P-279 The role of autophagy in the development of mouse preimplantation embryos and morphokinetics

Study question

Which role does autophagy play in the development of mammalian preimplantation embryos?

Summary answer

This study suggests the critical role of autophagy in the fertilized oocytes and embryo development.

What is known already

Cellular nutrition plays an important role in improving reproductive efficiency in all animals. Homeostasis of nutrient metabolism is tightly controlled by a cellular pathway called autophagy, which can recycle nutrients and organelles to allow cells adapting to nutritional stress such as nutrient deficiency or excess. Increasing evidence shows that autophagy is involved in a wide range of cellular events within mammalian reproduction. Since it is known that autophagy has paradoxical functions in many cellular processes, it is still unclear which role autophagy plays in the development of mammalian preimplantation embryos.

Study design, size, duration

To determine the role of autophagy in the development of mammalian preimplantation embryos, a randomized parallel group study with hybride Bl6CBa/ca mouse embryos was designed.

Participants/materials, setting, methods

207 zygotes of Bl6CBAca mice were randomly distributed into two groups. The control embryos were cultured in 2ml GTL media (Vitrolife) supplemented with DMSO (vehicle), while the treatment embryos were cultured in 2ml GTL media supplemented with 100 nM autophagy inhibitor Bafilomycin (Baf). Embryos were non-invasively monitored with a Primovision time-lapse system (Vitrolife) for 5 days. Blastocyst, degeneration rate and morphokinetics were analyzed. Furthermore, confocal microscopy staining of 2PN embryos with autophagy marker LC3 was performed.

Main results and the role of chance

Our study showed a statistically significant difference in the expanded blastocyst as well as degeneration rate among groups (p < 0.0001). 89,19% of embryos in the control group (non-treated) (N = 111) reached to expanded blastocysts, while most of the embryos in Baf-treated group (N = 96) stopped development at 4C-stage. No embryo in Baf-treated group reached expanded blastocysts (blastocyst rate = 0) and 100% embryos degenerated. However, there is no statistically significant difference in the development time from 2C to 4C stage between non-treated (1330 ± 17.35 min, N = 50) and Baf-treated group (1364 ± 22.20 min, N = 50).

Moreover, confocal microscopy staining of 2PN embryos with autophagy marker LC3 showed that non-treated embryos expressed weakly and dispersed LC3 signal in the whole cell. In contrast, LC3 signal in Baf-treated embryos were significantly accumulated and translocated in the cell membranes.

The accumulation of autophagy-marker LC3 after treatment with Bafilomycin, an autophagy inhibitor, indicated the high expression of autophagosomal activity during the embryo development. This may explain the toxicity in Baf-treated embryos, which prevent the embryos to develop further than 4C-stage. Altogether our study suggests the critical role of autophagy in the fertilized oocytes and embryo development

Limitations, reasons for caution

Murine embryos model is widely used for safety testing in assisted reproduction technologies, however human embryos might behave differently. Moreover, although treatment with Bafilomycin is the gold standard in autophagy research in vitro, it might not mimic exactly the autophagy dysfunction in human embryo development.

Wider implications of the findings

Emergent evidences show that dysfunction of autophagy, which maintains the cellular homeostasis, correlates with metabolic disorders including obesity. In women, obesity causes anovulation and menstrual irregularities. Therefore, we aim to investigate the potential role of autophagy in the obesity, which may help improving the pregnancy rate in the obesity-associated infertility.

Trial registration number

Not applicable

The role of follicular anti-Mullerian hormone in women undergoing IVF/ICSI with regard to size, oocyte presence, sociodemographic parameters, treatment variables, and other hormones and vitamins

AIMS

The aim of this study was to evaluate the relationship between follicular anti-Mullerian hormone (fAMH) regarding follicle size, the presence of an oocyte, sociodemographic parameters, and other hormones and vitamins in follicular fluid.

MATERIALS AND METHODS

This prospective exploratory cohort study included 376 follicles from 61 women undergoing IVF/ICSI cycles. The size of each follicle was measured individually, and they were divided into a large and a small group according to their size. The presence of oocytes was detected on the day of oocyte retrieval. Sociodemographic factors were documented during the course of preliminary testing. Then, other parameters of patients' serum and follicular fluid were measured.

RESULTS

Small follicles contained a significantly higher concentration of fAMH than large ones did. We showed that the presence of an oocyte in a follicle is associated with a significantly higher fAMH level than in those without one (p < .001). There exists a significant but weak correlation between fAMH and the sociodemographic parameter of patients' age (r = -0.11, p < .001). We did not find a correlation with the patients' BMI (r = 0.03, p < .006). We also investigated the connections between fAMH and other parameters, such as vitamin D (r = -0.13, p < .001), LH (r = 0.35, p < .001)), and progesterone (r = -0.21, p < .001) in follicular fluid.

CONCLUSIONS

This knowledge can be useful for the future development of reproductive medicine. Our results can provide an important building block for this matter.

Cost-effectiveness of social oocyte freezing in Germany: estimates based on a Markov model

PURPOSE

Is oocyte freezing for non-medical reasons-the so-called "social freezing" (SF)-cost-effective compared to standard in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) in Germany today?

METHODS

We developed a model based on three strategies for women planning to postpone pregnancy. In each strategy, women actively practiced contraception until 40 then tried to conceive naturally for 1 year. If unsuccessful, women using strategy I (oocyte cryopreservation) attempted ICSI with frozen oocytes in the 2nd year, while women using strategy II (no action) further attempted natural conception. In strategy III (IVF/ICSI), women underwent 1 year of IVF/ICSI. If still unsuccessful, each strategy was followed by attempting natural conception again until 45. We used an adaptive Markov model to estimate and compare live birth rates and cost-effectiveness measures.

RESULTS

For strategy I, cumulative live birth rates at age 45 generally declined with the woman's age at freezing and were between 71.4% (25 years) and 67.6% (38 years), while the cumulative success rate was 51.5% for strategy II and 60.8% for strategy III. The costs per live birth of egg freezing were age-dependent ranging between 22,418 € (30 years) and 25,590 € (38 years). The costs for strategy III were lower at 20,293 € per live birth.

CONCLUSION

Based on our results, social freezing in Germany may lead to additional pregnancies among women over 40 but also to significantly higher costs, since given the current live birth success rates and pricing, social freezing does not appear to be cost-effective.

[Pregnancy after breast cancer in germany - results of a retrospective database analysis]

BACKGROUND

After the establishment of the FertiPROTEKT network in 2006, an impetus for possibilities of pregnancy during and after breast cancer was introduced. Nowadays, breast cancer survivors are confronted with the question how often women become pregnant after breast cancer and whether there have been significant changes in this respect during the past 10 years. The aim of the study was, therefore, to examine the change in frequency of pregnancies after breast cancer treatment and the time from the first breast cancer diagnosis to pregnancy over one decade, i. e., the period from 2010-2012 compared to the period from 2000-2002.

METHODS

The study is based on data from the IMS Disease Analyzer database, which enables access to anonymous data from registered physicians. Data from 102 gynecological practices were available for the present study. The study included women aged 20-45 with breast cancer.

RESULTS

A total of 179 pregnant women were included in this study from 2000-2002 and 2010-2012. 65 pregnancies were recorded in the period from 2000-2002, 114 pregnancies from 2010-2012. The time interval from the breast cancer diagnosis to pregnancy (analysed time period was 10 years) was 896 days (SD: 690) in the period from 2000-2002 and 552 days (SD: 696) in the period from 2010-2012 (p<0.001).

CONCLUSION

There was a significant increase in pregnancies within the first 2 years after the breast cancer diagnosis. These data are consistent with the intensified consultations after the introduction of the FertiPROTEKT network.

The prescribing of contraceptives for adolescents in German gynecologic practices in 2007 and 2011: a retrospective database analysis

OBJECTIVE

To investigate the prescribing trend of contraceptives in adolescent girls aged 12-18 years and to compare prescribing patterns of the most frequently used contraceptives among this population in Germany in 2007 and 2011.

METHODS

A retrospective cohort study was conducted to analyze contraceptive prescriptions written by gynecologists in 2007 and 2011 in Germany by using the IMS Disease Analyzer database (IMS HEALTH). All adolescent girls aged 12-18 years with at least 1 prescription of a contraceptive drug in 2007 or 2011 were identified. The prevalence of contraceptive prescriptions was calculated and the types of contraceptive substances prescribed were examined.

RESULTS

A total of 21,026 teenage girls in 2007 and 18,969 in 2011 received contraceptive prescriptions. The prevalence of contraceptive prescribing rose significantly between 2007 and 2011 (P < .001). The percentage of teen girls who received prescriptions of levonorgestrel and chlormadinone pills was significantly higher in 2011 compared to 2007 (P < .001). However, the portion of contraceptive pills containing drospirenone or desogestrel significantly decreased in 2011 compared to 2007 (P < .01).

CONCLUSION

There was a significant increase in contraceptive prescription usage among adolescent girls between 2007 and 2011 in Germany. However, the prescription behavior of doctors also changed; they consequently prescribed contraceptives with more evidence. Further research is needed to better understand the various factors associated with contraceptive use among this population.

Prevalence of female subfertility in German gynecological practices

INTRODUCTION

The aim of this study was to calculate the number of women with a subfertility diagnosis in gynecological practices in Germany between 2006 and 2010 based on the data from a large epidemiological database.

METHODS

All calculations are based on a representative, epidemiological database called "disease analyzer". Women with a confirmed diagnosis of female infertility (ICD 10: N97) or/and with documentation of procreative management (ICD 10: Z31) were identified. They were summarized under the term "subfertility".

RESULTS

In total, data on 1,975,253 female patients with between 2006 and 2010 were included. Estimates for patients with "subfertility" compared to number of women lived in Germany (aged 18-45) was 2.44% (CI: 2.43-2.45) in 2006, 2.52% (CI: 2.51-2.53) in 2007, 2.56% (CI: 2.55-2.57) in 2008, 2.68% (CI: 2.67-2.69) in 2009 and 2.69% (CI: 2.68-2.70) in 2010. The difference was significant (p < 0.01). In total, between 2006 and 2010 an estimated 8.91% of all German women had been diagnosed "subfertile".

CONCLUSION

When calculated for 5 years almost 1 out of 10 women aged 18 to 45 was counseled, investigated or treated by her gynecologist for "subfertility". This study provides reliable, representative data on a major healthcare issue in Germany.

Persistence with bisphosphonates in patients with metastatic breast cancer: a retrospective database analysis

BACKGROUND

In women with breast cancer and bone metastasis, compliance to antiresorptive treatment is of upmost importance to ensure maximum effectiveness in clinical practice. The aim of our study was to investigate persistence with oral and intravenous bisphosphonates (BIS) in a large group of women with metastatic breast cancer and to identify the determinants of non-persistence.

PATIENTS AND METHODS

We used data from the Disease Analyzer database (IMS Health, Germany), which includes 2,067 general practices and 397 gynaecological practices. From a dataset of 20 million patients, we identified 1,045 patients diagnosed between January 2001 and December 2010 with bone metastasis (ICD 10: C795) following breast cancer (ICD 10: C50) with first-time cancer-related bisphosphonate prescriptions (ATC: M03B4). Of these, 763 patients received intravenous treatment, and 280 patients received oral BIS treatment.

RESULTS

After 1 year, 35.3 % of patients treated with intravenous, and 45.6 % of patients treated with oral bisphosphonates discontinued their therapy (p = 0.002). Multivariate Cox Regression analyses showed a significant increased risk of treatment discontinuation in patients using intravenous BIS (HR: 0.82) compared with oral BIS. Patients younger than 50 (HR: 1.52) were most likely to discontinue treatment compared with the reference group of women over 70. The use of other treatments, such as chemotherapy or hormone therapy, was associated with a decreased risk of treatment discontinuation. Moreover, treatment discontinuation was higher in West Germany compared with East Germany (HR: 1.65) and in patients covered under private health insurance (HR: 1.33).

CONCLUSIONS

Persistence with all bisphosphonate treatments in women with breast cancer and bone metastasis is low and needs to be significantly increased to improved outcomes in clinical practice. Further research is required to understand this complex issue.

Persistence in patients with breast cancer treated with tamoxifen or aromatase inhibitors: a retrospective database analysis

Compliance and persistence are often underestimated in breast cancer (BC) treatment. The aim of our study was to analyze the persistence with tamoxifen (TAM) and aromatase inhibitors (AI) in postmenopausal women with hormone-receptor-positive BC and to identify determinants of non-persistence. We used data of the Disease Analyzer database (IMS HEALTH, Germany) including 2,067 general practices and 397 gynecological practices. Out of a dataset of 15 million patients, we identified BC patients with a first-time TAM or AI prescriptions from October 2001 to December 2010. For persistence analyses, 12,412 women on tamoxifen, 2,796 on anastrozole, 647 on exemestane, and 1,657 on letrozole met the inclusion/exclusion criteria. Within 3 years of follow-up, the discontinuation rates increased to 52.2 % for tamoxifen, 47 % for anastrozole, 55.1 % for exemestane, and 44.3 % for letrozole treated women. A minor proportion of patients switched to a different endocrine treatment; 33 % tamoxifen, 20 % anastrozole, 22.9 % exemestane, and 23 % letrozole. The multivariate hazard ratios of the cox regression models showed that patients younger than 50 were most likely to discontinue initial therapy when compared with the reference group of women over 70 (p < 0.001). In contrast, patients treated in gynecologist practice had significantly longer persistence than patients who obtained their prescriptions in general practitioner practice (p < 0.001). In addition, the presence of the co morbidities like diabetes (p < 0.001) or depression (p < 0.002) was also associated with decreased risk of treatment discontinuation. Persistence with all endocrine treatments in women with hormone-receptor-positive BC is low and needs to be significantly increased to improved outcome in clinical practice. Further research is required to understand this complex issue.

Quality of life and health status with zoledronic acid and generic alendronate--a secondary analysis of the Rapid Onset and Sustained Efficacy (ROSE) study in postmenopausal women with low bone mass

SUMMARY

The ROSE study compared annual infusion with zoledronic acid and weekly generic alendronate. No significant differences in quality of life or health status between treatment groups were observed. Adherence to alendronate during the study was high, with 80.9% of patients achieving adequate adherence.

INTRODUCTION

A secondary analysis to evaluate quality of life, health status, adherence to alendronate and therapy preference in postmenopausal women with low bone mass who received treatment with zoledronic acid or alendronate was conducted.

METHODS

Postmenopausal women with low bone mass were randomised 2:1 to receive an annual infusion of zoledronic acid or weekly oral generic alendronate in this open-label, multicentre study. Changes in quality of life and health status were assessed using questionnaires at baseline and month 12. Adherence to alendronate was assessed by the investigator and/or study personnel, and subjective therapy preference was assessed using a questionnaire at month 12.

RESULTS

Patients were randomised to zoledronic acid (n = 408) and alendronate (n = 191). Overall, there were no significant differences in quality of life between zoledronic acid and alendronate. However, improvements in quality of life with zoledronic acid versus alendronate could be detected by posthoc analysis in patients with previous fractures. There were no significant differences in health status between patients receiving zoledronic acid or alendronate. Adherence to alendronate during the study was high, with 80.9% of patients achieving adequate adherence. A total of 81% of patients who had received zoledronic acid indicated that they would prefer to continue with that treatment, and 43% of the patients who received oral alendronate would like to switch to zoledronic acid.

CONCLUSIONS

There were no significant differences in quality of life between patients receiving zoledronic acid or alendronate.

Rapid Onset and Sustained Efficacy (ROSE) study: results of a randomised, multicentre trial comparing the effect of zoledronic acid or alendronate on bone metabolism in postmenopausal women with low bone mass

SUMMARY

The ROSE study compared a once-yearly intravenous dose of zoledronic acid with a once-weekly oral dose of alendronate in postmenopausal women. Once-yearly zoledronic acid showed a greater and faster reduction in the levels of two markers of bone turnover and may be an effective option for the treatment of osteoporosis.

INTRODUCTION

The open-label Rapid Onset and Sustained Efficacy (ROSE) study was designed to compare a once-yearly intravenous (iv) dose of zoledronic acid with a once-weekly oral dose of alendronate with respect to markers of bone turnover in approximately 600 postmenopausal women in Germany.

METHODS

Levels of N-telopeptide of collagen type I (NTx) and procollagen 1 C terminal extension peptide (P1NP) were assessed during the study. The primary objective was to assess if zoledronic acid was superior to alendronate in reducing serum NTx levels after 12 months' treatment.

RESULTS

A significantly greater reduction in NTx levels from baseline to month 12 (as determined by the area under the curve) was observed in patients treated with zoledronic acid (n = 408) versus those receiving alendronate (n = 196; 0.282 ng/mL vs. 0.270 ng/mL; P = 0.012). The reduction in levels of P1NP after 1 year was also significantly greater in patients treated with zoledronic acid compared with those receiving alendronate (28.21 vs. 25.53 ng/mL; P = 0.0024). The overall incidence of adverse events was similar between groups; both treatments were generally well tolerated. Although post-dose symptoms, including the incidence of influenza-like symptoms, were higher with zoledronic acid than alendronate initially, the incidence was similar between groups from days 4-360. Gastrointestinal symptoms were more frequent with alendronate than zoledronic acid throughout the study.

CONCLUSION

In this study, once-yearly iv zoledronic acid provided a greater and faster reduction in the levels of NTx and P1NP versus once-weekly oral alendronate.

GRAND: the German retrospective cohort analysis on compliance and persistence and the associated risk of fractures in osteoporotic women treated with oral bisphosphonates

This database analysis of over 4,000 German women prescribed oral bisphosphonates between December 2004 and November 2007 showed that compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate.

INTRODUCTION

GRAND is a database analysis designed to investigate persistence and compliance with oral bisphosphonate regimens, and their association with fracture incidence, in women with osteoporosis.

METHODS

Diagnostic, treatment and fracture data were obtained from the IMS Disease Analyzer patient database in Germany. Women with osteoporosis prescribed one of six specified oral bisphosphonates between December 2004 and November 2007 with no similar prescription for at least 1 year beforehand were eligible for analysis. Those treated with intravenous bisphosphonates were excluded. Persistence (prescription refill gap of ≤ 30 days or change of treatment frequency) and compliance (medication possession ratio) were measured for 2 years from therapy start.

RESULTS

Data from 4,147 women were evaluable, with a median oral bisphosphonate treatment duration of 145.5 days. Persistence rates after 1 and 2 years were 27.9% and 12.9%, respectively, and 66.3% of women were compliant. As expected, persistence rates were higher when the refill gap was increased to 60 or 90 days. No significant differences in 1-year persistence between patients on weekly or monthly treatment regimens were observed (28.6% and 29.4%, respectively), although 1-year persistence with daily treatment was only 7.2%. After 24 months of therapy, compliant women had fewer fractures than non-compliant women (88.1% and 85.0% fracture-free, respectively; p = 0.0147). In multivariate Cox regression analysis, treatment compliance was the only factor that significantly decreased fracture risk (p = 0.0034).

CONCLUSIONS

Compliance and persistence with oral bisphosphonates in German women with osteoporosis were inadequate. Better compliance and persistence can prevent fractures in these women.

Adherence and persistence in patients with postmenopausal osteoporosis treated with raloxifene

OBJECTIVE

A major impediment in osteoporosis care is poor therapeutic adherence. Real-life surveys show that adherence and persistence with oral bisphosphonates decrease to 30-60% within 1 year. The aim of this study was to analyze the adherence and persistence with raloxifene in patients visiting our outpatient clinic.

MATERIAL AND METHODS

A total of 342 patients were evaluated from the conventional osteoporosis practice receiving treatment with raloxifene. Patient self-reporting was combined with the medication possession ratio (MPR) assessed via prescription refill counts. In addition, persistence and other self-reported and patient file-based data were assessed.

RESULTS

The final analysis comprised 300 patients with a mean age of 66.3 years (standard deviation ± 7.2 years). At 6 months 84%, at 12 months 81%, at 24 months 78% and at 36 months 77% of patients were persistent with therapy according to patients' self-reports. If MPR and self-reported data were combined, 56%, 48% and 35% of patients remained on therapy at 12, 24 and 36 months, respectively. The mean duration of therapy was 19 months with a mean MPR of 52.8%. Finally, 31.7% of all patients were classified as adherent. Significant correlation to adherence was found for tolerability and motivational factors.

CONCLUSION

This study revealed that approximately half of the patients treated with raloxifene in regular clinical practice stay on therapy for the first 2 years. Furthermore, the patients do not adhere sufficiently to the recommended dosage, and reduced clinical efficacy in clinical practice is presumable. The reasons for non-adherence comprise tolerability and motivational factors but further investigation is needed.

Adherence and persistence in patients with severe osteoporosis treated with teriparatide

INTRODUCTION

Medical intervention plays a key role in the treatment of postmenopausal osteoporosis and patients' adherence to therapy is essential for optimal clinical outcomes. While adherence in RCTs is usually around 70-90%, a previous study showed that in clinical practice only 27.8% and 46.5% of the women on oral daily vs. weekly alendronate were still on treatment after 12 months. Data on adherence to teriparatide (TPTD) treatment of severe postmenopausal osteoporosis are available from only few countries. This study assessed adherence and persistence with TPTD in Germany.

MATERIAL AND METHODS

A sample of 50 women with severe postmenopausal osteoporosis treated with TPTD in accordance to the German osteoporosis guidelines was included. Treatment was initiated 12-24 months before recruitment. Patient self report was assessed using a validated questionnaire. In addition medication possession ratio (MPR) was calculated by counting prescription refills, and therefore all physicians who were treating the patients for any disease were contacted. Patients were classified adherent at 12 months of therapy if self-reported adherence and an MPR of > or =80% were achieved. Persistence was calculated in months and analysed with a Kaplan-Meier estimate.

RESULTS

Apart from a significantly lower age at menopause in the adherent group (46.1 vs. 50.0; p < 0.006) there were no significant differences in baseline demographics between adherent and non-adherent patients. After 12 months, 80% of the patients treated with TPTD were adherent, while 20% were non-adherent. A significant correlation with treatment adherence was found for self-reported medication tolerability (p < 0.001). Furthermore 79% of patients were persistent after 12 months.

CONCLUSION

These results indicate that more patients seem to be adherent and persistent with TPTD than with oral treatments of postmenopausal osteoporosis. As these patients suffered from severe osteoporosis and sustained several fragility fractures, the generalisability of our retrospective study analysing a small sample is limited. The major factor that reduced adherence and persistence was tolerability. These findings are of practical relevance as numerous studies on antiresorptive therapies have shown that high adherence and persistence were needed to ensure an optimal therapeutic outcome.

Quantitative ultrasonometry of the phalanges during pregnancy: a longitudinal study

OBJECTIVE

The aim of this study was to determine prospectively the change in results of bone ultrasonometry measurement during pregnancy in healthy German women. Study design Quantitative ultrasonometry (QUS) of the phalanges was performed in 60 healthy, pregnant women. Measurements of amplitude-dependent bone propagation velocity (speed of sound; AdSOS) and the bone transmission time (BTT) were performed during the three trimesters of pregnancy in 60 patients.

RESULTS

During pregnancy, a significant increase in body weight and body mass index (p < or = 0.001) were observed. In accordance with bone ultrasonometry, a significant reduction in AdSOS was found in each trimester; AdSOS was significantly lower in the second and third trimesters compared with the first (p < or = 0.001). The BTT values also decreased significantly in the second and third trimesters compared with the first (p < or = 0.001). No significant influence was found of possible risk factors such as family risk of osteoporosis, previous pregnancies, age at menarche and prior use of oral contraceptives on QUS measurement results.

CONCLUSIONS

During normal pregnancy, we found a significant reduction of quantitative ultrasonometry variables AdSOS and BTT in healthy pregnant women. This decrease had a large influence on the t score and Z score of QUS in our study and demonstrates therefore a possible clinical relevance. The decrease was independent of osteoporosis-related risk factors and the increase in body weight. More large-scale, prospective studies are needed to increase our knowledge about the mechanism of bone turnover during pregnancy and lactation.

Fracture risk in women with breast cancer: can baseline assessment of risk be used to guide treatment?

Abstract #6130

Background: Breast cancer (BC) therapies have been associated with decreases in bone health. Recent studies have shown that BC survivors have a 31% increased fracture risk compared with their peers, elevating the importance of monitoring bone health in women diagnosed with BC. Bone mineral density (BMD) has been the standard used by clinical guidelines (WHO, ASCO) to direct therapeutic decisions. However, emerging guidelines place BMD in the context of several other clinical risk factors that have been correlated with overall fracture risk. This retrospective, case-controlled study uses current and emerging guidelines to estimate the percentage of patients with newly diagnosed breast cancer who may be at increased risk for fracture and who require preventive therapy. Methods: Baseline data from 88 pre- and 402 postmenopausal women (PMW) with BC were compared with data from an equal number of healthy age- and body mass index-matched women. BMD was assessed by 2 methods; dual-energy x-ray absorptiometry (DXA) at the lumbar spine (LS) and total hip, and quantitative ultrasonometry (QUS) at the os calcaneus and phalanges. Baseline BMD measurements were collected at a mean duration of 15 and 242 days after diagnosis of cancer in pre- and PMW, respectively. Results: Baseline LS and total hip BMD was similar between the healthy control groups and patients with BC. Among estrogen receptor-positive (ER+) BC patients, 18.8% of premenopausal women and 36.9% of PMW were osteopenic, and 8.9% of PMW were osteoporotic (according to LS BMD). Among ER+ PMW with BC, 15.9% of patients &gt; 65 years of age, 8.3% of patients 55 to 65 years of age, and 1.4% of patients &lt; 55 years of age had osteoporosis. Only 9% of ER+ PMW with BC would have received bone-protective therapy using the BMD limits (T-score ≤ –2.5) set by ASCO treatment guidelines. Based solely on clinical risk factors (eg, if DXA were not available), 6.5% of patients would have been identified for bone-protective therapy. When clinical risk factors and BMD were both used in the fracture-risk assessment, 28.6% of women would have been eligible for bone-protective therapy. Overall, therapy based on ASCO guidelines was estimated to prevent 18% of fractures, whereas combining risk factors and BMD would prevent more than 45% of fractures. Conclusions: Current treatment thresholds seem to inadequately identify patients who would benefit from bone-protective therapy. The results presented here support the use of overall fracture risk assessment in PMW with breast cancer. Using both BMD and clinical risk factors may more effectively identify patients at risk for fracture, although further studies are needed.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6130.

Adherence to adjuvant endocrine therapy in postmenopausal women with breast cancer

BACKGROUND

The level of adherence of various pharmacological therapies in chronic diseases varies, but is predominantly low. With tamoxifen (TAM), 23% and 50% nonadherence after 1 and 4 years have been reported. Day-to-day clinical observation suggests that adherence may even be lower with aromatase inhibitors, but limited data exist on the situation in daily clinical routine. The aim of this study was to evaluate the rate of adherent patients in a randomly selected sample of postmenopausal women with primary breast cancer, who had been assigned to an adjuvant endocrine treatment with TAM or anastrozole (ANA).

MATERIALS AND METHODS

We investigated a random sample of 100 postmenopausal women with breast cancer (50 TAM and 50 ANA) who had received surgery for their primary breast cancer at our hospital in 2004/2005 and thereafter had been assigned to an adjuvant endocrine treatment. We evaluated the adherence rate with a detailed questionnaire and additionally carried out a retrospective prescription check of the hospital chart as well as calling the local physicians of our patients. A patient was counted as adherent with a self-reported tablet intake of 80% or more and if a medication possession ratio of 80% or more was achieved.

RESULTS

Regarding the baseline characteristics, a significant difference in mean age was noticed in women on ANA versus TAM [65 (+/-3) and 72 (+/-3); P<0.001]. All women on TAM and ANA reported to be adherent (100%). After controlling for prescriptions, only 40 (80%) and 27 (69%) of the women on TAM and ANA were still classified as adherent (P<0.01 and P<0.01 versus self-report). We found no significant correlation of adherence to any baseline characteristics or side-effects in a logistic regression model.

CONCLUSIONS

An important goal of any therapeutic intervention is to achieve comparable efficacy in routine clinical practice to that demonstrated in randomised clinical trials. However, a similar magnitude of adherence will be necessary in routine clinical practice to assure comparable clinical effects. Our results further support the data on suboptimal adherence of women with breast cancer on adjuvant TAM treatment. Here, we evaluated for the first time the patient reported and real-world adherence on adjuvant ANA and were able to show a similarly low adherence compared with TAM. More prospective studies are needed to increase our understanding of the underlying reasons for nonadherence in women with breast cancer.

Bone mass and the risk of breast cancer: The influence of cumulative exposure to oestrogen and reproductive correlates. Results of the Marburg breast cancer and osteoporosis trial (MABOT)

BACKGROUND

Recent studies suggest an inverse relation between breast cancer and osteoporosis. Oestrogen is important in the pathophysiology of both breast and bone, and although cumulative exposure to oestrogen may explain the link between breast cancer and bone mass, this has never been proved. The Marburg breast cancer and osteoporosis trial (MABOT) aimed to elucidate the relation between breast cancer and bone mass ascertained by ultrasonometry measurement and to investigate whether endogenous and exogenous exposure to oestrogen and reproductive correlates has a role in this association.

METHODS

We performed a case-control study including 2492 women (mean age+/-S.D., 54.4+/-10.3 years) in whom diseases and drug treatments known to affect bone metabolism, except for HT, had been excluded. All women underwent ultrasonometry measurement at the heel; 242 of the women had an incident breast cancer without a prior, specific pharmacological breast cancer treatment. The ultrasonometry variables - speed of sound (SOS), broadband ultrasound attenuation (BUA) and the stiffness index (SI) - were calculated and compared in women with and without breast cancer. Because of significant intergroup differences in factors such as age, body mass index and exposure to oestrogen, a multiple linear regression analysis as well as a second analysis of ultrasonometry variables was undertaken using a randomly selected sample of 242 healthy women post-matched with the breast cancer group for possible confounding variables. Odds ratios were used to compare the relation between breast cancer risk and ultrasonometry heel measurements.

RESULTS

Women with breast cancer were significantly older, weighed more, had a higher body mass index, were more likely to be parous and to have breast fed, were older at the menopause and had been exposed to oestrogen for longer than control women. In addition, the ultrasonometry variables speed of sound and the stiffness index T- and Z-score were significantly higher in women with breast cancer even after a matched pair analysis was performed (p<0.001). Additionally, results of a multiple linear regression showed that women with breast cancer had a significantly higher SOS (p<0.001), body weight (p<0.05) and duration of breast feeding (p<0.05) while osteoporotic fracture were reduced (p<0.001). When women with breast cancer and their matched controls were finally grouped according to SOS and T-score quartiles, the odds ratios (95% confidence intervals) for breast cancer risk in the second, third and fourth quartiles compared with the lowest quartile were 2.5 (1.4-4.3), 3.1 (1.8-5.3) and 4.7 (2.7-8.2) as well as 1.9 (1.1-3.2), 2.3 (1.3-3.9) and 2.9 (1.7-5.0), respectively.

CONCLUSIONS

The ultrasonometry variables speed of sound, stiffness index, T- and Z-score are higher in women with an incident breast cancer than in healthy controls, even after post-matching for possible confounding variables. This association was confirmed in a multiple linear regression model. Women with SOS and T-score values in the higher quartiles have a greater risk of breast cancer than women in the lowest quartile. We found no association between the higher ultrasonometry variables and cancer specific characteristics or reproductive correlates such as age at menarche and menopause or cumulative oestrogen exposure. Although the biological mechanisms linking bone mass and the risk of breast cancer are not fully understood, factors other than reproductive correlates, endogenous and exogenous exposure to oestrogen must play a part.

The Use of i. v. Bisphosphonate in Pregnancy-Associated Osteoporosis - Case Study

OBJECTIVE

Diagnosis of pregnancy-associated osteoporosis is often delayed and therapeutic interventions insufficient.

STUDY DESIGN

A 28-year-old patient (BMI=18.6) with no additional risks for osteoporosis experienced acute lumbosacral pain two months postpartum, while lactating. After conservative therapy, thoracic and lumbar spine were X-rayed: severe pregnancy-associated osteoporosis with vertebral fractures was diagnosed. 2-year treatment with i. v. bisphosphonate ibandronate was initiated (2 mg every 3 months) and calcium and vitamin D supplementation.

RESULTS

Rapid improvement was observed. Conclusion: In cases with multiple fractures i. v. bisphosphonate leads to substantial decrease of symptoms and further fractures and significant increase of bone mass density (BMD).

CONCLUSION

In severe cases of pregnancy-associated osteoporosis with multiple fractures i. v. biphosphonate therapy leads to a decrease of symptoms and fracture risk and an increase of bone mass density (BMD).

Biochemical Markers of Bone Turnover during Pregnancy: A Longitudinal Study

OBJECTIVE

The objective of this study was to prospectively investigate the effect of pregnancy on biochemical markers of bone turnover in healthy pregnant women.

METHODS

During the course of our longitudinal study, biochemical markers of bone remodeling were measured in all three trimester of pregnancy (first trimester: 12.5+/-1.8 SD, second trimester: 21.6+/-1 SD, third trimester: 34.8+/-1.6 SD weeks of gestation). Serum type I collagen C-telopeptides (CTX) and a crosslinked peptide of the carboxy-terminal telopeptide of type I collagen (ICTP) were used as markers of bone resorption. Bone alkaline phosphatase (BAP) and the N-terminal propeptides of type I collagen (PINP) were used as biochemical markers of bone formation. Blood samples for the analysis of all 4 biochemical markers according to each trimester of pregnancy were available in 49 patients.

RESULTS

The main changes for all biochemical markers were seen between the second and the third trimester. According to the markers of bone resorption, both serum CTX and ICTP showed a significant increase from the first to the third and from the second to the third trimester (p<0.001; median percentage change: CTX=101.5% and ICTP=40%). Concerning markers of bone formation, PINP showed a significant decrease from the first to the second trimester (p=0.001) followed by a significant increase from the second to the third trimester (p<0.001, 63.8%) and an overall increase from the first to the third trimester (p<0.001). BAP also showed a significant increase from the second to the third trimester (p<0.001; 51.7%) and an overall increase from the first to the third trimester (p<0.001).

CONCLUSION

Markers of bone resorption were significantly increased during pregnancy. In contrast to bone resorption, markers of bone formation showed an increase as well as a decrease during pregnancy indicating a state of high bone turnover. This might coincide with the change in bone mineral density that was observed in some, but not all, studies using "dual-energy x-ray absorptiometry" (DXA) as well as "quantitative ultrasonometry" (QUS).

Evaluierung der quantitativen Ultrasonometrie des Knochens bei Einlings- und Mehrlingsschwangerschaften

OBJECTIVE

During pregnancy about 30 grams of calcium are transferred to a full-term neonate. The enormous demand for calcium can be regulated by compensatory mechanisms in the maternal metabolism such as elevated steroid hormone levels, increased intestinal absorption of dietary calcium, and renal conservation, but also by mobilization of calcium from the maternal skeleton. Therefore we have investigated whether a decrease in maternal bone mineral density (BMD) can be observed during pregnancy and whether it differs between singleton and twin pregnancies.

METHODS

Quantitative ultrasonometry (QUS) was performed at the distal metaphysis of the phalanges (digits II - V). 54 singleton pregnancies and 6 twin pregnancies were longitudinally followed throughout pregnancy. In each trimester the amplitude-dependent speed of sound (AD-SOS) and the bone transmission time (BTT) were measured.

RESULTS

In 54 singleton pregnancies significant decreases in AD-SOS of 1.9 % (p </= 0.001) and in BTT of 7.2 % (p < or = 0.001) were observed. In the corresponding twin pregnancies no significant decreases in AD-SOS (1.6 %) or BTT (6.6 %) could be detected.

CONCLUSIONS

The results show that the compensatory mechanisms in maternal metabolism are not able to cover the fetal calcium demand and lead to a decrease in QUS parameters. In our pilot study due to the small number of twin pregnancies the decrease in QUS parameters did not reach statistical significance although the results seemed comparable to those of singleton pregnancies.

Knochendichte bei postmenopausalen Frauen mit proximaler Femurfraktur

INTRODUCTION

Osteoporosis associated proximal femoral fracture is a major public health problem. Diagnostic assessment includes patients history, laboratory testings and bone mineral density measurements. Hereby, dual X-ray absorptiometry (DXA) is regarded as the "Goldstandard". Quantitative ultrasonometry (QUS) of bone is a safe, simple, free of radiation, portable, cost-effective and therefore powerful diagnostic tool. QUS should be taken in account for primary assessment in patients with supposed osteoporosis in clinical practice.

AIM OF THE STUDY

We performed this cross sectional pilot study to evaluate the ability of two different QUS-devices (os calcis) in comparison to DXA (lumbar spine and femoral neck) to discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls.

PATIENTS AND METHODS

All together, 44 postmenopausal women were included. Of these, 22 suffered a proximal femoral fracture and were compared with 22 healthy, age- and BMI-matched controls. Bone assessments were performed by DXA (femoral neck and lumbar spine) and QUS of the heel using Achilles and Insight.

RESULTS

T- and Z-Score of DXA (femoral neck) were significantly lower in women with hip fracture compared to controls (p < 0.008 and p < 0.01). QUS-Insight also revealed significantly lower values of T- and Z-Score in women with hip fracture compared to controls (p < 0.01 and p < 0.005). QUS-Achilles measurement results also comprised significant differences between the groups (T-Score und Z-Score: p < 0.02). In accordance to the T-Score (femoral neck), all three devices (DXA femoral neck, Achilles and Insight) showed an equal significant correlation (p < 0.001). The correlation in between both QUS-devices was higher (0.956; p < 0.0001) than in between DXA-results (femoral neck vs. lumbar spine, 0.577; p < 0.01). The Z-Score also showed a significant correlation. DXA (lumbar spine) didn't show any significant differences in T- and Z-Score.

CONCLUSION

In comparison to the gold standard DXA (femoral neck), both QUS-devices showed an equal ability to significantly discriminate postmenopausal women with proximal femoral fractures from healthy, age- and BMI-matched controls. If our results are confirmed by more cross-sectional and longitudinal studies, QUS could be a helpful and valuable technique in clinical practice. Finally, all patients with osteoporosis-related fractures should be thoroughly investigated during their hospitalisation and effective treatment must be instituted.

Influence of pregnancy and breast-feeding on quantitative ultrasonometry of bone in postmenopausal women

OBJECTIVE

Reproductive factors such as parity and breast-feeding may be associated with low bone mass and osteoporotic fractures in later years. In this study, os calcis quantitative ultrasonometry was used to elucidate the relationship between parity, lactation and bone mass in postmenopausal women.

DESIGN

This was a comparison study using subsequent matched pairs analysis as well as multiple linear regression analysis. The study was carried out at five centers in Germany. The study included 2,080 postmenopausal women (age (mean +/- SD) 58.8 +/- 8.2 years), who were attending for routine check-up and in whom diseases and drug treatments known to affect bone metabolism had been excluded.

METHODS AND OUTCOME MEASURES

Women underwent quantitative ultrasonometry (QUS) measurement at the heel. Values of the ultrasonometry variables -speed of sound, broadband ultrasound attenuation and stiffness index -were calculated and compared for nulliparous and parous women and for women who had and had not breast-fed. Because of some significant intergroup differences, and to determine any effect of the number of live births and the duration of breast-feeding on ultrasonometry results, second analyses were undertaken using equally sized samples, matched for possible confounding variables such as age and body mass index (matched pairs). In these analyses, nulliparous women were compared with parous women, grouped according to number of live births, and women who had never breast-fed were compared with women who had breast-fed, grouped according to duration of breast-feeding. Furthermore, a multiple linear regression analysis was performed to examine the combined effects of reproductive factors on QUS variables.

RESULTS

No statistically significant associations were found between ultrasonometry variables and parity or breast-feeding, even after controlling for confounding variables in matched-pairs analysis or in a multiple linear regression analysis.