The use of bone-modifying agents in early breast cancer: AIOM Guidelines update and perspectives

Breast cancer (BC) is the leading cause of cancer-related mortality among women, with early BC (EBC) comprising most cases. Advancements in neo(adjuvant) therapies have significantly improved outcomes, although they are often associated with cancer treatment-induced bone loss, which increases the risk of fractures and negatively impacts quality of life. Bone-modifying agents (BMAs), such as bisphosphonates and denosumab can mitigate this adverse effect. By reviewing and summarizing the most recent evidence published on BMAs use in EBC, an expert Italian Panel, composed of the authors of the Italian Association of Medical Oncology (AIOM) guidelines, offers an extended clinical interpretation and updated overview of key questions and recommendation, including the optimal timing of BMAs initiation, appropriate treatment duration, and the most effective agents for fracture risk reduction. Additionally, a critical and previously unaddressed topic is also discussed: BMAs impact on survival outcomes in EBC scenario. This paper offers practical insights into bone health management for EBC patients, explores the potential survival benefits offered by BMAs, and highlights differences among international guidelines regarding their recommended use.