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Molinelli C, Jacobs F, Nader-Marta G, Borea R, Scavone G, Ottonello S, Fregatti P, Villarreal-Garza C, Bajpai J, Kim HJ, Puglisi S, de Azambuja E, Lambertini M. Ovarian Suppression: Early Menopause and Late Effects. Curr Treat Options Oncol 2024; 25:523-542. [PMID: 38478329 PMCID: PMC10997548 DOI: 10.1007/s11864-024-01190-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/06/2024]
Abstract
OPINION STATEMENT Around 90% of breast tumours are diagnosed in the early stage, with approximately 70% being hormone receptor-positive. The cornerstone of adjuvant therapy for early-stage hormone receptor-positive breast cancer is endocrine therapy, tailored according to disease stage, biological characteristics of the tumour, patient's comorbidities, preferences and age. In premenopausal patients with hormone receptor-positive breast cancer, ovarian function suppression is a key component of the adjuvant endocrine treatment in combination with an aromatase inhibitor or tamoxifen. Moreover, it can be used during chemotherapy as a standard strategy for ovarian function preservation in all breast cancer subtypes. In the metastatic setting, ovarian function suppression should be used in all premenopausal patients with hormone receptor-positive breast cancer to achieve a post-menopausal status. Despite its efficacy, ovarian function suppression may lead to several side effects that can have a major negative impact on patients' quality of life if not properly managed (e.g. hot flashes, depression, cognitive impairment, osteoporosis, sexual dysfunction, weight gain). A deep knowledge of the side effects of ovarian function suppression is necessary for clinicians. A correct counselling in this regard and proactive management should be considered a fundamental part of survivorship care to improve treatment adherence and patients' quality of life.
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Affiliation(s)
- Chiara Molinelli
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinical Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Flavia Jacobs
- Humanitas Clinical and Research Center - IRCCS, Humanitas Cancer Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Guilherme Nader-Marta
- Academic Trials Promoting Team, Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), 90, Rue Meylemeersch, 1070, Anderlecht, Brussels, Belgium
| | - Roberto Borea
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
- Department of Medical Oncology, U.O. Clinical Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Graziana Scavone
- Department of Medical Oncology, U.O. Clinical Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Silvia Ottonello
- Department of Medical Oncology, U.O. Clinical Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Piero Fregatti
- Department of Surgery, U.O. Senologia Chirurgica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), School of Medicine, University of Genoa, 16132, Genoa, Italy
| | - Cynthia Villarreal-Garza
- Breast Cancer Center, Hospital Zambrano Hellion - TecSalud, Tecnologico de Monterrey, Monterrey, Mexico
| | - Jyoti Bajpai
- Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Ernest Borges Rd, Parel East, Parel, Mumbai, Maharashtra, 400012, India
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-Gu, Seoul, South Korea
| | - Silvia Puglisi
- Medical Oncology Unit 1, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy
| | - Evandro de Azambuja
- Academic Trials Promoting Team, Institut Jules Bordet and l'Université Libre de Bruxelles (U.L.B), 90, Rue Meylemeersch, 1070, Anderlecht, Brussels, Belgium
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy.
- Department of Medical Oncology, U.O. Clinical Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132, Genoa, Italy.
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Pandey P, Sharma A, Gogia A. Bone health in breast cancer. Curr Probl Cancer 2023; 47:100959. [PMID: 37236055 DOI: 10.1016/j.currproblcancer.2023.100959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 01/09/2023] [Accepted: 04/10/2023] [Indexed: 05/28/2023]
Abstract
Early breast cancer is among the most common cancers worldwide. Recent advances continue to improve outcomes and increase long-term survivorship. However, therapeutic modalities are deleterious for patients' bone health. While antiresorptive therapy may partially negate this, consequent reduction in rates of fragility fractures remains unproven. Selective prescription of bisphosphonates or denosumab may be an amicable middle ground. Recent evidence also suggests a possible role of osteoclast inhibitors as adjuvant therapy, but the evidence is modest at best. In this narrative clinical review, we explore the impact of various adjuvant modalities on bone mineral density and fragility fracture rates of early breast cancer survivors. We also review optimal patient selection for antiresorptive agents, their impact on rates of fragility fractures, and the possible role of these agents as adjuvant therapy.
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Affiliation(s)
- Praful Pandey
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Sharma
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Ajay Gogia
- Department of Medical Oncology, Dr. B.R.A. IRCH, All India Institute of Medical Sciences, New Delhi, India.
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Nisha Y, Dubashi B, Bobby Z, Sahoo JP, Kayal S, Ananthakrishnan R, Ganesan P. Cytotoxic chemotherapy is associated with decreased bone mineral density in postmenopausal women with early and locally advanced breast cancer. Arch Osteoporos 2023; 18:41. [PMID: 36899284 PMCID: PMC10004442 DOI: 10.1007/s11657-023-01231-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 03/01/2023] [Indexed: 03/12/2023]
Abstract
PURPOSE The burden and mechanisms of endocrine therapy-related bone loss have been studied in detail. However, there is limited data regarding cytotoxic chemotherapy's impact on bone health. There are no definitive guidelines for bone mineral density (BMD) monitoring and treatment with bone-modifying agents during cytotoxic chemotherapy. The study's primary objective was to evaluate the changes in BMD and fracture risk assessment tool (FRAX) scores among breast cancer women on cytotoxic chemotherapy. METHODS One hundred and nine newly diagnosed early and locally advanced postmenopausal breast cancer patients planned for anthracycline and taxane-based chemotherapy were recruited prospectively during the study period from July 2018 to December 2021. BMD of the lumbar spine, the femoral neck, and the total hip were assessed by dual-energy X-ray absorptiometry scan. BMD and FRAX scores were evaluated at baseline, end of chemotherapy, and 6 months of follow-up. RESULTS The median age of the study population was 53 (45-65) years. Early and locally advanced breast cancers were seen in 34 (31.2%) and 75 (68.8%) patients, respectively. The duration of follow-up between two BMD measurements was 6 months. The percentage of decrease in BMD at the lumbar spine, femoral neck, and total hip were - 2.36 ± 2.90, - 2.63 ± 3.79, and - 2.08 ± 2.80, respectively (P-value = 0.0001). The median risk of major osteoporotic fracture (MOF) at 10 years (FRAX score) increased from 1.7 (1.4) to 2.7% (2.4) (P-value = 0.0001). CONCLUSION This prospective study in postmenopausal breast cancer women shows a significant association of cytotoxic chemotherapy with the worsening of bone health in terms of BMD and FRAX score.
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Affiliation(s)
- Yadav Nisha
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India.
| | - Zachariah Bobby
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Jaya Prakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Smita Kayal
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
| | - Ramesh Ananthakrishnan
- Department of Radiodiagnosis, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, 605006, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, 605006, India
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Malagrinò M, Zavatta G. Review of bone health in women with estrogen receptor-positive breast cancer receiving endocrine therapy. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057221149493. [PMID: 36644991 PMCID: PMC9846301 DOI: 10.1177/17455057221149493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
In estrogen-receptor-positive tumors, adjuvant endocrine therapy has been shown to be highly beneficial for both overall and disease-free survival. Estradiol is key in regulating bone and mineral physiology, and several studies found a strong correlation between these therapies and the risk of fractures. Since these therapies are often given for 5 through 10 years, the timing for bisphosphonates or denosumab initiation seems essential to managing bone metabolism. However, gray zones and discrepancies between guidelines remain as to the best threshold when to start antiresorptive treatment, or whether antiresorptive treatment should be administered to every woman undergoing adjuvant endocrine therapy, independent of their risk factors for fractures. Treatment options and strategies should be discussed at the start of hormone adjuvant therapy to come to a shared decision with the patient, with the final aim of reducing the risk of future fractures as much as possible. This review will cover present guidelines and literature on antiresorptive treatment in this setting, to provide clinicians with useful clues for managing these patients.
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Affiliation(s)
- Matteo Malagrinò
- Division of Endocrinology and Diabetes
Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy,Department of Medical and Surgical
Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Guido Zavatta
- Division of Endocrinology and Diabetes
Prevention and Care, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna,
Italy,Department of Medical and Surgical
Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy,Guido Zavatta, Department of Medical and
Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Via
Massarenti 9, 40138 Bologna, Italy.
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5
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Santini D, Berruti A, Di Maio M, Procopio G, Bracarda S, Ibrahim T, Bertoldo F. Bone health management in the continuum of prostate cancer disease: a review of the evidence with an expert panel opinion. ESMO Open 2021; 5:S2059-7029(20)30062-4. [PMID: 32220946 PMCID: PMC7174015 DOI: 10.1136/esmoopen-2019-000652] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/07/2020] [Accepted: 01/07/2020] [Indexed: 12/20/2022] Open
Abstract
Bone health impairment is a frequent detrimental consequence of the high bone tropism of prostate cancer (PCa) cells. It is further worsened by administration of androgen-deprivation therapy (ADT), the current standard of care in the management of advanced PCa, through a rapid and dramatic increase in bone turnover and body mass changes. As a result, patients may experience substantial pain and poor quality of life (QoL) and have an increased risk of death. Notwithstanding the importance of this issue, however, bone health preservation is not yet a widespread clinical goal in daily practice. To address this urgent unmet need, following a thorough discussion of available data and sharing of their clinical practice experience, a panel of Italian experts in the field of bone health and metabolism formulated a number of practical advices for optimising the monitoring and treatment of bone health in men undergoing ADT during all phases of the disease. The rationale behind the venture was to raise awareness on the importance of bone preservation in this complex setting, while providing an instrument to support physicians and facilitate the management of bone health. Current evidence regarding the effects on bone health of ADT, of novel hormone therapies (which improve progression delay, pain control and QoL while consistently carrying the risk of non-pathological fractures in both non-metastatic and metastatic PCa) and of bone turnover inhibitors (whose use is frequently suboptimal) is reviewed. Finally, the expert opinion to optimise bone health preservation is given.
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Affiliation(s)
- Daniele Santini
- Department of Oncology, Campus Bio-Medico University, Roma, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Massimo Di Maio
- Department of Oncology, AO Ordine Mauriziano, Universita degli Studi di Torino, Torino, Italy
| | - Giuseppe Procopio
- Department of Medical Oncology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
| | - Sergio Bracarda
- Medical Oncology, Department of Oncology, Azienda Ospedaliera S.Maria, Terni, Italy
| | - Toni Ibrahim
- Osteoncology and Rare Tumors Center, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori Srl, Meldola, Italy
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Ouchi Y, Nakatsukasa K, Sakaguchi K, Morita M, Koyama H, Matsuda T, Kato M, Konishi E, Ono H, Taguchi T. The effect of denosumab in breast cancer patients receiving adjuvant aromatase inhibitors: 36-month results. J Bone Miner Metab 2021; 39:224-229. [PMID: 32889575 DOI: 10.1007/s00774-020-01138-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Aromatase inhibitor (AI)-associated bone loss increases the risk of bone fracture and reduces patients' quality of life, making it a critical issue worldwide. We conducted a prospective non-randomized clinical trial (UMIN-CTR, UMIN 000016173) to assess the effect of denosumab on bone loss in patients treated with adjuvant AI and have previously reported the results at 12 and 24 months. This study aimed to present the results at 36 months of treatment with denosumab for osteopenia in breast cancer patients who were undergoing treatment with adjuvant AI; 36 months is the longest denosumab treatment period reported so far. MATERIALS AND METHODS Patients received 60-mg denosumab subcutaneously every 6 months. Daily supplements containing 500-mg elemental calcium and at least 400 international units of vitamin D were highly recommended throughout the study period. The levels of bone mineral density (BMD) and bone turnover markers, serum tartrate-resistant acid phosphatase isoform 5b, and bone alkaline phosphatase were determined at baseline and 6, 12, 18, 24, and 36 months. RESULTS At 36 months, the bone mineral density of the lumbar spine, right femoral neck, and left femoral neck were found to increase by 8.8% (95% confidence interval CI 7.6-10.1), 4.3% (95% CI 3.0-5.5), and 3.1% (95% CI 2.1-4.1), respectively. No non-traumatic clinical fractures occurred in patients receiving AI and denosumab. CONCLUSION Twice-yearly administration of denosumab to the breast cancer patients treated with adjuvant AI, regardless of the skeletal site, resulted in consistent increases in BMD without severe adverse events at 36 months.
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Affiliation(s)
- Yoshimi Ouchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | - Koichi Sakaguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | - Midori Morita
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan
| | | | | | | | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisako Ono
- Drug Discovery Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuya Taguchi
- Department of Endocrine and Breast Surgery, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-hirokoji, Kamigyo-ku, Kyoto, 602-8566, Japan.
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Dell'Aquila E, Armento G, Iuliani M, Simonetti S, D'Onofrio L, Zeppola T, Madaudo C, Russano M, Citarella F, Ribelli G, Pantano F, Vincenzi B, Tonini G, Santini D. Denosumab for cancer-related bone loss. Expert Opin Biol Ther 2020; 20:1261-1274. [PMID: 32835531 DOI: 10.1080/14712598.2020.1814731] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Prolonged use of anti-cancer treatments in breast and prostate tumors alters physiological bone turnover leading to adverse skeletal related events, such as osteoporosis, loss of bone mass, and increased risk of fractures. These complications known as cancer treatment-induced bone loss (CTIBL) should be managed with bone targeting agents such as the bisphosphonates and denosumab. The latter is a monoclonal antibody against the receptor activator of nuclear factor-kB ligand (RANKL) that suppresses osteoclasts function and survival increasing bone mass. AREAS COVERED This review will focus on the mechanisms associated with bone loss induced by cancer treatments and the most recent evidence about the use of denosumab as preventive and therapeutic strategy to protect bone health. Moreover, we will discuss several key aspects regarding the clinical practical use of denosumab to optimize the management of CTLIB in breast and prostate cancer. EXPERT OPINION Denosumab treatment strongly prevents cancer therapies-related skeletal issues in breast and prostate cancer with a good safety profile. Adjuvant six-monthly denosumab delays the time to first fracture onset in early stage breast cancer patients with normal or altered bone mineral density (BMD). Similarly, denosumab treatment is able to prevent fractures and BMD loss in nonmetastatic prostate cancer patients.
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Affiliation(s)
| | - Grazia Armento
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Michele Iuliani
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Sonia Simonetti
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Loretta D'Onofrio
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Tea Zeppola
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Cristina Madaudo
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Marco Russano
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Fabrizio Citarella
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Giulia Ribelli
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Francesco Pantano
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Bruno Vincenzi
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Giuseppe Tonini
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
| | - Daniele Santini
- Medical Oncology Department, Campus Bio-Medico University of Rome , Rome, Itlay
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Rozenberg S, Bruyère O, Bergmann P, Cavalier E, Gielen E, Goemaere S, Kaufman JM, Lapauw B, Laurent MR, De Schepper J, Body JJ. How to manage osteoporosis before the age of 50. Maturitas 2020; 138:14-25. [PMID: 32631584 DOI: 10.1016/j.maturitas.2020.05.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/16/2022]
Abstract
This narrative review discusses several aspects of the management of osteoporosis in patients under 50 years of age. Peak bone mass is genetically determined but can also be affected by lifestyle factors. Puberty constitutes a vulnerable period. Idiopathic osteoporosis is a rare, heterogeneous condition in young adults due in part to decreased osteoblast function and deficient bone acquisition. There are no evidence-based treatment recommendations. Drugs use can be proposed to elderly patients at very high risk. Diagnosis and management of osteoporosis in the young can be challenging, in particular in the absence of a manifest secondary cause. Young adults with low bone mineral density (BMD) do not necessarily have osteoporosis and it is important to avoid unnecessary treatment. A determination of BMD is recommended for premenopausal women who have had a fragility fracture or who have secondary causes of osteoporosis: secondary causes of excessive bone loss need to be excluded and treatment should be targeted. Adequate calcium, vitamin D, and a healthy lifestyle should be recommended. In the absence of fractures, conservative management is generally sufficient, but in rare cases, such as chemotherapy-induced osteoporosis, antiresorptive medication can be used. Osteoporosis in young men is most often of secondary origin and hypogonadism is a major cause; testosterone replacement therapy will improve BMD in these patients. Diabetes is characterized by major alterations in bone quality, implying that medical therapy should be started sooner than for other causes of osteoporosis. Primary hyperparathyroidism, hyperthyroidism, Cushing's syndrome and growth hormone deficiency or excess affect cortical bone more often than trabecular bone.
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Affiliation(s)
- S Rozenberg
- Department of Gynaecology-Obstetrics, CHU St Pierre, Université Libre de Bruxelles, Brussels, Belgium.
| | - O Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.
| | - P Bergmann
- Honorary Consulent, Nuclear Medicine CHU Brugmann CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - E Cavalier
- Department of Clinical Chemistry, UnilabLg, CIRM, University of Liège, CHU de Liège, Domaine du Sart-Tilman, 4000 Liège, Belgium
| | - E Gielen
- Gerontology & Geriatrics, Department of Public Health and Primary Care, KU Leuven & Department of Geriatric Medicine, UZ Leuven, Leuven, Belgium
| | - S Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - J M Kaufman
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Department of Endocrinology Ghent University Hospital, Ghent, Belgium
| | - M R Laurent
- Centre for Metabolic Bone Diseases, University Hospitals Leuven, Imelda Hospital, Bonheiden, Belgium
| | - J De Schepper
- Department of Pediatrics, UZ Brussel, Brussels, Belgium, Belgium
| | - J J Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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9
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Sale JEM, Marwah A, Naeem F, Yu W, Meadows L. Evidence of patient beliefs, values, and preferences is not provided in osteoporosis clinical practice guidelines. Osteoporos Int 2019; 30:1325-1337. [PMID: 30859238 DOI: 10.1007/s00198-019-04913-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 02/20/2019] [Indexed: 01/13/2023]
Abstract
UNLABELLED We examined how patient beliefs, values, and preferences (BVPs) were included and conceptualized in international osteoporosis guidelines. The majority of guidelines did not mention BVPs. When mentioned, BVPs were conceptualized as preference for one medication over another. A broader conceptualization and inclusion of BVPs should be incorporated in osteoporosis guidelines. INTRODUCTION Our objectives were to determine (1) the extent to which osteoporosis guidelines reflected patients' beliefs, values, and preferences (BVPs); (2) how BVPs were conceptualized; and (3) the methods used to elicit BVPs in the references cited by the guidelines. METHODS We conducted a document analysis of English-language international osteoporosis guidelines based on the International Osteoporosis Foundation website. We examined each guideline and extracted all instances of statements pertaining to BVPs. The statements were reviewed by two independent researchers. Discrepancies in data extraction were resolved by the first author. We developed categories based on five common elements that represented the BVP statements. RESULTS Twenty-seven of 70 (39%) guidelines included 95 statements about patient BVPs. Of the 95 statements, 32 statements (14 guidelines) were classified under BVP related to the choice of pharmacotherapy or general treatment, 10 (7 guidelines) under BVP related to adherence to pharmacotherapy or treatment in general, 5 (5 guidelines) under BVP related to financial costs and benefits, 43 (19 guidelines) under other BVP mentioned but not supported by a reference to a primary study or systematic review, and 5 (3 guidelines) under other BVP mentioned and supported by at least one reference to a primary study or systematic review. Twenty-nine references were cited to reflect the BVPs mentioned, including an editorial and quantitative studies. CONCLUSIONS Twenty-seven (39%) of the guidelines included mention of patients' BVPs. In 19 guidelines, the importance of BVPs was mentioned but these statements were not supported by references to a primary study or systematic review. BVPs were most often (14 guidelines) conceptualized as preference for one medication over another. We suggest that qualitative data be included as evidence of BVPs in guidelines.
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Affiliation(s)
- J E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.
| | - A Marwah
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - F Naeem
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - W Yu
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - L Meadows
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3D10, 3280 Hospital Drive NW, Calgary, Alberta, T2N 4Z6, Canada
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10
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Kendler DL, Body JJ, Brandi ML, Broady R, Cannata-Andia J, Cannata-Ortiz MJ, El Maghraoui A, Guglielmi G, Hadji P, Pierroz DD, de Villiers TJ, Rizzoli R, Ebeling PR. Bone management in hematologic stem cell transplant recipients. Osteoporos Int 2018; 29:2597-2610. [PMID: 30178158 DOI: 10.1007/s00198-018-4669-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 08/13/2018] [Indexed: 12/13/2022]
Abstract
Autologous and allogeneic hematopoietic stem cell transplantation (HSCT) is the treatment of choice for patients with some malignant and non-malignant hematological diseases. Advances in transplantation techniques and supportive care measures have substantially increased the number of long-term HSCT survivors. This has led to an increasing patient population suffering from the late effects of HSCT, of which, bone loss and its consequent fragility fractures lead to substantial morbidity. Altered bone health, with consequent fragility fractures, and chronic graft-versus-host disease (GVHD) are factors affecting long-term quality of life after HSCT. Hypogonadism, HSCT preparative regimens, nutritional factors, and glucocorticoids all contribute to accelerated bone loss and increased fracture risk. Management strategies should include bone mineral density examination, evaluation of clinical risk factors, and general dietary and physical activity measures. Evidence has accumulated permitting recommendations for more attentiveness to evaluation and monitoring of bone health, with appropriate application of osteoporosis pharmacotherapies to patients at increased risk of bone loss and fracture.
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Affiliation(s)
- D L Kendler
- Department of Medicine, Division of Endocrinology, University of British Columbia, 150 - 943 W. Broadway, Vancouver, V5Z 4E1, Canada.
| | - J J Body
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M L Brandi
- Mineral and Bone Metabolic Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - R Broady
- Department of Medicine, Division of Hematology, University of British Columbia, Vancouver, Canada
| | - J Cannata-Andia
- Servicio de Metabolismo Óseo y Mineral, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - M J Cannata-Ortiz
- Haematology Department, IIS Princesa, Hospital de la Princesa, Madrid, Spain
| | - A El Maghraoui
- Rheumatology Department, Military Hospital Mohammed V, Mohammed V-Souissi University, Rabat, Morocco
| | - G Guglielmi
- Department of Radiology, University of Foggia, Foggia, Italy
| | - P Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, Nord West Hospital, Frankfurt, Germany
| | - D D Pierroz
- International Osteoporosis Foundation (IOF), Nyon, Switzerland
| | - T J de Villiers
- Department of Gynaecology, Faculty of Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Mediclinic Panorama, Cape Town, South Africa
| | - R Rizzoli
- Division of Bone Diseases, Faculty of Medicine, Geneva University Hospital, Geneva, Switzerland
| | - P R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Australia
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Sale JEM, Gray M, Mancuso D, Inrig T, Boire G, Beaulieu MC, Funnell L, Bogoch E. Treatment recommendations based on fracture risk status are not consistently provided in osteoporosis guidelines. Rheumatol Int 2018; 38:2193-2208. [PMID: 30367203 DOI: 10.1007/s00296-018-4181-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/19/2018] [Indexed: 11/25/2022]
Abstract
We examined international osteoporosis guidelines to determine the tools used to assess fracture risk, the classification of fracture risk presented, and the recommendations based on fracture risk status. We conducted a document analysis of guidelines from the International Osteoporosis Foundation (IOF) website retrieved as of May 10, 2018, focusing on guidelines written in English only. Two reviewers independently reviewed each document and the following data were extracted: (1) fracture risk tool(s) endorsed; (2) classification system used to describe fracture risk status (e.g., low, moderate, high); and (3) recommendations based on risk status (e.g., pharmacological treatment). Two additional reviewers verified all data extraction. A total of 112 guidelines were listed on the IOF website, of which 94 were located either through the provided link or through a PubMed search. Of 70 guidelines written in English, 63 guidelines discussed the concept of fracture risk of which, 39 endorsed FRAX. Twenty-eight guidelines defined fracture risk categories or thresholds which determined recommendations. In total, 26 provided a risk category or threshold which constituted an indication for pharmacotherapy. Twelve guidelines reported a moderate, medium, or intermediate risk category which was associated with variable recommendations for testing and treatment. Despite the generally accepted international shift to fracture risk as a basis for treatment decisions, the majority of guidelines in English did not provide treatment recommendations based on fracture risk status. In guidelines with recommendations based on fracture risk status, thresholds and recommendations varied making international comparisons of treatment difficult.
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Affiliation(s)
- Joanna E M Sale
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada.
| | - Matthew Gray
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Daniel Mancuso
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Taucha Inrig
- Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Gilles Boire
- Department of Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12th Avenue North, Room 3853, Sherbrooke, QC, J1H 5N4, Canada
| | - Marie-Claude Beaulieu
- Department of Family Medicine and Emergency Medicine, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001, 12e Avenue North, Sherbrooke, QC, J1H 5N4, Canada
| | - Larry Funnell
- Osteoporosis Canada, 1200 Eglinton Avenue East, Suite 500, Toronto, ON, M3C 1H9, Canada
| | - Earl Bogoch
- Department of Surgery, University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
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12
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Alibhai SMH, Ritvo P, Santa Mina D, Sabiston C, Krahn M, Tomlinson G, Matthew A, Lukka H, Warde P, Durbano S, O’Neill M, Culos-Reed SN. Protocol for a phase III RCT and economic analysis of two exercise delivery methods in men with PC on ADT. BMC Cancer 2018; 18:1031. [PMID: 30352568 PMCID: PMC6199786 DOI: 10.1186/s12885-018-4937-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/10/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Androgen deprivation therapy (ADT) is commonly used to treat prostate cancer. However, side effects of ADT often lead to reduced quality of life and physical function. Existing evidence demonstrates that exercise can ameliorate multiple treatment-related side effects for men on ADT, yet adherence rates are often low. The method of exercise delivery (e.g., supervised group in-centre vs. individual home-based) may be important from clinical and economic perspectives; however, few studies have compared different delivery models. Additionally, long-term exercise adherence and an understanding of predictors of adherence are critical to achieving sustained benefits, but such data are lacking. The primary aim of this multi-centre phase III non-inferiority randomized controlled trial is to determine whether a home-based delivery model is non-inferior to a group-based delivery model in terms of benefits in fatigue and fitness in this population. Two other key aims include examining cost-effectiveness and long-term adherence. METHODS Men diagnosed with prostate cancer of any stage, starting or continuing on ADT for at least 6 months, fluent in English, and living close to a study centre are eligible. Participants complete five assessments over 12 months (baseline and every 3 months during the 6-month intervention and 6-month follow-up phases), including a fitness assessment and self-report questionnaires. Biological outcomes are collected at baseline, 6, and 12 months. A total of 200 participants will be randomized in a 1:1 fashion to supervised group training or home-based training supported by smartphones, health coaches, and Fitbit technology. Participants are asked to complete 4 to 5 exercise sessions per week, incorporating aerobic, resistance and flexibility training. Outcomes include fatigue, quality of life, fitness measures, body composition, biological outcomes, and program adherence. Cost information will be obtained using patient diary-based self-report and utilities via the EQ-5D. DISCUSSION To disseminate publicly funded exercise programs widely, clinical efficacy and cost-effectiveness have to be demonstrated. The goals of this trial are to provide these data along with an increased understanding of adherence to exercise among men with prostate cancer receiving ADT. TRIAL REGISTRATION The trial has been registered at clinicaltrials.gov (Registration # NCT02834416 ). Registration date was June 2, 2016.
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Affiliation(s)
- Shabbir M. H. Alibhai
- University Health Network, Toronto, ON M5G 2C4 Canada
- University of Toronto, Toronto, ON M5S 2J7 Canada
- Toronto General Hospital, 200 Elizabeth St Room EN14-214, Toronto, ON M5G 2C4 Canada
| | - Paul Ritvo
- Cancer Care Ontario, Toronto, ON M5G 2L3 Canada
| | - Daniel Santa Mina
- University Health Network, Toronto, ON M5G 2C4 Canada
- University of Toronto, Toronto, ON M5S 2J7 Canada
| | | | - Murray Krahn
- University Health Network, Toronto, ON M5G 2C4 Canada
- University of Toronto, Toronto, ON M5S 2J7 Canada
| | - George Tomlinson
- University Health Network, Toronto, ON M5G 2C4 Canada
- University of Toronto, Toronto, ON M5S 2J7 Canada
| | | | - Himu Lukka
- The Juravinski Cancer Centre, Hamilton, ON L8V 5C2 Canada
| | - Padraig Warde
- University Health Network, Toronto, ON M5G 2C4 Canada
- University of Toronto, Toronto, ON M5S 2J7 Canada
- Cancer Care Ontario, Toronto, ON M5G 2L3 Canada
| | - Sara Durbano
- University Health Network, Toronto, ON M5G 2C4 Canada
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13
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Nguyen KD, Bagheri B, Bagheri H. Drug-induced bone loss: a major safety concern in Europe. Expert Opin Drug Saf 2018; 17:1005-1014. [DOI: 10.1080/14740338.2018.1524868] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Khac-Dung Nguyen
- Laboratoire de Pharmacologie Médicale et Clinique, Equipe de Pharmacoépidémiologie de l’UMR INSERM 1027, Faculté de Médecine de l’Université Paul-Sabatier et Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d’Information sur le Médicament de l’UMR INSERM 1027, Centre Hospitalier Universitaire, Toulouse, France
- The National Centre of Drug Information and Adverse Drug Reaction Monitoring, Hanoi University of Pharmacy, Hanoi, Vietnam
| | - Bahador Bagheri
- Cancer Research Center and Department of Pharmacology, Semnan University of Medical Sciences, Semnan, Iran
| | - Haleh Bagheri
- Laboratoire de Pharmacologie Médicale et Clinique, Equipe de Pharmacoépidémiologie de l’UMR INSERM 1027, Faculté de Médecine de l’Université Paul-Sabatier et Centre Midi-Pyrénées de PharmacoVigilance, de Pharmacoépidémiologie et d’Information sur le Médicament de l’UMR INSERM 1027, Centre Hospitalier Universitaire, Toulouse, France
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14
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Alibhai SMH, Breunis H, Timilshina N, Hamidi MS, Cheung AM, Tomlinson GA, Manokumar T, Samadi O, Sandoval J, Durbano S, Warde P, Jones JM. Improving bone health in men with prostate cancer receiving androgen deprivation therapy: Results of a randomized phase 2 trial. Cancer 2017; 124:1132-1140. [PMID: 29211305 DOI: 10.1002/cncr.31171] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/06/2017] [Accepted: 11/10/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Strategies to improve bone health care in men receiving androgen deprivation therapy (ADT) are not consistently implemented. The authors conducted a phase 2 randomized controlled trial of 2 education-based models-of-care interventions to determine their feasibility and ability to improve bone health care. METHODS A single-center parallel-group randomized controlled trial of men with prostate cancer who were receiving ADT was performed. Participants were randomized 1:1:1 to 1) a patient bone health pamphlet and brief recommendations for their family physician (BHP+FP); 2) a BHP and support from a bone health care coordinator (BHP+BHCC); or 3) usual care. The primary efficacy outcome was receipt of a bone mineral density (BMD) test within 6 months. Secondary efficacy outcomes included guideline-appropriate calcium and vitamin D use and bisphosphonate prescriptions for men at high fracture risk. Feasibility endpoints included recruitment, retention, satisfaction, contamination, and outcome capture. The main analysis used logistic regression with a 1-sided P of .10. The trial is registered at ClinicalTrials.gov (identifier NCT02043236). RESULTS A total of 119 men were recruited. The BHP+BHCC strategy was associated with a greater percentage of men undergoing a BMD test compared with the usual-care group (78% vs 36%; P<.001). BMD ordering also was found to be increased with the BHP+FP strategy (58% vs 36%; P = .047). Both strategies were associated with higher percentages of patients using calcium and vitamin D, but only the BHP+FP arm was statistically significant (P = .039). No men were detected to be at high fracture risk. All but one feasibility endpoint was met. CONCLUSIONS Educational strategies to improve bone health care appear feasible and are associated with improved BMD ordering in men receiving ADT. Cancer 2018;124:1132-40. © 2017 American Cancer Society.
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Affiliation(s)
- Shabbir M H Alibhai
- Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Henriette Breunis
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Narhari Timilshina
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Maryam S Hamidi
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Angela M Cheung
- Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - George A Tomlinson
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Tharsika Manokumar
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Osai Samadi
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Joanna Sandoval
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sara Durbano
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Padraig Warde
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Radiation Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Jennifer M Jones
- Department of Psychosocial Oncology, University Health Network, Toronto, Ontario, Canada
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15
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Evidence for the prevention of bone loss in elderly and old early non-metastatic breast cancer patients treated with aromatase inhibitors. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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Gschwantler-Kaulich D, Weingartshofer S, Grunt TW, Mairhofer M, Tan Y, Gamper J, Singer CF. Estradiol impairs the antiproliferative and proapoptotic effect of Zoledronic acid in hormone sensitive breast cancer cells in vitro. PLoS One 2017; 12:e0185566. [PMID: 28945801 PMCID: PMC5612728 DOI: 10.1371/journal.pone.0185566] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 09/14/2017] [Indexed: 11/19/2022] Open
Abstract
Background Zoledronic acid (ZA) has antiresorptive effects and protects from bone metastasis in women with early breast cancer. In addition, in postmenopausal women with endocrine responsive breast cancer ZA prolongs DFS. The exact mechanism is still unclear. We have therefore investigated the effect of increasing concentrations of ZA in breast cancer cell lines in the absence or presence of estradiol to mimic the hormonal environment in vitro. Materials and methods Using assays for cell proliferation (EZ4U, BrdU) and cell death (Annexin/PI), we have analyzed the dose-dependent antiproliferative and pro-apoptotic effects of ZA in two hormone sensitive cell lines (MCF-7 and T47D) and a hormone insensitive, triple negative cell line (MDA-MB-231) in the presence of 0, 1 and 10 nM estradiol. Results In the absence of estradiol, ZA exerts dose-dependent antiproliferative and pro-apoptotic antitumor effects in both, hormone sensitive (MCF-7, T47D) and -insensitive (MDA-MB-231) breast cancer cell lines (p<0.0001). In the presence of estradiol, the antitumoral effect of ZA was significantly decreased only in the hormone sensitive MCF-7 and T47D cell lines (p = 0.0008 and p = 0.0008, respectively). Conclusion We have demonstrated that estradiol impairs the antiproliferative and proapoptotic effect of ZA in hormone sensitive, but not in hormone insensitive breast cancer cell lines. Our findings provide a possible explanation for the differential effect of ZA on DFS in pre- and postmenopausal patients with hormone sensitive early breast cancer, which has been demonstrated clinically. We further hypothesize that endocrine insensitive tumors such as triple negative breast cancer (TNBC) should benefit from ZA irrespective of their menopausal status.
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Affiliation(s)
- Daphne Gschwantler-Kaulich
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Sigrid Weingartshofer
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Thomas W. Grunt
- Clinical Division of Oncology, Department of Medicine I, Comprehensive Cancer Center & Ludwig Boltzmann Cluster Oncology, Medical University of Vienna, Vienna, Austria
| | | | - Yen Tan
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- QIMR Berghofer Medical Research Institute, Herston QLD, Australia
| | - Jutta Gamper
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Christian F. Singer
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
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17
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Kommalapati A, Tella SH, Esquivel MA, Correa R. Evaluation and management of skeletal disease in cancer care. Crit Rev Oncol Hematol 2017; 120:217-226. [PMID: 29032892 DOI: 10.1016/j.critrevonc.2017.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/15/2017] [Accepted: 09/07/2017] [Indexed: 01/04/2023] Open
Abstract
Recently, there have been considerable advancements in cancer therapies thereby prolonging the life of cancer survivors. However, these recent advancements present new challenges in the management of bone disease in cancer survivors. Bone acts as a fertile soil for cancer seeding and bone health is often compromised because of increased inflammatory cytokines in cancer, direct cancer metastasis and toxic effects of anti-cancer therapies. This effect is more pronounced in elderly population who already have compromised bone mineral density leading to increased skeletal related events and bone pain. Timely diagnosis and effective interventions are essential for reducing bone-related morbidity in cancer survivors. Also, a complex interdependence exists between cancer related bone disease and tumor growth, creating a vicious circle of extensive bone destruction and cancer progression. Hence, maintenance of bone health and integrity plays a pivotal role in comprehensive cancer care. The bone-targeted treatments have been shown to preserve bone health, and modify the course of the underlying cancer. Management of long-term bone health requires a broad knowledge base that endocrinologists, oncologists and other care team members should be aware of. The manuscript highlights the skeletal effects of cancer, adjuvant therapies used for hormone-responsive cancers, chemotherapy induced bone loss and steps for accurate diagnosis and management of bone disease in cancer survivors by bridging the gaps in the comprehensive cancer care.
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Affiliation(s)
- Anuhya Kommalapati
- Department of Internal Medicine, Washington Hospital Center, Washington DC, USA
| | | | - Mary Angelynne Esquivel
- Endocrinology, Diabetes and Metabolism, Warren Alpert Medical School of Brown University, Rhode Island, USA
| | - Ricardo Correa
- Endocrinology, Diabetes and Metabolism, Warren Alpert Medical School of Brown University, Rhode Island, USA
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18
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Bruyère O, Bergmann P, Cavalier E, Gielen E, Goemaere S, Kaufman JM, Rozenberg S, Body JJ. Skeletal health in breast cancer survivors. Maturitas 2017; 105:78-82. [PMID: 28838807 DOI: 10.1016/j.maturitas.2017.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 08/07/2017] [Accepted: 08/11/2017] [Indexed: 12/23/2022]
Abstract
Although some risk factors for breast cancer might be protective for osteoporosis, several cross-sectional studies have reported, nevertheless, that patients with breast cancer have a lower bone mass and potentially a higher incidence of fractures than expected. In any case, it appears that patients with breast cancer are not protected from osteoporosis, which provides further support for the recommendation that bone health is assessed after a diagnosis of breast cancer. Most adjuvant therapies will lead to increased bone loss and a higher fracture rate. Among the adjuvant therapy options for premenopausal patients with breast cancer, endocrine therapy (ovarian suppression) and chemotherapy can result in cancer treatment-induced bone loss (CTIBL) of up to 10% at the lumbar spine after one year. Antiresorptive therapies prevent CTIBL in premenopausal women with breast cancer. Most of the evidence demonstrating the efficacy of bisphosphonates in the prevention of CTIBL is derived from clinical trials with zoledronic acid. The addition of zoledronic acid 4mg per six months to adjuvant endocrine therapy maintained and even increased bone mass during a 3-year treatment period and significantly improved disease-free survival in a population of young women who underwent menopause due to the adjuvant treatment. The major contributor to bone loss in the adjuvant treatment of breast cancer in postmenopausal women is the use of aromatase inhibitors (AIs). Oncology trials have underestimated the fracture risk in the setting of AI-induced bone loss. In the ABCSG-18 study, the only trial in which fracture incidence was the primary endpoint, the rate of clinical fractures was close to 10% after 3 years in the placebo group on AIs only. Bisphosphonates and denosumab at osteoporosis treatment doses can counteract AI-induced bone loss. In the ABCSG-18 trial, treatment with denosumab 60mg injection every 6 months reduced the risk of first clinical fracture relative to placebo by 50%. Current guidelines recommend antiresorptive therapy in patients with a baseline T score of <-2.0 or with two or more clinical risk factors for fracture. These recent guidelines will need to be updated, as similar significant protective effects were seen in women with either normal or low bone mass. Moreover, a formal meta-analysis of individual patient data from more than 18,000 women in 26 randomized trials of adjuvant zoledronic acid or clodronate treatment for early breast cancer revealed that bisphosphonates significantly reduced the risk of first distant recurrence in bone and the risk of breast cancer mortality, at least in postmenopausal women. Even though the increased risk of fracture during adjuvant treatment for breast cancer in postmenopausal women is notable, an enhanced risk of fracture in long-term survivors of breast cancer remains under debate. The most recent studies suggest that Caucasian breast cancer survivors do not have a significantly increased risk of osteoporotic fracture over the long term.
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Affiliation(s)
- Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liège, Belgium.
| | - Pierre Bergmann
- Department of Radioisotopes, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Etienne Cavalier
- Department of Clinical Chemistry, UnilabLg, CIRM, University of Liège, CHU de Liège, Domaine du Sart-Tilman, 4000 Liège, Belgium
| | - Evelien Gielen
- Section of Gerontology and Geriatrics, Department of Clinical and Experimental Medicine, K.U. Leuven, Leuven, Belgium
| | - Stefan Goemaere
- Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Jean-Marc Kaufman
- Department of Endocrinology and Unit for Osteoporosis and Metabolic Bone Diseases, Ghent University Hospital, Ghent, Belgium
| | - Serge Rozenberg
- Department of Gynaecology-Obstetrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Jacques Body
- Department of Medicine, CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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Tremblay D, Patel V, Fifer KM, Caro J, Kolodka O, Mandelli J, Shapiro CL. Management of bone health in postmenopausal women on aromatase inhibitors (AIs): a single health care system experience. Support Care Cancer 2017; 26:197-202. [DOI: 10.1007/s00520-017-3834-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/10/2017] [Indexed: 01/01/2023]
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20
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Hadji P, Aapro MS, Body JJ, Gnant M, Brandi ML, Reginster JY, Zillikens MC, Glüer CC, de Villiers T, Baber R, Roodman GD, Cooper C, Langdahl B, Palacios S, Kanis J, Al-Daghri N, Nogues X, Eriksen EF, Kurth A, Rizzoli R, Coleman RE. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol 2017; 7:1-12. [PMID: 28413771 PMCID: PMC5384888 DOI: 10.1016/j.jbo.2017.03.001] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Several guidelines have been reported for bone-directed treatment in women with early breast cancer (EBC) for averting fractures, particularly during aromatase inhibitor (AI) therapy. Recently, a number of studies on additional fracture related risk factors, new treatment options as well as real world studies demonstrating a much higher fracture rate than suggested by randomized clinical controlled trials (RCTs). Therefore, this updated algorithm was developed to better assess fracture risk and direct treatment as a position statement of several interdisciplinary cancer and bone societies involved in the management of AI-associated bone loss (AIBL). PATIENTS AND METHODS A systematic literature review identified recent advances in the management of AIBL. Results with individual agents were assessed based on trial design, size, follow-up, and safety. RESULTS Several fracture related risk factors in patients with EBC were identified. Although, the FRAX algorithm includes fracture risk factors (RF) in addition to BMD, it does not seem to adequately address the effects of AIBL. Several antiresorptive agents can prevent and treat AIBL. However, concerns regarding compliance and long-term safety remain. Overall, the evidence for fracture prevention is strongest for denosumab 60 mg s.c. every 6 months. Additionally, recent studies as well as an individual patient data meta-analysis of all available randomized trial data support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality that needs to be taken into account when advising on management of AIBL. CONCLUSIONS In all patients initiating AI treatment, fracture risk should be assessed and recommendation with regard to exercise and calcium/vitamin D supplementation given. Bone-directed therapy should be given to all patients with a T-score<-2.0 or with a T-score of <-1.5 SD with one additional RF, or with ≥2 risk factors (without BMD) for the duration of AI treatment. Patients with T-score>-1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Compliance should be regularly assessed as well as BMD on treatment after 12 - 24 months. Furthermore, because of the decreased incidence of bone recurrence and breast cancer specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - John Kanis
- Catholic University of Australia, Melbourne, Australia and University of Sheffield, UK
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Impact of chemotherapy followed by aromatase inhibitors on bone health of women with ER-positive early breast cancer in real world clinical settings in Greece: Results of the POCHARBI trial conducted by the Hellenic Society of Breast Surgeons. Breast 2016; 27:27-34. [DOI: 10.1016/j.breast.2016.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 01/28/2016] [Accepted: 02/22/2016] [Indexed: 11/17/2022] Open
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Edwards BJ, Gradishar WJ, Smith ME, Pacheco JA, Holbrook J, McKoy JM, Nardone B, Tica S, Godinez-Puig V, Rademaker AW, Helenowski IB, Bunta AD, Stern PH, Rosen ST, West DP, Guise TA. Elevated incidence of fractures in women with invasive breast cancer. Osteoporos Int 2016; 27:499-507. [PMID: 26294292 DOI: 10.1007/s00198-015-3246-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 07/08/2015] [Indexed: 01/13/2023]
Abstract
UNLABELLED This study evaluates the incidence of bone fractures in women with BC.We found that women with invasive breast cancer are at an increased risk for bone fractures, with fractures most commonly occurring at lower extremity and vertebral sites. The risk is further increased in women undergoing cancer therapy. INTRODUCTION Bone loss and fractures in breast cancer have generally been attributed to aromatase inhibitor use. This study assessed the incidence of fractures after invasive breast cancer diagnosis and evaluated bone density and FRAX risk calculation at time of fracture occurrence. METHODS Retrospective cohort study of women with invasive breast cancer [June 2003-December 2011] who participated in an academic hospital based genetic biobank. Demographic and clinical characteristics were abstracted from the electronic medical record (EMR). RESULTS A total of 422 women with invasive breast cancer were assessed; 79 (28 %) sustained fractures during the observation period; fractures occurred at multiple skeletal sites in 27 cases (116 fractures). The incidence of fractures was 40 per 1000 person-years. Women who sustained fractures were mostly white and had a family history of osteoporosis (36.9 %, p = 0.03) or history of a prior fracture (6/79, p = 0.004). Fractures occurred 4.0 years (range 0-12 years) after cancer diagnosis. Fracture cases had femoral neck bone mineral density (BMD) of 0.72 + 0.12 g/cm(2), T-score of -1.2, that is, within the low bone mass range. Fractures most commonly occurred in lower extremities, vertebral, and wrist sites. Hip fractures accounted for 11 % of fractures, occurring at a median age of 61 years. CONCLUSIONS Fractures occur shortly after commencing cancer therapy. Rapid bone loss associated with cancer therapy may precipitate fractures. Fractures occur at relatively higher BMD in BC. Occurrence of fractures in invasive breast cancer raises the possibility of cancer-induced impairment in bone quality.
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Affiliation(s)
- B J Edwards
- Department of General Internal Medicine, University of Texas, MD Anderson Cancer Center, 1515 Holcombe, unit 1465, Houston, TX, 77030, USA.
| | - W J Gradishar
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - M E Smith
- NUgene Project, Center for Genetic Medicine, Northwestern University, Chicago, IL, USA
| | - J A Pacheco
- NUgene Project, Center for Genetic Medicine, Northwestern University, Chicago, IL, USA
| | - J Holbrook
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J M McKoy
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - B Nardone
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S Tica
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - V Godinez-Puig
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A W Rademaker
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - I B Helenowski
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - A D Bunta
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P H Stern
- Department of Molecular Pharmacology and Biological Chemistry, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - S T Rosen
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D P West
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - T A Guise
- Department of Medicine, Division of Endocrinology, Indiana University, Indianapolis, IN, USA
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23
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Roberts R, Miller M, O'Callaghan M, Koczwara B. Bone health management of Australian breast cancer survivors receiving hormonal therapy. Intern Med J 2015; 45:1182-5. [DOI: 10.1111/imj.12897] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/01/2015] [Indexed: 11/30/2022]
Affiliation(s)
- R. Roberts
- Discipline of Nutrition and Dietetics; Flinders University; Adelaide South Australia Australia
| | - M. Miller
- Discipline of Nutrition and Dietetics; Flinders University; Adelaide South Australia Australia
| | - M. O'Callaghan
- Urology Unit, SA Health; Repatriation General Hospital; Adelaide South Australia Australia
| | - B. Koczwara
- Department of Medical Oncology, Flinders Centre for Innovation in Cancer; Flinders University and Flinders Medical Centre; Adelaide South Australia Australia
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Byreddy DV, Bouchonville MF, Lewiecki EM. Drug-induced osteoporosis: from Fuller Albright to aromatase inhibitors. Climacteric 2015; 18 Suppl 2:39-46. [PMID: 26488130 DOI: 10.3109/13697137.2015.1103615] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Many commonly prescribed medications, such as selective serotonin reuptake inhibitors, proton pump inhibitors, thiazolidinediones, aromatase inhibitors, and androgen deprivation therapy, have been associated with adverse skeletal effects. The levels of evidence in support of a causal relationship between drug use and the development of bone loss and fractures are variable. For some drugs, a causal relationship is suspected (but not proven) based on observational studies, while in others causality is firmly established with randomized, controlled clinical trials. The mechanism of action for skeletal damage is poorly understood for some drugs and well known for others. Guidelines for managing bone health in patients taking some medications with potential skeletal toxicity have been developed using the best available evidence and expert opinion. This is a review of selected medications that have been associated with bone loss and fractures, with recommendations for clinical care.
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Affiliation(s)
- D V Byreddy
- a Division of Endocrinology and Metabolism, Department of Internal Medicine , University of New Mexico , Albuquerque, Albuquerque , New Mexico
| | - M F Bouchonville
- a Division of Endocrinology and Metabolism, Department of Internal Medicine , University of New Mexico , Albuquerque, Albuquerque , New Mexico
| | - E M Lewiecki
- b New Mexico Clinical Research & Osteoporosis Center , University of New Mexico School of Medicine , Albuquerque , New Mexico , USA
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25
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Cançado BL, Miranda LC, Madeira M, Farias MLF. Importance of bone assessment and prevention of osteoporotic fracture in patients with prostate cancer in the gonadotropic hormone analogues use. Rev Col Bras Cir 2015; 42:62-6. [PMID: 25992703 DOI: 10.1590/0100-69912015001012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 02/20/2014] [Indexed: 11/22/2022] Open
Abstract
The antiandrogenic therapy (ADT) for prostate cancer represents an additional risk factor for the development of osteoporosis and fragility fractures. Still, bone health of patients on ADT is often not evaluated. After literature research we found that simple preventive measures can prevent bone loss in these patients, resulting in more cost-effective solutions to the public health system and family when compared to the treatment of fractures.
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Affiliation(s)
| | | | - Miguel Madeira
- Departament of Endocrinology, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Lucia Fleiuss Farias
- Departament of Endocrinology, Faculty of Medicine, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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26
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Hadji P. Cancer Treatment-Induced Bone Loss in women with breast cancer. BONEKEY REPORTS 2015; 4:692. [PMID: 26029361 PMCID: PMC4440228 DOI: 10.1038/bonekey.2015.60] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/25/2015] [Indexed: 01/16/2023]
Abstract
Osteoporosis is one of the most frequent diseases in postmenopausal women, leading to an increased fracture risk due to the physiologic loss of the bone protective effects of estrogen. Hereby, several risk factors for fracture such as prevalent fracture, low bone mineral density (BMD), age, low body mass index, family history, tendency to falls, smoking, use of SSRIs, glucocorticoid use etc. have been identified. In addition, the further reduction in endogenous estrogens with chemotherapy (CHT), GnRH analoga or aromatase inhibitors (AIs) continuously increases fracture risk. Breast cancer (BC) on the other hand is the most frequent cancer type in women. Recent reports indicate a continuous increased incidence, whereas mortality, due to early diagnosis and treatment improvements, is decreasing. Dependent on specific tumor characteristics, radiation, CHT, antibody treatment as well as endocrine treatment have been included into the adjuvant clinical treatment setting. Some but not all of these cancer-specific treatments interfere with bone turnover, leading to an accelerated bone loss referred to as cancer treatment-induced bone loss (CTIBL). Whereas CHT leads to an unspecific increase in bone resorption, AI reduces residual serum endogenous estrogen level and is associated with a decrease in BMD and increased fracture risk. Independent of the type of AI administered, bone loss is 2-3-fold increased compared with healthy, age-matched postmenopausal controls. Therefore, several guidelines have emerged to help managing CTIBL in women with BC including strategies to identify and treat those at highest risk for fractures. This review summarizes the current knowledge on CTIBL and fracturing risk and indicates preventative strategies.
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Affiliation(s)
- Peyman Hadji
- Department of Bone Oncology, Krankenhaus Nordwest, Endocrinology and Reproductive Medicine, Philipps University of Marburg, Frankfurt, Germany
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27
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Ottanelli S. Prevention and treatment of bone fragility in cancer patient. CLINICAL CASES IN MINERAL AND BONE METABOLISM : THE OFFICIAL JOURNAL OF THE ITALIAN SOCIETY OF OSTEOPOROSIS, MINERAL METABOLISM, AND SKELETAL DISEASES 2015; 12:116-29. [PMID: 26604936 PMCID: PMC4625767 DOI: 10.11138/ccmbm/2015.12.2.116] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
It is well known that fractures increase the risk of morbidity and mortality. The various mechanisms responsible for bone loss in cancer patients may have a different impact depending on the characteristics of the clinical case and correlates with the therapies used, or caused by the therapies used against cancer. Some hormonal treatments cause hypogonadism, event which contributes to the progressive loss of bone mass. This is detectable in patients with breast cancer receiving determines that estrogen-deprivation and in men with prostate cancer with therapies that determine androgen deprivation. Chemotherapy treatments used in cancer patients have reduced bone mass. In addition, low bone mass is detectable in patients with lymphoma treated with corticosteroids or radiation or alkylating agents. In premenopausal patients suffering from breast cancer, treatment with cytotoxic therapy or ablation of ovarian function, can lead to an 8% reduction in bone mineral density at the spine and 4% in the femur. With a chemotherapy regimen in CMF, the reduction of BMD is 6.5%; this bone loss is not recovered after discontinuation of therapy. Tamoxifen given for five years reduces bone remodeling and cause a 32% increase in the risk of osteoporotic fractures when used in premenopausal. After menopause, tamoxifen has a protective effect on bone mass, with a reduced risk of new fractures. Aromatase inhibitors in post-menopausal women, depending on the formulation can cause different effects on the reduction of BMD and fracture risk. We have in fact steroids, exemestane and nonsteroidal, letrozole and anastrozole. Patients at increased risk of fragility fractures should undergo preventive therapies as soon as possible after tests performed for the study of bone health. They can be used DEXA and the FRAX algorithm, which can define a secondary osteoporosis. Prevention and treatment of the increased risk of osteoporotic fracture is to maintain adequate levels of calcium and vitamin D. Bisphosphonates and denosumab are used for the management of bone remodeling and bone loss induced by cancer treatments. Bisphosphonates also have anti-tumor effects per se, which are expressed in potentially prevent the development of bone metastases. In men with metastatic prostate cancer and which is induced androgen deprivation, it is usefully used denosumab 120 mg monthly or zoledronic acid 4 mg monthly.
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Affiliation(s)
- Silva Ottanelli
- Bone Metabolic Diseases Unit, Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
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28
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Traitements inhibiteurs de la résorption osseuse en situation métastatique : bilan actuel et perspectives. ONCOLOGIE 2015. [DOI: 10.1007/s10269-015-2494-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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29
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O'Sullivan S, Grey A. Adverse skeletal effects of drugs - beyond Glucocorticoids. Clin Endocrinol (Oxf) 2015; 82:12-22. [PMID: 25039381 DOI: 10.1111/cen.12549] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 06/28/2014] [Accepted: 07/07/2014] [Indexed: 12/13/2022]
Abstract
Osteoporotic fractures are an important public health problem with significant individual and societal costs. In addition to the major risk factors for osteoporotic fracture, low bone mineral density (BMD), age, low body weight and history of fracture or falls, some drugs are now considered to be important secondary risk factor for bone loss and fracture, particularly amongst predisposed individuals. Currently available data are often generated from small observational clinical studies, making risk assessment and development of management guidelines difficult. In many cases, the exposed population has a low baseline risk for fracture and additional assessment and treatment may not be necessary. In this review, we focus on drugs other than glucocorticoids identified as potentially causing adverse skeletal effects, summarizing the existing evidence from preclinical and clinical studies, and suggest recommendations for patient management.
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30
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Bone health history in breast cancer patients on aromatase inhibitors. PLoS One 2014; 9:e111477. [PMID: 25354083 PMCID: PMC4213031 DOI: 10.1371/journal.pone.0111477] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 09/11/2014] [Indexed: 11/20/2022] Open
Abstract
A cross-sectional study was performed to assess bone health history among aromatase inhibitor (AI) users before breast cancer (BC) diagnosis, which may impact fracture risk after AI therapy and choice of initial hormonal therapy. A total of 2,157 invasive BC patients initially treated with an AI were identified from a prospective cohort study at Kaiser Permanente Northern California (KPNC). Data on demographic and lifestyle factors were obtained from in-person interviews, and bone health history and clinical data from KPNC clinical databases. The prevalence of osteoporosis and fractures in postmenopausal AI users was assessed, compared with 325 postmenopausal TAM users. The associations of bone health history with demographic and lifestyle factors in AI users were also examined. Among all initial AI users, 11.2% had a prior history of osteoporosis, 16.3% had a prior history of any fracture, and 4.6% had a prior history of major fracture. Postmenopausal women who were taking TAM as their initial hormonal therapy had significantly higher prevalence of prior osteoporosis than postmenopausal AI users (21.5% vs. 11.8%, p<0.0001). Among initial AI users, the associations of history of osteoporosis and fracture in BC patients with demographic and lifestyle factors were, in general, consistent with those known in healthy older women. This study is one of the first to characterize AI users and risk factors for bone morbidity before BC diagnosis. In the future, this study will examine lifestyle, molecular, and genetic risk factors for AI-induced fractures.
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31
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Panday K, Gona A, Humphrey MB. Medication-induced osteoporosis: screening and treatment strategies. Ther Adv Musculoskelet Dis 2014; 6:185-202. [PMID: 25342997 DOI: 10.1177/1759720x14546350] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Drug-induced osteoporosis is a significant health problem and many physicians are unaware that many commonly prescribed medications contribute to significant bone loss and fractures. In addition to glucocorticoids, proton pump inhibitors, selective serotonin receptor inhibitors, thiazolidinediones, anticonvulsants, medroxyprogesterone acetate, aromatase inhibitors, androgen deprivation therapy, heparin, calcineurin inhibitors, and some chemotherapies have deleterious effects on bone health. Furthermore, many patients are treated with combinations of these medications, possibly compounding the harmful effects of these drugs. Increasing physician awareness of these side effects will allow for monitoring of bone health and therapeutic interventions to prevent or treat drug-induced osteoporosis.
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Affiliation(s)
- Keshav Panday
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Amitha Gona
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mary Beth Humphrey
- Department of Medicine, University of Oklahoma Health Sciences Center, and Veterans Affairs Medical Center, 975 NE 10th St, BRC209, Oklahoma City, OK 73104, USA
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32
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McLendon AN, Woodis CB. A review of osteoporosis management in younger premenopausal women. ACTA ACUST UNITED AC 2014; 10:59-77. [PMID: 24328599 DOI: 10.2217/whe.13.73] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The purpose of this review is to describe the available evidence for osteoporosis treatments in young and premenopausal women. A review of articles evaluating the treatment or prevention of osteoporosis in young (age less than 50 years) or premenopausal women was conducted. Several trials evaluating the treatment of anorexia nervosa and use of hormone therapy in those women, the use of bisphosphonates in women undergoing chemotherapy for breast cancer and the use of bisphosphonates, teriparatide and vitamin D in women with glucocorticoid-induced osteoporosis are described. Limited data were found to support the treatment of osteoporosis in women with idiopathic osteoporosis or cystic fibrosis, or after kidney transplant. The evidence for treatment of osteoporosis in premenopausal women is not nearly as robust as that for postmenopausal osteoporosis. Although fracture risk in the premenopausal population is low, women with secondary osteoporosis may benefit from treatment with various agents, depending upon the condition.
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Affiliation(s)
- Amber N McLendon
- Campbell University College of Pharmacy & Health Sciences & Glenaire, Inc., PO Box 1090, Buies Creek, NC 27511, USA.
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33
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Tsang DS, Alibhai SM. Bone health care for patients with prostate cancer receiving androgen deprivation therapy. Hosp Pract (1995) 2014; 42:89-102. [PMID: 24769788 DOI: 10.3810/hp.2014.04.1107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Patients with prostate cancer often receive androgen deprivation therapy (ADT) as part of their treatment regimen. However, treatment with ADT causes multiple side effects, including reduced bone mineral density (BMD), lower lean body mass, and a higher risk for fractures. Several organizations provide clinical practice guidelines for osteoporosis screening, prevention, and treatment in this population, but adherence to these guidelines remains low. Areas for improvement in provider adherence include baseline and follow-up BMD testing, as well as counseling regarding healthy bone behaviors such as calcium/vitamin D intake, lifestyle changes, and physical exercise. Comparison of osteoporosis care in breast cancer and non-oncology populations shows that suboptimal bone health care is not isolated to prostate cancer. A summary of the literature examining improvements in patient adherence and provider delivery of bone health care is included in this review, but high-quality studies are lacking. Patients may be the most receptive to written educational information delivered at or near the time of ADT initiation. Involvement of a primary care practitioner and oncologist in care delivery is associated with higher BMD test use. Institution-level programs that automatically initiate osteoporosis screening and management may be effective at reducing the incidence of hip fracture. Lastly, suggestions are provided for future approaches to knowledge translation and quality of care studies to improve bone health.
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Affiliation(s)
- Derek S Tsang
- Resident Physician, Department of Radiation Oncology, University of Toronto, Toronto, Canada
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34
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Coleman R, Body JJ, Aapro M, Hadji P, Herrstedt J. Bone health in cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2014; 25 Suppl 3:iii124-37. [PMID: 24782453 DOI: 10.1093/annonc/mdu103] [Citation(s) in RCA: 347] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
There are three distinct areas of cancer management that make bone health in cancer patients of increasing clinical importance. First, bone metastases are common in many solid tumours, notably those arising from the breast, prostate and lung, as well as multiple myeloma, and may cause major morbidity including fractures, severe pain, nerve compression and hypercalcaemia. Through optimum multidisciplinary management of patients with bone metastases, including the use of bone-targeted treatments such as potent bisphosphonates or denosumab, it has been possible to transform the course of advanced cancer for many patients resulting in a major reduction in skeletal complications, reduced bone pain and improved quality of life. Secondly, many of the treatments we use to treat cancer patients have effects on reproductive hormones, which are critical for the maintenance of normal bone remodelling. This endocrine disturbance results in accelerated bone loss and an increased risk of osteoporosis and fractures that can have a significant negative impact on the lives of the rapidly expanding number of long-term cancer survivors. Finally, the bone marrow micro-environment is also intimately involved in the metastatic processes required for cancer dissemination, and there are emerging data showing that, at least in some clinical situations, the use of bone-targeted treatments can reduce metastasis to bone and has potential impact on patient survival.
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Affiliation(s)
- R Coleman
- Weston Park Hospital, Cancer Research-UK/Yorkshire Cancer Research Sheffield Cancer Research Centre, Sheffield, UK
| | - J J Body
- CHU Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - M Aapro
- Multidisciplinary Oncology Institute, Genolier, Switzerland
| | - P Hadji
- Department of Gynecology, Endocrinology and Oncology, Philipps-University of Marburg, Marburg, Germany
| | - J Herrstedt
- Department of Oncology, Odense University Hospital, Odense, Denmark
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35
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Juozaitytė E, Aleknavičius E, Jančiauskienė R, Česas A, Pipirienė-Želvienė T, Liutkauskienė S, Krasauskienė A, Vencevičienė L. Guidelines for diagnostics and treatment of aromatase inhibitor-induced bone loss in women with breast cancer. Medicina (B Aires) 2014; 50:197-203. [DOI: 10.1016/j.medici.2014.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 09/15/2014] [Indexed: 11/15/2022] Open
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36
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Rizzoli R, Body JJ, Brandi ML, Cannata-Andia J, Chappard D, El Maghraoui A, Glüer CC, Kendler D, Napoli N, Papaioannou A, Pierroz DD, Rahme M, Van Poznak CH, de Villiers TJ, El Hajj Fuleihan G. Cancer-associated bone disease. Osteoporos Int 2013; 24:2929-53. [PMID: 24146095 PMCID: PMC5104551 DOI: 10.1007/s00198-013-2530-3] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 09/25/2013] [Indexed: 12/11/2022]
Abstract
Bone is commonly affected in cancer. Cancer-induced bone disease results from the primary disease, or from therapies against the primary condition, causing bone fragility. Bone-modifying agents, such as bisphosphonates and denosumab, are efficacious in preventing and delaying cancer-related bone disease. With evidence-based care pathways, guidelines assist physicians in clinical decision-making. Of the 57 million deaths in 2008 worldwide, almost two thirds were due to non-communicable diseases, led by cardiovascular diseases and cancers. Bone is a commonly affected organ in cancer, and although the incidence of metastatic bone disease is not well defined, it is estimated that around half of patients who die from cancer in the USA each year have bone involvement. Furthermore, cancer-induced bone disease can result from the primary disease itself, either due to circulating bone resorbing substances or metastatic bone disease, such as commonly occurs with breast, lung and prostate cancer, or from therapies administered to treat the primary condition thus causing bone loss and fractures. Treatment-induced osteoporosis may occur in the setting of glucocorticoid therapy or oestrogen deprivation therapy, chemotherapy-induced ovarian failure and androgen deprivation therapy. Tumour skeletal-related events include pathologic fractures, spinal cord compression, surgery and radiotherapy to bone and may or may not include hypercalcaemia of malignancy while skeletal complication refers to pain and other symptoms. Some evidence demonstrates the efficacy of various interventions including bone-modifying agents, such as bisphosphonates and denosumab, in preventing or delaying cancer-related bone disease. The latter includes treatment of patients with metastatic skeletal lesions in general, adjuvant treatment of breast and prostate cancer in particular, and the prevention of cancer-associated bone disease. This has led to the development of guidelines by several societies and working groups to assist physicians in clinical decision making, providing them with evidence-based care pathways to prevent skeletal-related events and bone loss. The goal of this paper is to put forth an IOF position paper addressing bone diseases and cancer and summarizing the position papers of other organizations.
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Affiliation(s)
- R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland,
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37
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Abstract
With long-term survival for recipients of autologous and allogeneic hematopoietic cell transplantation (HCT) increasing, the recognition of late complications such as decreased bone mineral density leading to osteoporosis (OP) has also increased. With an incidence that is reported to affect as many 50 % of allo HCT recipients, studies continue to mount supporting the need and success in treatment of this HCT complication. In this review, we highlight the major pathological mechanisms behind the development of OP, its diagnosis, and the literature supporting consensus treatment recommendations while noting areas of uncertainty that need further research.
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Affiliation(s)
- Brian L McClune
- Division of Hematology, Oncology and Transplantation, University of Minnesota, 420 Delaware St, SE, Minneapolis, MN, 55455, USA,
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38
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Abstract
With increasing use of screening mammography and more effective adjuvant systemic therapies, the majority of women diagnosed with early stage breast cancer will be long-term survivors and experience personal cures. Among the common side effects of adjuvant therapies is treatment-related bone loss, primarily as a result of estrogen deprivation. Whereas this occurs in both postmenopausal and premenopausal women, this brief review will focus on pre- or perimenopausal women when initially diagnosed with breast cancer. An important distinction is between those women who retain ovarian function despite cancer or preventative treatments and the more common situation of premenopausal women who as result of cancer treatments undergo ovarian failure or early menopause. Some women with treatment-related ovarian failure will have sufficient treatment-related bone loss to be at increased risks of subsequent nontraumatic fractures and/or osteoporosis and will be candidates for antiresorptive treatments. The noncancer treatment risk factors, screening and treatments for the management of osteopenia and osteoporosis are generally the same in postmenopausal women with and without breast cancer. However, premenopausal women with relatively rapid onset of treatment-related ovarian failure and bone loss pose several challenges. Awareness of treatment-related bone loss and risks of subsequent osteoporosis is a high priority in an ever-increasing population of breast cancer survivors.
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Affiliation(s)
- Loomee Doo
- Wexner College of Medicine, The Ohio State University, Columbus, OH, USA
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39
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Datta M, Schwartz GG. Calcium and vitamin D supplementation and loss of bone mineral density in women undergoing breast cancer therapy. Crit Rev Oncol Hematol 2013; 88:613-24. [PMID: 23932583 DOI: 10.1016/j.critrevonc.2013.07.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 06/20/2013] [Accepted: 07/09/2013] [Indexed: 02/07/2023] Open
Abstract
An unintended consequence of breast cancer therapies is an increased risk of osteoporosis due to accelerated bone loss. We conducted a systematic review of calcium and/or vitamin D (Ca±D) supplementation trials for maintaining bone mineral density (BMD) in women with breast cancer using the "before-after" data from the Ca±D supplemented comparison group of trials evaluating the effect of drugs such as bisphosphonates on BMD. Whether Ca±D supplements increase BMD in women undergoing breast cancer therapy has never been tested against an unsupplemented control group. However, results from 16 trials indicate that the Ca±D doses tested (500-1500mg calcium; 200-1000IU vitamin D) were inadequate to prevent BMD loss in these women. Cardiovascular disease is the main cause of mortality in women with breast cancer. Because calcium supplements may increase cardiovascular disease risk, future trials should evaluate the safety and efficacy of Ca±D supplementation in women undergoing breast cancer therapy.
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Affiliation(s)
- Mridul Datta
- Department of Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Rinaldi RZ. Aromatase inhibitor adjuvant chemotherapy of breast cancer results in cancer therapy induced bone loss. Curr Osteoporos Rep 2013; 11:61-4. [PMID: 23408144 DOI: 10.1007/s11914-013-0134-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aromatase Inhibitors are anti-estrogen agents that have proven efficacy for adjuvant therapy of estrogen receptor positive breast cancer primarily in post menopausal women with estrogen receptor positive breast cancer but increase the risk of cancer therapy induced bone loss (CTIBL). Recent studies have shown the potential benefit of bisphosphonate therapy to play a dual role in the management of breast cancer. These studies provide evidence that bisphosphonate therapy in conjunction with aromatase inhibitors (AI), not only decreases the risk of osteoporosis but, in addition, may improve survival from breast cancer.
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Affiliation(s)
- Renee Z Rinaldi
- Cedars Sinai Medical Center, The David Geffen School of Medicine, UCLA, 150 North Robertson Blvd, Beverly Hills, CA 90211, USA.
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41
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[Treatment effect of breast cancer and prostate cancer on bone]. Med Clin (Barc) 2013; 140:164-8. [PMID: 22841464 DOI: 10.1016/j.medcli.2012.05.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/17/2012] [Accepted: 05/31/2012] [Indexed: 11/23/2022]
Abstract
Aromatase inhibitors are used in the treatment of breast cancer and androgen deprivation therapy is used in prostate cancer. Both of them induce bone loss and increase fracture incidence. Early detection is important for patients with increased risk of osteoporotic fractures. In this article we review the available treatments and their indication to prevent the onset of osteoporosis and osteoporotic fractures in this patient group.
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Stavraka C, Maclaran K, Gabra H, Agarwal R, Ghaem-Maghami S, Taylor A, Dhillo WS, Panay N, Blagden SP. A study to evaluate the cause of bone demineralization in gynecological cancer survivors. Oncologist 2013; 18:423-9. [PMID: 23363808 PMCID: PMC3639529 DOI: 10.1634/theoncologist.2012-0416] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/19/2012] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND An association between treatment for gynecological cancers and risk of osteoporosis has never been formally evaluated. Women treated for these cancers are now living longer than ever before, and prevention of treatment-induced morbidities is important. We aimed to distinguish, in gynecological cancer survivors, whether cancer therapy has additional detrimental effects on bone health above those attributable to hormone withdrawal. METHODS We performed a retrospective cross-sectional analysis of dual energy x-ray absorptiometry (DEXA) scan results from 105 women; 64 had undergone bilateral salpingo-oophorectomy (BSO) followed by chemotherapy or radiotherapy for gynecological malignancies, and 41 age-matched women had undergone BSO for benign etiologies. All were premenopausal prior to surgery. RESULTS The median age at DEXA scan for the cancer group was 42 years, and 66% had received hormonal replacement therapy (HRT) following their cancer treatment. For the benign group, the median age was 40 years, and 87% had received HRT. Thirty-nine percent of cancer survivors had abnormal DEXA scan results compared to 15% of the control group, with the majority demonstrating osteopenia. The mean lumbar spine and femoral neck bone mineral densities (BMDs) were significantly lower in cancer patients. A history of gynecological cancer treatment was associated with significantly lower BMD in a multivariate logistic regression. CONCLUSIONS Women treated for gynecological malignancies with surgery and adjuvant chemotherapy have significantly lower BMDs than age-matched women who have undergone oophorectomy for noncancer indications. Prospective evaluation of BMD in gynecological cancer patients is recommended to facilitate interventions that will reduce the risk of subsequent fragility fractures.
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Affiliation(s)
| | | | - Hani Gabra
- Queen Charlotte's & Chelsea and Westminster Hospital, London, United Kingdom
| | | | | | | | - Waljit S. Dhillo
- Section of Investigative Medicine, Department of Medicine, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nick Panay
- Queen Charlotte's & Chelsea and Westminster Hospital, London, United Kingdom
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Aromatase inhibitors in the treatment of elderly women with metastatic breast cancer. Breast 2013; 22:142-149. [PMID: 23321585 DOI: 10.1016/j.breast.2012.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 10/26/2012] [Accepted: 12/17/2012] [Indexed: 11/22/2022] Open
Abstract
The proportion of elderly women in the population is rising, and in tandem, the incidence of breast cancer rises with age. Because of health and tolerability concerns, as well as life expectancy, physicians may be reluctant to advise a standard treatment regimen for elderly patients with metastatic breast cancer. To elucidate this issue, we performed a literature review of clinical studies that included women with metastatic breast cancer who were over the age of 65. Our results show that although little clinical evidence exists, what is available suggests that standard treatment is tolerated and beneficial for patients meeting certain criteria. A geriatric assessment may identify specific patient groups (independent, dependent, or frail) and thereby guide treatment. Treatment recommendations for elderly patients with metastatic breast cancer are sparse, although first-line endocrine treatment, usually aromatase inhibitors or tamoxifen, is recommended for hormone-sensitive disease. In general, the evidence from clinical studies suggests that aromatase inhibitors are more effective than either tamoxifen or megestrol acetate as first- or second-line treatment in postmenopausal women with metastatic breast cancer. Ultimately, quality of life, treatment effects, and comorbidities are important aspects in this population and may guide treatment choice. To provide evidence-based treatment guidance, future clinical trials should include more patients over the age of 65 years.
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Bocanegra-Pérez MS, Vicente-Barrero M, Sosa-Henríquez M, Rodríguez-Bocanegra E, Limiñana-Cañal JM, López-Márquez A, Pérez-Plasencia D, Ramos-Macías A. Bone metabolism and clinical study of 44 patients with bisphosphonate-related osteonecrosis of the jaws. Med Oral Patol Oral Cir Bucal 2012; 17:e948-55. [PMID: 22926469 PMCID: PMC3505715 DOI: 10.4317/medoral.17946] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 03/08/2012] [Indexed: 11/28/2022] Open
Abstract
Osteonecrosis of the jaws is a clinical entity described and linked to treatment with bisphosphonates in 2003. Its real incidence is unknown and it could increase due to the large number of patients treated with these drugs, and its cumulative effect on the bone. State of the art knowledge regarding its etiopathogeny, clinical course and suitable treatments is limited.
Objectives: To study the clinical characteristics of 44 patients with bisphosphonate-related osteonecrosis of the jaws and the state of their bone mineral metabolism: bone remodeling state, prevalence of fractures, bone mineral density study, and assessment of the different treatment strategies.
Design of the Study: Observational. Information was gathered prospectively through interviews, clinical examinations, additional tests and review of medical records.
Results: We studied 16 men and 28 women with a mean age of 64.7 years. Breast cancer was the most frequent underlying disease. Zoledronate was used in 82% of the cases and in the non-oncology group of patients; alendronate was the most frequently used bisphosphonate. The mean duration of the zoledronate and alendronate treatments was 25 months and 88 months respectively. The lower jaw was the most frequent location, and previous exodontias—among the triggering factors known—were the most closely linked to its onset. We found considerable osteoblastic activity in patients suffering from neoplasia, with artifacts present in their bone densitometry and a high percentage of vertebral fractures.
Conclusions: According to our results, osteonecrosis of the jaws affects elderly patients. We found a direct relationship between the duration of exposure and the accumulated dose. Other relevant factors are: Poor oral and dental health, corticoids, diabetes and teeth extractions. In essence, it is a clinical diagnosis. Prevention is the best strategy to handle this clinical entity.
Key words:Alendronate, bisphosphonate, jaw, maxilla, osteonecrosis, osteoporosis, prevention, zoledronate.
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Affiliation(s)
- María-Sacramento Bocanegra-Pérez
- Insular Maternal and Child University Hospital Complex of Las Palmas of Gran Canaria, Stomatology Department, Bone Metabolism Unit and Research Unit, Las Palmas of Gran Canaria, Spain
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Rizzoli R, Body JJ, DeCensi A, Reginster JY, Piscitelli P, Brandi ML. Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper. Osteoporos Int 2012; 23:2567-76. [PMID: 22270857 DOI: 10.1007/s00198-011-1870-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 12/05/2011] [Indexed: 10/14/2022]
Abstract
UNLABELLED Aromatase inhibitors (AIs) are widely used in women with breast cancer, but they are known to increase bone loss and risk of fractures. Based on available evidence and recommendations, an ESCEO working group proposes specific guidance for the prevention of AIs-induced bone loss and fragility fractures. INTRODUCTION Aromatase inhibitors (AIs) are now the standard treatment for hormone receptor-positive breast cancer. However, deleterious effects of AIs on bone health have been reported. An ESCEO working group proposes guidance for the prevention of bone loss and fragility fractures in post-menopausal women with breast cancer receiving AIs. METHODS A panel of experts addressed the issue of skeletal effects of AIs and effectiveness of antifracture therapies for the prevention of AI-induced bone loss and fractures. Recommendations by national and international organizations, and experts' opinions on this topic were evaluated. RESULTS All aromatase inhibitors are associated with negative effects on the skeleton, resulting in bone loss and increased risk of fragility fractures. Current guidelines suggest approaches that differ both in terms of drugs proposed for fracture prevention and duration of treatment. CONCLUSION The ESCEO working group recommends that all AI-treated women should be evaluated for fracture risk. Besides general recommendations, zoledronic acid 4 mg i.v. every 6 months, denosumab s.c., or possibly oral bisphosphonates should be administered for the entire period of AI treatment to all osteoporotic women (T-score hip/spine <-2.5 or ≥ 1 prevalent fragility fracture), to women aged ≥ 75 irrespective of BMD, and to patients with T-score <-1.5 + ≥ 1 clinical risk factor or T-score <-1.0 + ≥ 2 clinical risk factors. Alternatively, therapy could be considered in patients with a FRAX-determined 10-year hip fracture probability ≥ 3%.
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Affiliation(s)
- R Rizzoli
- Division of Bone Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Body JJ. Aromatase inhibitors-induced bone loss in early breast cancer. BONEKEY REPORTS 2012; 1:201. [PMID: 24936287 PMCID: PMC4056949 DOI: 10.1038/bonekey.2012.201] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/26/2012] [Indexed: 12/31/2022]
Abstract
Women with breast cancer have an increased prevalence and incidence of fractures. This increased risk of fracture has become most evident following the use of aromatase inhibitors (AIs) as standard adjuvant therapy. AI-induced bone loss occurs at more than twice the rate of physiologic postmenopausal bone loss. Moreover, peripheral quantitative computed tomography data indicate that effects of AIs on bone strength and on cortical bone have been substantially underestimated by dual-energy X-ray absorptiometry. All AIs have been associated with an increased fracture risk. The incidence of fractures is at least 33-43% higher in AI-treated patients than in tamoxifen-treated patients, and this increase in fracture risk is maintained at least for the duration of AI therapy. Over the last few years, clinical trials have established the effectiveness of bisphosphonates and denosumab to preserve and even increase bone mineral density (BMD) during adjuvant AIs. Most data have been obtained with zoledronic acid administered twice a year, which effectively maintains or increases BMD in women receiving AIs. In addition, zoledronic acid has been shown to delay disease recurrence and maybe prolong survival in women with hormone-responsive tumors, thereby providing an adjuvant antitumor benefit besides preserving BMD. It is likely that a combined fracture risk assessment will more accurately identify women with breast cancer who require bone protective therapy. The FRAX tool probably underestimates the net increase in fracture risk due to AI therapy. Recent guidelines for the prevention of AI-induced bone loss have adequately considered the presence of several established clinical risk factors for fractures, in addition to BMD, when selecting patients to be treated with inhibitors of bone resorption.
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Affiliation(s)
- Jean-Jacques Body
- CHU Brugmann, Department of Medicine, Université Libre de Bruxelles, Brussels, Belgium
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Abstract
Optimizing health outcomes, including prevention of osteoporotic fractures, is essential for promoting the well-being of the growing number of cancer survivors. Medical providers who participate in the care of cancer survivors should be aware that various cancer treatments may cause bone loss, which can increase the risk of subsequent of osteoporosis. Healthy bone remodeling is a balanced and dynamic equation between new bone formation and bone resorption. Aging, natural menopause, and cancer treatments such as surgical oophorectomy, gonadotropin-releasing hormone agonists, chemotherapy-induced ovarian failure, androgen deprivation therapy, and aromatase inhibitors can all promote bone loss. The WHO Fracture Assessment Tool can be used as a clinical aid to assess an individual's osteoporotic fracture risk, with or without bone mineral density measurements obtained from dual-energy x-ray absorptiometry. Preventative strategies include adequate calcium and vitamin D supplementation and modifying risk factors such as alcohol intake, tobacco use, and lack of exercise. Bisphosphonate therapy and rank-ligand monoclonal antibody therapy are the most commonly used agents for management of bone loss resulting from cancer treatment. This review will summarize the mechanisms by which cancer treatments cause bone loss as well provide screening and treatment recommendations for the management of bone loss.
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Kudlacek S, Puntus T. [Osteoporosis in men receiving androgen deprivation therapy for non-metastatic prostate cancer]. Wien Med Wochenschr 2012; 162:380-5. [PMID: 22875632 DOI: 10.1007/s10354-012-0106-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 05/03/2012] [Indexed: 11/28/2022]
Abstract
Osteoporosis is defined as a continuous loss of bone mineral density accompanied by an increased fracture risk in females and males. A fall of estrogen concentrations at the menopause and the consecutive rapid bone loss are an established pathogenic mechanism in female osteoporosis. Males do not have a menopause equivalent during which significant amounts of bone are lost. Several diseases, therapeutic strategies and nutritional deficiencies may also result in bone loss and reduced bone mineral density. Prostate cancer is the most common visceral malignancy in men. Suppression of endogenous androgen production as a therapeutic tool is commonly used in patients with non-metastatic prostate cancer and is associated with significant bone loss and an increased fracture risk. Androgen deprivation therapy is prescribed both for men with locally advanced or high-risk non-metastatic prostate cancer. Osteoclast inhibition with any of several bisphosphonates improves bone mineral density and reduces fracture risk. Denosumab (a monoclonal antibody against RANK ligand) and toremifene (a selective estrogen receptor modulator) recently have been shown to be effective to reduce vertebral fractures in patients with non-metastatic prostate cancer receiving androgen-deprivation therapy. This overview focuses on cancer-treatment-induced bone loss in patients with non-metastatic prostate cancer.
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Affiliation(s)
- Stefan Kudlacek
- Lehrkrankenhaus der Barmherzigen Brüder, Medizinische Abteilung, Johannes von Gott Platz 1, 1020, Wien, Österreich.
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Ito K, Blinder VS, Elkin EB. Cost Effectiveness of Fracture Prevention in Postmenopausal Women Who Receive Aromatase Inhibitors for Early Breast Cancer. J Clin Oncol 2012; 30:1468-75. [DOI: 10.1200/jco.2011.38.7001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Purpose Aromatase inhibitors (AIs) increase the risk of osteoporosis and related fractures in postmenopausal women who receive adjuvant AIs for hormone receptor (HR) –positive early breast cancer (EBC). We compared the cost effectiveness of alternative screening and treatment strategies for fracture prevention. Methods We developed a Markov state transition model to simulate clinical practice and outcomes in a hypothetical cohort of women age 60 years with HR-positive EBC starting a 5-year course of AI therapy after primary surgery for breast cancer. Outcomes were quality-adjusted life-years (QALYs), lifetime cost, and incremental cost-effectiveness ratio (ICER). We compared the following strategies: no intervention; one-time bone mineral density (BMD) screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; annual BMD screening and selective bisphosphonate therapy in women with osteoporosis or osteopenia; and universal bisphosphonate therapy. Results ICERs for annual BMD screening followed by oral bisphosphonates for those with osteoporosis, annual BMD screening followed by oral bisphosphonates for those with osteopenia, and universal treatment with oral bisphosphonates were $87,300, $129,300, and $283,600 per QALY gained, respectively. One-time BMD screening followed by oral bisphosphonates for those with osteoporosis or osteopenia was dominated. Our results were sensitive to age at the initiation of AI therapy, type of bisphosphonates, post-treatment residual effect of bisphosphonates, and a potential adjuvant benefit of intravenous bisphosphonates. Conclusion In postmenopausal women receiving adjuvant AIs for HR-positive EBC, a policy of baseline and annual BMD screening followed by selective treatment with oral bisphosphonates for those diagnosed with osteoporosis is a cost-effective use of societal resources.
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Affiliation(s)
- Kouta Ito
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Victoria S. Blinder
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Elena B. Elkin
- Kouta Ito, Brigham and Women's Hospital, Boston, MA; and Victoria S. Blinder and Elena B. Elkin, Memorial Sloan-Kettering Cancer Center, New York, NY
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Recommendations for antiresorptive therapy in postmenopausal patients with breast cancer: Marburg AIBL Guideline Evaluation Study (MAGES). Breast Cancer Res Treat 2012; 133:1089-96. [PMID: 22453753 DOI: 10.1007/s10549-012-2023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 03/07/2012] [Indexed: 12/21/2022]
Abstract
Postmenopausal women with hormone-receptor-positive breast cancer usually receive aromatase inhibitor (AI) therapy at some point in their disease management. Accelerated bone loss during AI therapy poses a problem, especially in postmenopausal women who may already have age-related osteopenia or several fracture-related risk factors. Guidelines and algorithms have been developed to identify women at risk for fractures from low bone mineral density and to provide recommendations for antiresorptive treatment. However, the factors used to calculate fracture risk and the thresholds for antiresorptive treatment vary among the current guidelines and algorithms, potentially leading to inconsistent recommendations for or against antiresorptive treatment. The present study analyzed antiresorptive treatment decisions in a population of postmenopausal women with hormone-receptor-positive breast cancer receiving AI therapy using five different guidelines/algorithms (World Health Organization Fracture Risk Assessment tool [FRAX], expert consensus, German Dachverband Osteologie, American Society of Clinical Oncology, and World Health Organization). The consistency of a recommendation for antiresorptive treatment among the five methods was low (4 %). The consistency of a recommendation against antiresorptive treatment among the five methods was higher (57 %), but left approximately 40 % of patients with an inconsistent recommendation. The consequences of overtreatment (unnecessary exposure to adverse events) and undertreatment (increased risk of fractures and possibly decreased disease-free survival) make it imperative that the existing guidelines and algorithms be improved. Moreover, evidence-based outcomes from antiresorptive treatment decisions are required to validate guidelines and algorithms.
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