How long should we treat patients with newly diagnosed myeloma with bisphosphonates or RANKL inhibitors for their myeloma bone disease given recent data?  

The OS benefit with Zometa was seen only in patients with myeloma bone disease achieving less than or equal to a partial response. SRE risk reduction compared to placebo was dependent on myeloma control: PR: 26% reduced risk, VGPR 13%, and CR with no reduced SRE risk (see Larocca et al., PMID 23974194).

Apart from the Novartis written manuscript, the benefit for myeloma patients without myeloma bone disease does not seem to warrant the additional cost, risk of renal insufficiency, risk of VTE.

The recently published MAGNOLIA trial (Lund et al., PMID 38622134) did not incorporate the presence of myeloma bone disease nor the treatment regimen of the patient, but showed benefit in their primary endpoint. Understanding their primary endpoint without paying attention to disease control is counterintuitive.  

So what should we all do based on the best data?