Should bisphosphonates be standard therapy for bone pain?

 We have been studying bisphosphonates since the early 1980s, initially investigating etidronate in the management of hypercalcaemia and, since the mid-1980s, clodronate in the management of hypercalcaemia, bone pain, and skeletal complications in patients with bone metastases. We have also recently reported that bone metastases can be prevented or delayed in patients without evidence of bone disease but with recurrent disease at other sites. Bisphosphonates are now the standard therapy for hypercalcaemia after rehydration. For patients with bone metastases and bone pain, a trial of clodronate 600–1500 mg i.v. in 500 ml normal saline over 3 h given every 1–2 weeks is worthwhile in association with other modalities such as radiotherapy and analgesic medications. Oral clodronate or intravenous pamidronate should be given as a preventive measure in patients with established bone metastases from breast cancer and myeloma. In patients with no evidence of bone metastases, it may be that bisphosphonates can delay the emergence of bone metastases; at present this remains under clinical investigation and our pioneer trials require confirmation. Clinical trials of bisphosphonates in the treatment of hypercalcaemia, bone pain, management of patients with bone metastases and management of patients with recurrent cancer but no evidence of bone metastases will be discussed.