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    • To our knowledge this is the first

    2019-05-18

    To our knowledge, this is the first survey to specifically assess, in daily clinical practice, the management of bone buy potassium phosphate monobasic and, in general, the perception of bone healthcare in Italy. However, the findings of this analysis are in overall agreement with those of previous studies, some referring to the Italian situation, in other fields of cancer treatment, which have highlighted the wide gap between guideline recommendations and clinical practice in the oncology and bone health setting [13–17]. In all of these studies, the level of care was suboptimal, and it was generally concluded that, although the education of oncologists and healthcare providers is improving, further procedures and implementation of educational programs to optimize their level of attention and awareness are required [17]. A detailed summary of the current recommendations for the management of bone metastasis in cancer patients is beyond the scope of the present publication. However, we believe some critical points deserve mentioning. For instance, while BPs, and in particular zoledronic acid, are prescribed by the majority of oncologists, it must be recognized that the main objectives of this therapy are, in the participants\' opinion, of a palliative nature (e.g. pain relief) rather than curative (e.g. reduction of risk of death related to SRE). Moreover, about half of the participating oncologists may decide not to treat asymptomatic bone metastases: current consensus recommends that BP treatment should be initiated regardless of the presence of symptomatic metastases and the development of SRE [6,8,18]. About 30% of participants do not support the association between SREs and the increase in the risk of death, despite it being well-documented in the medical literature [19,20]. Moreover, only a minor proportion of specialists consider bone turnover (measured with bone turnover markers such as urinary NTX or serum CTX) as a predictive factor for the appearance of SRE, despite different suggestions published in literature [1]. Some gaps between the actual prescribing attitudes of oncology specialists and current guidelines about BP treatment in oncology patients have also been highlighted by the present survey. About one out of four of the involved oncologists does not start BP treatment at the diagnosis of bone metastasis, contrary to current international recommendations [5–10]. Additionally, about 40% of oncologists interrupt zoledronic acid therapy when skeletal disease progresses, pain develops, or an SRE occurs, rather than continuing the same bisphosphonate as suggested by guidelines [6,8]. Interestingly, for about 40% of oncologists, ONJ still represents a concern in patients during BP treatment, despite current guidelines agreeing on the high efficacy of preventive measures, which should be implemented in all patients assigned to BP therapy [5–10]. Finally, the most alarming result was that about 20% of oncologists appear not to be aware of or follow any guidelines for the maintenance of bone health in their clinical practice.
    Funding
    Conflict of interest statement
    Acknowledgments Editorial assistance for the preparation of this manuscript was provided by Luca Giacomelli, Ph.D., on behalf of inScience Communication; this assistance was funded by Novartis Oncology.
    Introduction Approximately 75% of patients with advanced breast cancer develop bone metastasis [1]. Patients with such bone metastasis suffer skeletal-related events (SREs) such as pathologic fracture, bone pain, spinal cord compression, and hypercalcemia [2]. As pathologic fracture is associated with a significantly increased risk of death, prevention of bone metastasis improves not only the quality of life but also the survival rate of patients with advanced breast cancer [3–5]. Zoledronic acid (Zol), which contains two nitrogen atoms within an imidazole ring structure, is the most potent inhibitor of bone metastasis-related osteolysis and effectively reduces the incidence of SREs [2]. Zol inhibits the mevalonate pathway in osteoclasts, thus inhibiting the synthesis of farnesyl pyrophosphate synthase and geranylgeranyl pyrophosphonate, which are required for prenylation of signaling GTPases. Recent preclinical studies have suggested that Zol exerts specific anti-tumor effects including inhibition of cancer cell proliferation and/or invasion [6–8].