from PAM to ZA leads to a reduction in sCTX levels but may be associated with more toxicity. Quality of life and pain scores were similar between the two treatments. While the literature suggests that a reduction in sCTX may correlate with reduced rate of SREs, given the lack of symptom improvement a switching strategy cannot be recommended. NCT01907880 Clinical trial information: NCT01907880.