Sir, we read with interest Aggressive denosumab-related jaw necrosis – a case series.1 It highlighted the contentious role of the drug holiday in the treatment of MRONJ in patients taking denosumab.

It is a clinical challenge to determine the risks versus benefits of stopping denosumab for dental treatment in patients with metastatic disease.

Denosumab-related osteonecrosis of jaw is rare. In some cases it can cause significant morbidity.1 According to the literature, skeletal related events (SREs) such as pathologic fractures and spinal cord compression in patients with metastatic disease are common and reduce quality of life.2 In our clinical experience some patients have been placed on a pre-emptive denosumab drug holiday by their oncologists to presumably reduce the risk of MRONJ if they require dental extraction. The evidence for the efficacy of drug holidays is poor and it is not supported by published guidance.3

However, performing dental treatment before denosumab therapy has started is a recognised preventive approach.4 The skeletal complications of bone metastases are responsible for a range of complications and costs and decreased quality of life.2 The role of denosumab in delaying SREs and thus maintaining quality of life is clear.

Therefore, by stopping denosumab temporarily we may be increasing the risk of SREs in these patients and ultimately reducing their longevity.

Therefore, is it prudent to stop this therapy at all? Are we at risk of losing focus holistically speaking? Further research and evidence-based guidance is needed to aid oncologists and dentists on the effects of drug holidays in patients with metastatic disease.