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. 2025 Jun 11;27(1):102.
doi: 10.1186/s13058-025-02062-1.

Patterns of adjuvant bone modifying agent use in patients with early-stage breast cancer in the United States

Nicole Odzer  1 , Rachel Jaber Chehayeb  2 , Sarah E Schellhorn  1   3 , Maryam Lustberg  1 , Cary P Gross  1   3 , Do Lee  3 , Julia Foldi  4
Affiliations

Patterns of adjuvant bone modifying agent use in patients with early-stage breast cancer in the United States

Nicole Odzer et al. Breast Cancer Res. .

Abstract

Purpose: Based on improved survival, the 2017 ASCO and Cancer Care Ontario clinical guidelines (ACGD) recommended consideration of adjuvant bisphosphonates for postmenopausal women with early-stage breast cancer (EBC). However, small survey-based studies suggest inconsistent prescribing. This study evaluated receipt of adjuvant bone modifying agents (BMAs) in the United States before and after publication of the 2017 ACGD.

Methods: This nationwide retrospective cohort study used a deidentified electronic health record-derived database to identify patients diagnosed with stage I-III EBC treated at health care practices from 2012 to 2019. We defined adjuvant BMA (bisphosphonates or denosumab) use as first dose received within 24 months of EBC diagnosis. We used Chi-squared and multivariable logistic regression analyses to compare the proportion of patients receiving adjuvant BMAs pre- and post-ACGD and identify factors associated with receipt of any BMA as well as bisphosphonates alone.

Results: Our cohort included 11,470 patients. Most patients were 50 years of age or older (82%), and had stage I (57%), node-negative (70%) and estrogen receptor (ER)-positive (76%) breast cancer. Patients diagnosed post-ACGD (2017-19) were more likely to receive adjuvant BMAs (9%) than patients diagnosed in earlier years (7.4%; odds ratio [OR] 1.23; 95% confidence interval (CI) 1.08-1.42; p = 0.002). Post-menopausal status, age ≥ 50, receipt of adjuvant chemotherapy and endocrine therapy, and coexisting bone loss diagnoses were significantly associated with increased receipt of adjuvant BMAs. Among BMA recipients, 65.8% received denosumab only, 32.6% received bisphosphonates only, and 1.4% received both.

Conclusions: Even after release of the ACGD guidelines, adjuvant BMA prescribing was low, and the majority of patients who received BMA did not receive bisphosphonates.

Keywords: Adjuvant therapy; Bisphosphonates; Bone modifying agents (BMAs); Breast cancer; Denosumab; Early-stage breast cancer (EBC); Prescribing patterns.

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Conflict of interest statement

Declarations. Ethical approval: The study was approved by the Institutional Review Boards (IRB) at Yale University (HIC #). Given the minimal risk of the study, the IRBs determined that the study was exempt from having to obtain informed consent from patients. Competing interests: Dr. Gross has received research funding from the NCCN Foundation (with funds provided to NCCN by Astra-Zeneca) and Genentech, as well as funding from Johnson and Johnson to help devise and implement new approaches to sharing clinical trial data. Dr. Foldi has received honoraria from OncLive and Research To Practice, Inc., consulting fees from BioTheranostics, Inc, a Hologic Company and research funding (to institution) from Conquer Cancer and the Pennsylvania Breast Cancer Coalition, outside of the submitted work. The remaining authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Change in frequency of prescribing of adjuvant bone modifying agents (BMAs) from pre- to post-ACGD in all patients. Comparison of percentage of patients who received adjuvant bisphosphonates and denosumab prior to and after the publication of the 2017 ASCO/CCO Clinical Guidelines (ACGD). Percentages above the bars indicate percent of all patients diagnosed pre- and post- ACGD who received BMAs; percentages within the bars indicate percent of all patients diagnosed pre- and post- ACGD who received bisphosphonates or denosumab
Fig. 2
Fig. 2
Change in frequency of prescribing of adjuvant bone modifying agents (BMAs) from pre- to post-ACGD in patients with stage II/III disease only. Comparison of percentage of stage II/IIII patients who received adjuvant bisphosphonates and denosumab prior to and after the publication of the 2017 ASCO/CCO Clinical Guidelines (ACGD). Percentages above the bars indicate percent of all patients diagnosed pre- and post- ACGD who received BMAs; percentages within the bars indicate percent of all stage II/III patients diagnosed pre- and post- ACGD who received bisphosphonates or denosumab
Fig. 3
Fig. 3
Bar chart showing the number of doses of bisphosphonates and denosumab patients in our cohort received. Of the patients who received adjuvant BMAs, comparison of the number of patients who received 1 dose only, 2–5 doses, or > 5 doses of bisphosphonates or denosumab
See this image and copyright information in PMC

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