Association of Osteonecrosis of the Jaw With Zoledronic Acid Treatment for Bone Metastases in Patients With Cancer

This cohort study defines the cumulative incidence of osteonecrosis of the jaw at 3 years in patients receiving zoledronic acid for metastatic bone disease from any malignant neoplasm. Question What is the incidence of osteonecrosis of the jaw (ONJ) in patients treated with zoledronic acid for bone metastases from any cancer? Findings In this cohort study of 3491 participants initiating zoledronic acid treatment for bone metastases, the cumulative incidence of ONJ was 0.8% at year 1, 2.0% at year 2, and 2.8% at year 3, with the highest incidence observed in multiple myeloma and the lowest in breast cancer. More frequent dosing of zoledronic acid and poor oral health were associated with higher rates of ONJ. Meaning These findings suggest that cancer type, oral health, and frequency of dosing are associated with the risk of ONJ, which should help to guide stratification of risk for developing ONJ in patients receiving zoledronic acid. Importance Osteonecrosis of the jaw (ONJ) affects patients with cancer and metastatic bone disease (MBD) treated with bone-modifying agents (BMAs), yet the true incidence is unknown. Objective To define the cumulative incidence of ONJ at 3 years in patients receiving zoledronic acid for MBD from any malignant neoplasm. Design, Setting, and Participants This multicenter, prospective observational cohort study (SWOG Cancer Research Network S0702) included patients with MBD with either limited or no prior exposure to BMAs and a clinical care plan that included use of zoledronic acid within 30 days of registration. Medical, dental, and patient-reported outcome forms were submitted at baseline and every 6 months. Follow-up was 3 years. Osteonecrosis of the jaw was defined using established criteria. Data were collected from January 30, 2009, to December 13, 2013, and analyzed from August 24, 2018, to August 6, 2020. Interventions/Exposures Cancer treatments, BMAs, and dental care were administered as clinically indicated. Main Outcomes and Measures Cumulative incidence of confirmed ONJ, defined as an area of exposed bone in the maxillofacial region present for more than 8 weeks with no concurrent radiotherapy to the craniofacial region. Risk factors for ONJ were also examined. Results The SWOG S0702 trial enrolled 3491 evaluable patients (1806 women [51.7%]; median age, 63.1 [range, 2.24-93.9] years), of whom 1120 had breast cancer; 580, myeloma; 702, prostate cancer; 666, lung cancer; and 423, other neoplasm. A baseline dental examination was performed in 2263 patients (64.8%). Overall, 90 patients developed confirmed ONJ, with cumulative incidence of 0.8% (95% CI, 0.5%-1.1%) at year 1, 2.0% (95% CI, 1.5%-2.5%) at year 2, and 2.8% (95% CI, 2.3%-3.5%) at year 3; 3-year cumulative incidence was highest in patients with myeloma (4.3%; 95% CI, 2.8%-6.4%). Patients with planned zoledronic acid dosing intervals of less than 5 weeks were more likely to experience ONJ than patients with planned dosing intervals of 5 weeks or more (hazard ratio [HR], 4.65; 95% CI, 1.46-14.81; P = .009). A higher rate of ONJ was associated with fewer total number of teeth (HR, 0.51; 95% CI, 0.31-0.83; P = .006), the presence of dentures (HR, 1.83; 95% CI, 1.10-3.03; P = .02), and current smoking (HR, 2.12; 95% CI, 1.12-4.02; P = .02). Conclusions and Relevance As the findings show, the cumulative incidence of ONJ after 3 years was 2.8% in patients receiving zoledronic acid for MBD. Cancer type, oral health, and frequency of dosing were associated with the risk of ONJ. These data provide information to guide stratification of risk for developing ONJ in patients with MBD receiving zoledronic acid.

Automated summary

The cumulative incidence of osteonecrosis of the jaw (ONJ) after 3 years was 2.8% in patients receiving zoledronic acid for metastatic bone disease. Cancer type, oral health, and frequency of dosing were associated with the risk of ONJ. These findings provide guidance for stratifying ONJ risk in patients with metastatic bone disease receiving zoledronic acid.