Bone mass and breast cancer risk in older women: differences by stage at diagnosis

The Sequential Therapy in Osteoporosis

Background

Osteoporosis management often involves a sequential treatment approach to optimize patient outcomes and minimize fracture risks. This strategy is tailored to individual patient characteristics, treatment responses, and fracture risk profiles.

Methods

A thorough literature review was systematically executed using prominent databases, including PubMed and EMBASE. The primary aim was to identify original articles and clinical trials evaluating the effectiveness of sequential therapy with anti-osteoporosis drugs, focusing on the period from 1995 to 2023. The analysis encompassed an in-depth examination of osteoporosis drugs, delineating their mechanisms of action, side effects, and current trends as elucidated in the literature.

Results and Discussion

Our study yielded noteworthy insights into the optimal sequencing of pharmacologic agents for the long-term treatment of patients necessitating multiple drugs. Notably, the achievement of optimal improvements in bone mass is observed when commencing treatment with an anabolic medication, followed by the subsequent utilization of an antiresorptive drug. This stands in contrast to initiating therapy with a bisphosphonate, which may potentially diminish outcomes in the post-anabolic intervention period. Furthermore, it has been discerned that caution should be exercised against transitioning from denosumab to PTH homologs due to the adverse effects of heightened bone turnover and sustained weakening of bone structure. Despite the absence of fracture data substantiating the implementation of integrated anabolic/antiresorptive pharmacotherapy, the incorporation of denosumab and teriparatide presents a potential avenue worthy of consideration for individuals at a heightened vulnerability to fragility fractures.

Conclusions

A judiciously implemented sequential treatment strategy in osteoporosis offers a flexible and tailored approach to address diverse clinical scenarios, optimizing fracture prevention and patient outcomes.

Stomatin-like protein-2 contributes the migration and invasion of breast cancer cells via regulating ERK/FOXO3a signaling pathway

Breast cancer (BC) is the most common tumor in women, and its incidence is increasing, ranking first among female malignant tumors. It is urgently needed to find new and reliable biomarkers of BC and to understand the cellular changes that cause metastasis. Stomatin-like protein-2 (SLP-2) is a member of the stomatin protein superfamily. Studies have shown that SLP-2 was highly expressed in some tumors and played an important role in tumor genesis and development. SLP-2 regulated the extracellular signal-regulated kinase (ERK) pathway, and activation of ERK phosphorylated FOXO3a, which was involved in BC progression. However, its possible role in the progression of BC remains unclear. In this study, we found the high expression of SLP-2 in BC tissues and cells. SLP-2 promoted the viability of BC cells. In addition, we found that SLP-2 stimulated the motility of BC cells in vitro. Mechanically, our results revealed that SLP-2 could mediate FOXO3a expression and ERK signaling pathway, thereby contributing to the viability and motility of BC cells. Therefore, SLP-2 has the potential to serve as a promising target for BC treatment.

Bone mineral density in women newly diagnosed with breast cancer: a prospective cohort study

Estrogen may have opposing effects on health, namely increasing the risk of breast cancer and improving bone health by increasing bone mineral density (BMD). The objective of this study was to compare dual-energy X-ray absorptiometry (DXA) BMD between women newly diagnosed with breast cancer and matched controls without breast cancer. Women newly diagnosed with breast cancer treated between April 2012 and October 2017 were prospectively enrolled. A control group was established of women with negative mammography or breast ultrasound, matched 1:1 by age, body mass index, parity, and the use of hormone replacement therapy. All those included had DXA BMD, and lab assessments at enrollment. Of 869 women with newly diagnosed breast cancer, 464 signed informed consent. Of the 344 who completed the study protocol, 284 were matched to controls. Overall, the mean age was 58 years. Compared to the control group, for the breast cancer group, the mean vitamin D level was lower (48.9 ± 19.0 vs. 53.8 ± 28.8 nmol/L, p = 0.022); and mean values were higher of total hip BMD (0.95 ± 0.14 vs. 0.92 ± 0.12 g/cm², p = 0.002), T score (−0.38 ± 1.17 vs. −0.68 ± 0.98, p = 0.002), and Z score (0.32 ± 1.09 vs. 0.01 ± 0.88, p < 0.001). Among the women with breast cancer, no correlations were found of baseline BMD with tumor size or grade, nodal involvement, or breast cancer stage. We concluded that women with newly diagnosed breast cancer tend to have higher BMD than women with similar characteristics but without breast cancer. This implies that BMD might be considered a biomarker for breast cancer risk.

Breast cancer therapy and bone

Breast cancer is the most common cancer in women and the leading cause of cancer-associated mortality. The estrogen deprivation associated with therapies used to treat this disease may result in significant loss of bone density and a consequent increase in fracture risk. Anti-resorptive osteoporosis therapies (bisphosphonates and the inhibitor of receptor activator of nuclear factor-κB ligand [RANKL] denosumab) play an important role in the mitigation of cancer therapy-induced bone loss (CTIBL), and may function as adjuvant therapy in moderate to high-risk breast cancer to prevent disease recurrence. Various international guidelines have delineated treatment thresholds based on both bone density assessment and clinical risk factors for CTIBL. The role of these bone-targeted therapies as adjuvant anti-cancer treatment is evolving. Currently, evidence supports the use of the bisphosphonates, zoledronic acid and clodronate, in this setting. Unfortunately, a focus on bone health in women with breast cancer is often not prioritized, leaving this group vulnerable to significant bone loss and subsequent fracture.

Breast cancer outcome in relation to bone mineral density and bisphosphonate use: a sub-study of the DATA trial

Purpose

The phase III DATA study compared 6 and 3 years of adjuvant anastrozole following 2–3 years of tamoxifen in postmenopausal breast cancer patients. This pre-planned side-study assessed the relationship between a reduced bone mineral density (BMD) and distant recurrence-free survival (DRFS), and evaluated the effect of bisphosphonates on DRFS.

Methods

We selected all patients with a BMD measurement within 3 years after randomisation (landmark) without any DRFS events. Kaplan–Meier methods and Cox proportional hazards models were used for analyses.

Results

Of 1860 eligible patients, 1142 had a DEXA scan before the landmark. The BMD was normal in 436 (38.2%) and showed osteopenia in 565 (49.5%) and osteoporosis in 141 (12.3%) patients. After a median follow-up of 5.0 years from the landmark, neither osteopenia nor osteoporosis (compared with normal BMD) were associated with DRFS in both the 6-year [osteopenia HR 0.82 (95% CI 0.45–1.49), osteoporosis HR 1.10 (95% CI 0.26–4.67)] and the 3-year arm [osteopenia HR 0.75 (95% CI 0.40–1.42), osteoporosis HR 1.86 (95% CI 0.43–8.01)]. Moreover, bisphosphonate use did not impact DRFS.

Conclusion

No association was observed between a reduced BMD and DRFS. Neither did we observe an impact of bisphosphonates on DRFS.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05567-9) contains supplementary material, which is available to authorized users.

French recommendations on strategies for preventing and treating osteoporosis induced by adjuvant breast cancer therapies

Standard adjuvant therapies for breast cancer such as chemotherapy or aromatase inhibitor and LH-RH agonist hormone therapy are associated with significant survival gains but also induce bone loss by aggravating the estrogen deprivation. The bone loss may be substantial, notably during early treatment, and occurs regardless of the baseline bone mineral density values. The objective of developing these recommendations was to achieve a practical consensus among various scientific societies, based on literature review, about osteoporosis prevention and treatment in these patients. The following scientific societies contributed to the work: Société Française de Rhumatologie (SFR), Groupe de Recherche et d'Information sur les Ostéoporoses (GRIO), Groupe Européen d'Etudes des Métastases Osseuses (GEMO), Association Francophone pour les Soins Oncologiques de Support (AFSOS), Société Française de Sénologie et de Pathologie Mammaire (SFSPM), Société Française de Radiothérapie Oncologique (SFRO). Drug prescription and reimbursement modalities in France were taken into account. These recommendations apply to postmenopausal women taking systemic chemotherapy and/or aromatase inhibitor therapy, non-postmenopausal women taking LH-RH agonist therapy, and non-postmenopausal women with persistent amenorrhea 1 year after chemotherapy completion. All women in these three categories should undergo an evaluation of bone health and receive interventions to combat risk factors for bone loss. Patients with a history of severe osteoporotic fracture and/or a T-score value <-2.5 should receive osteoporosis drug therapy. The FRAX® score should be used to guide treatment decisions in patients whose T-score is between -1 and -2.5. General osteoporosis prevention measures should be applied in patients without criteria for osteoporosis drug therapy, who should undergo bone mineral density measurements 18-24 months later if the baseline T-score is<-1 and 3-5 years later if the baseline T-score is>-1. The anti-tumor effect of bisphosphonates and denosumab was not considered when establishing these recommendations.

Bone Mineral Density and Breast Cancer Incidence and Mortality in Postmenopausal Women: A Long-Term Follow-Up Study

Purpose: To examine whether bone mineral density (BMD) is predictive of breast cancer risk and mortality in a population of early postmenopausal women participating in a medical prevention program in western Austria. Patients and Methods: Between May 1991 and February 1999, lumbar spine BMD was measured by dual-energy X-ray absorptiometry (N = 1163, mean age 56.9 ± 5.7 years) or quantitative computed tomography (N = 2283, mean age 56.8 ± 5.4 years) in 3446 women aged ≥50 years. Data on medication and lifestyle factors were collected by questionnaire. Participants were prospectively followed up for breast cancer incidence, and breast cancer patients were followed up for mortality. To calculate risk of breast cancer and mortality, Cox proportional hazards models were applied. Results: During median follow-up of 20.7 years, 185 invasive breast cancer cases and 22 deaths due to breast cancer occurred. Risk of breast cancer in the highest versus the lowest BMD quartile was nonsignificantly reduced, in particular when follow-up was restricted to 10 years (hazard ratio 0.53, 95% confidence interval 0.25-1.12). There was no risk reduction when follow-up began 10 years after BMD measurement. There was no association between BMD and all-cause or breast cancer-specific mortality among breast cancer patients, but a trend toward reduced mortality risk in the highest BMD quartile. Conclusions: We hypothesize that BMD is not reflective of estrogen exposure and not predictive of breast cancer risk, at least in young postmenopausal women. Confounders such as vitamin D might underlie low breast cancer risk at high BMD, thus mirroring better health status.

Bone mineral density and breast cancer risk: Results from the Vorarlberg Health Monitoring & Prevention Program and meta-analysis

We investigated the association between bone mineral density (BMD) and breast cancer risk in a large prospective cohort and quantified the evidence in a meta-analysis of prospective studies.

Baseline BMD has been measured by dual energy X-ray absorptiometry (DXA, N = 1418). Data on medication and lifestyle has been collected by questionnaire. Cox proportional Hazards models were applied to calculate Hazard Ratios for breast cancer. In addition, a meta-analysis on categorical and dose-response values including the current results has been performed applying random-effects models.

During mean follow-up of 16.3 (SD 3.3) years of 1380 women (mean age 55.5 ± 6.3 years), 52 cases of invasive breast cancer were identified. We found no statistically significant association of BMD with breast cancer risk (per one z-score increase, HR 0.91, 95% CI 0.67–1.23).

In the meta-analysis, however, breast cancer risk increased by 15% and 16% per 0.1 g/m² increase in BMD at the lumbar spine (95% CI 0.99–1.33) and at the femoral neck (95% CI 1.02–1.32), respectively. Compared to the lowest, the HRs for breast cancer were statistically significant for the highest BMD category, i.e. 1.49 (95% CI 1.04–2.13) at the lumbar spine and 1.66 (95% CI 1.26–2.18) at the femur.

We found no association between BMD (DXA) and breast cancer risk in our cohort. However, overall the present meta-analysis extends and confirms the statistically significant association between increasing BMD and increased breast cancer risk.

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In the VHM&PP BMD (DXA) was not associated with breast cancer risk.

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A meta-analysis showed a positive association between BMD and breast cancer risk in postmenopausal women.

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Per 0.1 g/m² increase in BMD breast cancer risk increased by 15% at the lumbar spine and 16% at the femoral neck.

Screening for osteoporosis after breast cancer: for whom, why and when

Osteoporosis and breast cancer are common diseases in postmenopausal women. Bone and the breast are both estrogenic dependent tissues and different surrogate markers for osteoporosis are opposite of those for the risk of breast cancer. In particular, numerous studies have reported a positive relationship between high bone mineral density (BMD) and a greater risk of breast cancer. On the other hand, most treatments in early breast cancer women including ovarian suppression treatments (chemotherapy, surgery or GnRH agonists) and aromatase inhibitor (AI) therapy induce a profound and rapid suppression of estrogen levels thereby increasing the rate of bone loss. Nevertheless, their impact on the risk of fracture is still questionable, especially in postmenopausal women with no osteoporosis at baseline. The purpose of this minireview is to examine the relationship between breast cancer and the risk of fracture and to discuss a screening strategy for osteoporosis after breast cancer.

Adjuvant bisphosphonates in breast cancer: has the time come?

SUMMARY Bone metabolism is highly affected by changes in ovarian function, which is a common consequence of the treatment of breast cancer patients. Osteopenia and osteoporosis increase the risk of fractures, which are associated with profound loss in quality of life. Bisphosphonates are used with the objective of preventing bone loss in patients with osteoporosis, but data suggest that agents such as zoledronic acid might play a role in the prevention of metastatic disease and therefore have been evaluated in numerous randomized trials in the adjuvant setting. This review article will discuss and analyze the available data regarding the use of bisphosphonates in the adjuvant setting for breast cancer patients. It will focus on the use of bisphosphonates as anticancer agents, but will also discuss the use of these agents for the prevention of bone loss.

Association between Tumor Characteristics and Bone Mineral Density in Postmenopausal Breast Cancer Patients

The aim of this study was to evaluate the association of bone mineral density (BMD) at the time of diagnosis with clinical-pathologic findings in patients with operable postmenopausal breast cancer. One hundred and fifty-eight postmenopausal women who had a baseline lumbar and hip BMD measurement were included in the analysis. Patients were divided into two groups based on the median BMD. p ≤ 0.002 was considered to be statistically significant. Hormone replacement therapy (HRT) use longer than 5 years was associated with increased lumbar BMD compared with patients who used HRT less than 5 years (p = 0.002). Patients with higher BMD tended to have low grade disease, no lympho-vascular invasion, progesterone receptor-positive tumors, and low Ki-67 levels (p < 0.05). Higher baseline BMD in postmenopausal patients with breast cancer is associated with favorable prognostic features.

Exposure to oral bisphosphonates and risk of cancer

Recently, oral bisphosphonate use has increased markedly in the United States and elsewhere. Little is known about cancer risks associated with these drugs. A few studies have observed associations between bisphosphonates and the risk of breast, colorectal and esophageal cancer. However, the risk of all cancer and the risk of other cancers have not been investigated. In our study, we examined the risk of all cancer and site specific cancers in individuals taking bisphosphonates. Data were extracted from the UK General Practice Research Database to compare site-specific cancer incidence in a cohort of oral bisphosphonate users and a control cohort. Hazard ratios (HRs) were calculated using Cox regression modeling. The bisphosphonate and control cohort contained 41,826 participants (mean age 70, 81% female). Overall, the bisphosphonate cohort compared with the control cohort had a reduced risk of all cancer after any bisphosphonate usage [HR=0.87, 95% confidence interval (CI) 0.82, 0.92]. In the bisphosphonate cohort, compared with the control cohort, there was no evidence of a difference in the risk of lung (HR=1.03, 95% CI 0.88, 1.20) or prostate cancer (HR=0.86, 95% CI 0.67, 1.09) but breast (HR=0.71, 95% CI 0.62, 0.81) and colorectal cancer (HR=0.74, 95% CI, 0.60-0.91) were both reduced. Our findings indicate that bisphosphonates do not appear to increase cancer risk. Although reductions in breast and colorectal cancer incidence were observed in bisphosphonate users it is unclear, particularly for breast cancer, to what extent confounding by low bone density may explain the association.

Bisphosphonates: prevention of bone metastases in breast cancer

Disease recurrence and distant metastases remain challenging for patients with breast cancer despite advances in early diagnosis, surgical expertise, and adjuvant therapy. Bone is the most common site for breast cancer metastasis, and the bone microenvironment plays a crucial role in harboring disseminated tumor cells (DTCs), a putative source of late relapse in and outside bone. Therefore, agents that affect bone metabolism might not only prevent the development of bone lesions but also provide meaningful reductions in the risk of relapse both in bone and beyond. Bisphosphonates bind to mineralized bone surfaces and are ingested by osteoclasts, wherein they inhibit osteolysis, thereby preventing the release of growth factors from the bone matrix. Therefore, the bone microenvironment becomes less conducive to survival and growth of DTCs and bone lesion formation. Recent trials of zoledronic acid in the adjuvant setting in breast cancer have demonstrated reduced disease recurrence in bone and other sites in premenopausal and postmenopausal women with early breast cancer. Based on the proven effect of bone protection during adjuvant endocrine therapy, new treatment guidelines recommend the routine use of bisphosphonates to prevent bone loss during adjuvant therapy, which may likely become the standard practice.

Bone mineral density and prediction of non-osteoporotic disease

It is widely recognized that bone mineral density (BMD) is one of the best predictors of osteoporotic fractures. Sex hormone status clearly affects bone either directly or indirectly and a longer estrogen exposure appears to be a major determinant of postmenopausal BMD. Accordingly, several studies have led to the hypothesis that BMD might represent a marker of the accumulated lifetime exposure of estrogen and therefore be used as a predictor factor of the risk of other postmenopausal conditions such as breast cancer or cardiovascular diseases (CVD). With regard to the risk of breast cancer, there is evidence that different surrogate markers of lifetime exposure to estrogen are associated with an increased risk for breast cancer. Most of these markers are the opposite of those for the risk of fracture. Furthermore, several studies have also reported that women with higher BMD have an increased risk of breast cancer compared to women with lower BMD. On the other hand, postmenopausal women with osteoporosis are at increased risk for acute cardiovascular events and mortality independently of age and cardiovascular risk factors. BMD has been shown to inversely correlate with surrogate markers of CVD including aortic calcifications and atherosclerosis. The underlying mechanisms of such a relationship are not fully understood. Several plausible molecular links are serum lipids, pro-inflammatory cytokines or the RANK/RANK ligand/osteoprotegerin system. Interestingly, all of these factors are modulated by estrogens. It could thus be hypothesized that the intensity of postmenopausal estrogen deficiency could be also the common pathogenic factor between atherosclerosis and osteoporosis.

Bone mineral content and prostate cancer risk: data from the Baltimore Longitudinal Study of Aging

STUDY TYPE

Aetiology (inception cohort) Level of Evidence 2b.

OBJECTIVE

To determine whether there might be differences in bone mineral content (BMC) between men who develop life-threatening prostate cancer and those who do not, as bone is a common site of prostate cancer metastases.

SUBJECTS AND METHODS

From 1973 to 1984, BMC was serially measured in 519 participants (778 observations) as part of a longitudinal study of ageing. We examined the association between serial BMC measurements with the development of overall and high-risk prostate cancer over the next one to three decades. For all prostate cancer cases, BMC was censored at the time of diagnosis.

RESULTS

During a median (range) overall follow-up of 21.1 (0.2-35.0) years after the last BMC measurement, 76 (14.6%) men were later diagnosed with prostate cancer (18 high-risk and 58 not high-risk). BMC declined with age to a greater extent in healthy controls than among men diagnosed with prostate cancer (P = 0.018, likelihood ratio test), and tended to decline less in high-risk than non-high-risk cases.

CONCLUSION

The distribution of BMC was significantly different between men who did and did not develop prostate cancer, over an extended follow-up. Specifically, BMC appeared to decline to a greater extent with age among healthy controls than in men with prostate cancer, especially high-risk disease. The biology underlying the lesser decline in BMC among men with prostate cancer remains unclear, but suggests that host factors in the bony milieu might be associated with prostate cancer development and progression.

The influence of chemotherapy on bone mineral density, quantitative ultrasonometry and bone turnover in pre-menopausal women with breast cancer

INTRODUCTION

The effects of doxorubicin/cyclophosphamide (A/C; 6 cycles) chemotherapy on bone mineral density (BMD), quantitative ultrasonography (QUS) and bone turnover markers in pre-menopausal women with oestrogen receptor-negative breast cancer (BC) were compared with age-matched controls.

METHODS

Among 106 women (BC=53, controls=53), BMD (spine and hip), QUS (calcaneus and phalanges) and bone marker levels were measured at baseline, 6 and 12 months. Correlations between parameters were determined by Spearman's rho.

RESULTS

All BC patients became amenorrhoeic after chemotherapy and remained so for the duration of treatment. BC patients had significant bone loss at all sites (P.005) and significant increases in bone turnover (P.05). There were significant correlations between BMD, QUS and bone markers (P.05).

CONCLUSIONS

Results confirm A/C's deleterious influence on bone health in pre-menopausal women with BC and established QUS's utility for monitoring bone effects. Large-scale longitudinal studies are needed to further understand and prevent bone changes following chemotherapy.

Cancer survivorship research: state of knowledge, challenges and opportunities

INTRODUCTION

Seminal advances in early detection of and treatment strategies for cancer have led to burgeoning numbers of cancer survivors. While most therapeutic modalities for cancer are beneficial and lifesaving, they are associated with adverse long-term and late sequelae.

MATERIALS AND METHODS

Literature review using MEDLINE to identify studies examining adverse medical outcomes and post-treatment follow-up care among long-term survivors. Emerging concepts in survivorship research such as definitional issues, research paradigms and methodologic concerns were also examined.

RESULTS

Long-term or late adverse sequelae are more prevalent, serious, and persistent than expected in survivors of pediatric and adult cancer, but remain understudied especially among those diagnosed as adults. Follow-up care relevant to survivorship outcomes is neither standardized nor guideline or evidence based for most adult cancers, and optimal practices have yet to be defined.

DISCUSSION

Adverse sequelae contribute to burden of illness, health care costs, and decreased length and quality of survival. To-date, very few studies have compared survivor outcomes pre-and post diagnosis. It is critical to examine under-researched questions and understudied survivor groups. Regular follow-up care and monitoring of health status post cancer treatment should 1) permit the timely diagnosis and treatment of adverse outcomes; 2) enable timely diagnosis and treatment of recurrences; 3) facilitate screening and early detection of second cancer(s); 4) allow for detection and management of co-morbidities; and 5) provide the opportunity for preventive strategies such as lifestyle changes. Research findings to-date underscore the need for continued cancer survivorship research that will: inform our understanding of the mechanisms underlying adverse sequelae; lead to the design of less toxic treatments; test the effectiveness of interventions - medical, pharmacologic, and behavioral - that reduce adverse outcomes; test models of post-treatment follow-up care; develop an evidence base for optimal follow-up care practices; and inform survivor and provider decision making.

The association of bone mineral density with prostate cancer risk in the Osteoporotic Fractures in Men (MrOS) Study

We investigated the association of bone mineral density (BMD) measures with prostate cancer (PCa) risk in older men enrolled in the Osteoporotic Fractures in Men Study. We hypothesized that men with higher BMD, a marker of exposure to endogenous sex hormones, would have an increased incidence of PCa. The cohort included 4,597 men (89% White, 65 years or older) with no prior history of PCa. Baseline total body, total hip, and spine BMD were assessed using dual energy X-ray absorptiometry. Prostate cancer was confirmed by review of medical records. Cox regression was used to assess the association of BMD quartiles with incident PCa, adjusting for age, body mass index, and other covariates. During an average follow-up of 5.2 years, 5.6% (n = 255) of men developed PCa. Total body BMD was inversely associated with incident PCa, with a significant trend for decreasing PCa risk with increasing BMD quartiles (P(trend) = 0.007). Men in the highest total body BMD quartile had a 41% reduced risk for PCa (hazard ratio, 0.59; 95% confidence interval, 0.40-0.86), compared with men in the lowest quartile. Total hip and spine BMD did not exhibit significant relationships with PCa. Associations of BMD measures differed for low-grade (Gleason sum, 2-6) versus high-grade tumors (Gleason sum, >or=7). Significant inverse relationships with high-grade disease were noted at the total body and total hip sites. However, no associations were observed with low-grade disease. Our results provide support for an inverse association between BMD and PCa risk. Possible pathophyisological mechanisms linking BMD and PCa should be elucidated.

Bone mineral density at menopause does not predict breast cancer incidence

In this prospective study in 2,137 perimenopausal and early postmenopausal women who were followed over a 13.1-year period of time, we observed no association between bone mineral density measured at the beginning of menopause and the subsequent risk of breast cancer.

INTRODUCTION

This study aimed to investigate the relationship between BMD and the risk of breast cancer (BC) in young postmenopausal women.

METHODS

As part of a clinical research program, 2,137 women who were perimenopausal or within their 5 first postmenopausal years were scanned between 1988-1990 and reviewed on average 13.1 years after their initial examination. Ninety-eight incident BC cases were recorded throughout the follow-up.

RESULTS

Women with incident BC significantly differed from those who had never had BC with regard to age at menarche, age of birth of 1st child, familial history of BC and postmenopausal hormone therapy (PHT) use. There was no significant difference between the two groups for baseline DXA of the spine. There was a trend for BC cases for having lower femoral neck BMD compared to women without BC. However, women with low BMD were more likely to have taken PHT by the end of the study. In Cox multivariate analyses the relationship between BC risk and femoral neck BMD no longer existed.

CONCLUSIONS

There was no relationship between BMD measured within the first postmenopausal years and the risk of BC, which makes unlikely the possibility of using BMD as a predictor factor for BC in early postmenopausal women.

Relationship between mammography breast density and bone mineral density

Mammography breast density (MBD) is a well-established and strong predictive risk factor for breast cancer. Bone mineral density (BMD) is another predictor of breast cancer risk in women. Both MBD and BMD are linked to a common pathway, which involves estrogens, and are highly heritable. This study evaluated the relationship between MBD and hip and spine BMD in Kuwaiti women. Mammograms and BMD data of 248 women were studied. BMD was measured at total lumbar spine (L1-L4) and total left hip using dual-energy X-ray absorptiometry. The women were classified into 3 groups: normal, osteopenia, and osteoporosis by their BMD, using the World Health Organization criteria. They were divided into another 4 groups: fatty, fibroglandular, heterogeneously dense, and extremely dense breast according to their MBD and as defined by the Breast Imaging Reporting and Data System. All MBD and BMD data were analyzed statistically. Statistical analysis showed no significant difference or correlation between the MBD and BMD groups even after adjusting for obesity and menopausal status. However, a highly significant difference in body weight was found among the MBD groups (p<0.005). No correlation between MBD and BMD was observed in the group of Kuwaiti women who took part in the present study.

Relationship between bone mass, invasive breast cancer incidence and raloxifene therapy in postmenopausal women with low bone mass or osteoporosis

OBJECTIVE

To evaluate the relationship between bone mass and risk of breast cancer and to determine the effect of raloxifene therapy on breast cancer incidence in women categorized by bone mass into low bone mass and osteoporosis subgroups.

DESIGN

In this post hoc analysis, data were analyzed from the Multiple Outcomes of Raloxifene Evaluation (MORE) trial, enrolling postmenopausal women with low bone mass (N = 7705), and the Continuing Outcomes Relevant to Evista (CORE) trial, a follow-up to MORE enrolling 4011 MORE participants. Total follow-up was for up to 8 years. Women with a total hip bone mineral density (BMD) T-score < -1 to > -2.5 or T-score < or = -2.5 (referent, NHANES III database) were classified as having low bone mass or osteoporosis, respectively. Women with a pre-existing vertebral fracture were considered as having osteoporosis irrespective of BMD T-score. Analyses were performed for invasive breast cancers and invasive estrogen-receptor (ER) positive breast cancers.

RESULTS

Women with low bone mass (N = 3829) had a twofold higher incidence of invasive ER-positive breast cancer than those with osteoporosis (N = 3836) (HR 2.13, 95% CI 1.12-4.03). The incidence of all invasive breast cancers did not differ significantly between the bone mass groups. The incidences of invasive and invasive ER-positive breast cancers were 65-78% lower in women assigned raloxifene versus placebo in both the low bone mass and osteoporosis groups (p < 0.05).

CONCLUSIONS

In this post hoc analysis of postmenopausal women participating in MORE and CORE, bone mass was a predictor of invasive ER-positive breast cancer. Raloxifene treatment reduced the risk of invasive and invasive ER-positive breast cancers in women with low bone mass and those with osteoporosis. Since participants were older postmenopausal women with low bone mass, whether these findings can be generalized to other postmenopausal women is unclear.

High bone density is associated with prostate cancer in older Afro-Caribbean men: Tobago prostate survey

OBJECTIVE

To test the hypothesis that bone mineral density (BMD), a possible surrogate of lifetime exposure to hormone/growth factor/vitamin D/calcium exposure, is higher in prostate cancer cases than controls.

METHODS

Hip BMD was measured by dual X-ray absorptiometry in 222 Afro-Caribbean screening-detected prostate cancer cases and 1,503 screened non-cases, aged 45-79, in the population-based Tobago Prostate Survey. Because possible skeletal metastases may modulate BMD, men with prostate specific antigen >20 ng/ml or highly undifferentiated tumors (Gleason score > or = 8) were excluded. Mean BMD, adjusted for age and body mass index, was compared in cases and non-cases by analysis of variance. Risk across age group-specific BMD quartiles was compared using logistic regression.

RESULTS

Overall, adjusted mean hip BMD was higher in cases (1.157 g/cm2) than non-cases (1.134 g/cm2) (p = 0.02). In men aged 60-79, prostate cancer risk was two-fold higher (OR, 2.12; 95% CI: 1.21-3.71) in the highest BMD quartile compared to the lowest. There was no association in younger men (interaction, p = 0.055).

CONCLUSIONS

High bone density is associated with prostate cancer among older men, consistent with an etiological role for lifetime exposure to factors which modulate bone density. However, other etiologies may dominate prostate cancer risk among younger men.

Bone mineral density in breast cancer patients with positive estrogen receptor tumor status

AIM

The aim was to investigate bone mineral density (BMD) in breast cancer patients with positive estrogen receptor (ER) tumor status.

METHODS

The participants were 110 postmenopausal breast cancer patients with positive estrogen receptor (ER+) tumor status. Two hundred and sixty-one age-matched, healthy postmenopausal women, all of whom were selected from our pooled data, served as controls. Age, age at menopause, years since menopause (YSM), height, weight, and body mass index (BMI, wt/ht(2)) were recorded. Lumbar spine (L2-4) BMD and Z-score were assessed by dual-energy X-ray absorptiometry.

RESULTS

Bone mineral density in breast cancer patients was significantly higher than that in controls (0.89+/-0.12 g/cm(2) versus 0.84+/-0.16 g/cm(2), P<0.01). The Z-score in breast cancer patients was also higher than that in controls (110+/-13.6% versus 100+/-9.8%, P<0.001). Higher BMD and Z-score in breast cancer patients remained significant after adjusting for age, YSM, and BMI (P<0.05).

CONCLUSIONS

Postmenopausal breast cancer patients with positive ER tumor status have higher BMD. Positive ER tumor status may be associated with higher cumulative exposure to estrogen.

Genetic determinants of bone mass do not relate with breast cancer risk in US white and African-American women

INTRODUCTION

The association between high bone mass and increased breast cancer risk has been established. Identification of polymorphisms and the resultant variant receptors suggests the possibility of differential effects on hormone responsive genes when complexed with the hormones. Both estrogen receptor-alpha (ER) and vitamin D receptor (VDR) polymorphisms have been associated with bone density. Thus, we examined these polymorphisms for association with increased breast cancer risk among US African-American and white women.

METHODS

A case-control study was conducted to measure ER and VDR polymorphisms and radial bone mineral density (BMD) in African-American and white women, and to examine the association between polymorphisms, bone density and breast cancer risk. Genotypes and bone density were obtained from 412 women (220 cases and 192 controls, with equal distribution between the two ethnic groups).

RESULTS

We found no evidence for an association between either the ER or VDR genotypes and breast cancer risk. Also, there was no difference in the risk of breast cancer by genotypes after adjusting for ethnicity. The addition of age, sex and ethnicity-specific BMD (Z-scores) did not significantly change the odds ratio for breast cancer.

CONCLUSIONS

Our data suggest that the polymorphisms investigated had no effect on risk of breast cancer in this population. Thus, we found no evidence to support our hypothesis that breast cancer cases and controls would have a different distribution of ER and VDR genotypes. Furthermore, the polymorphisms were not associated with differences in bone mass and its relationship with breast cancer risk.

Risk factors for breast cancer in older women: the relative contribution of bone mineral density and other established risk factors

AIM

To determine the contribution of bone mineral density (BMD) to breast cancer risk relative to other established breast cancer risk factors in postmenopausal women with osteoporosis.

METHODS

Data for this analysis comprised those collected from women randomized to placebo in the MORE and CORE trials (N = 2,576). Risk factors measured at baseline included age, family history of breast cancer, estradiol level, body mass index, prior hormone therapy, BMD and vertebral fracture status. Cox proportional hazards regression models were used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Over a total of 13,698 woman-years of follow-up, 65 incident breast cancers occurred. In univariate analyses, older age and family history of breast cancer were the strongest predictors of breast cancer risk, associated with a 2.4- and 2.6-fold increase in breast cancer incidence. A higher estradiol level was associated with a 1.9-fold increase in breast cancer incidence. The association between femoral neck BMD and breast cancer incidence was only significant after adjustment for age (P = 0.03). The final multivariable model included age, family history, estradiol, BMD, and the BMD-estradiol interaction since the effect of BMD on breast cancer varied by estradiol level (interaction P-value, 0.04); in those with a lower estradiol level, a higher BMD was associated with a 2.6-fold increased in breast cancer.

CONCLUSION

Overall, BMD is a relatively weak predictor of breast cancer risk in these postmenopausal women with osteoporosis, after taking into consideration age, family history and endogenous estradiol level.

Aromatase and regulation of bone remodeling

Estrogens play a key role in regulating bone mineralization. Bone tissue expresses the enzymes that metabolize estrogens, as well as the alpha and beta receptors that mediate responses to estrogens. After the menopause, estrogen secretion by the ovaries is promptly replaced by production within tissues, which occurs chiefly via aromatization of adrenal steroids. Therefore, aromatase activity is a major determinant of estrogen activity in postmenopausal women. Studies are beginning to shed light on the mechanisms by which aromatase activity influences bone remodeling.

Breast cancer and bone mass in older women: is bone density prescreening for mammography useful?

INTRODUCTION

The utility of screening mammography for older women with low bone mineral density (BMD) is controversial. This case-control study compares BMD at multiple sites in women with and without breast cancer to determine if BMD prescreening is useful in selecting women for continued screening mammograms.

METHODS

Women diagnosed with breast cancer in the preceding 4 months and age-matched controls (+/-2 years) with a normal mammogram, all aged 65 years and older, were recruited on a 1:2 basis; 237 women participated: 79 women (cases) with breast cancer and 158 controls. BMD at the lumbar spine, hip, radius, and whole body was measured with dual x-ray absorptiometry (DXA).

RESULTS

Among women with breast cancer, 17.1% had stage 0, 41.5% stage I, 40.0% stage II, and 1.4% stage III. Women with breast cancer had larger waist circumferences (p=0.002) and waist-hip ratios (p=0.01), and they exercised less (p=0.002) than women of the control group. However, there were no differences between the cases and controls for age, obesity, and reproductive and menopausal history variables, or other covariates (p>0.10). There were no differences in lumbar spine, total hip, femoral neck, midshaft radius, or total body BMD (p>0.10), although the cases had higher BMD at the ultradistal radius than the controls (means: 0.527 vs. 0.516, respectively; p=0.014). There were no differences in breast cancer risk by tertile of BMD or osteoporosis status at the hip or spine.

CONCLUSION

There is little difference in BMD between women with and without breast cancer. BMD is not useful as a prescreening predicator of mammography in older women and using it as such would result in cases of breast cancer being missed.

Breast cancer risk factors and mammographic breast density in women over age 70

BACKGROUND

Breast density is a strong risk factor for breast cancer, but little is known about factors associated with breast density in women over 70.

METHODS

Percent breast density, sex hormone levels and breast cancer risk factor data were obtained on 239 women ages 70-92 recruited from 1986 to 1988 in the United States. Multivariable linear regression was used to develop a model to describe factors associated with percent density.

RESULTS

Median (range) percent density among women was 23.7% (0-85%). Body mass index (beta=-0.345, p<0.001 adjusted for age and parity) and parity (beta=-0.277, p<0.001 adjusted for age and BMI) were significantly and inversely associated with percent breast density. After adjusting for parity and BMI, age was not associated with breast density (beta=0.05, p=0.45). Parous women had lower percent density than nulliparous women (23.7 versus 34.7%, p=0.005). Women who had undergone surgical menopause had greater breast density than those who had had a natural menopause (33.4 versus 24.8%, p=0.048), as did women who were not current smokers (26.0 versus 17.3% for smokers, p=0.02). Breast density was not associated with age at menarche, age at menopause, age at first birth, breastfeeding, estrogen levels or androgen levels. In a multivariable model, 24% of the variance in percent breast density was explained by BMI (beta=-0.35), parity (beta=-0.29), surgical menopause (beta=0.13) and current smoking (beta=-0.12).

CONCLUSION

Factors associated with breast density in older, post-menopausal women differ from traditional breast cancer risk factors and from factors associated with breast density in pre-menopausal and younger post-menopausal women.

Positive association between mammographic breast density and bone mineral density in the Postmenopausal Estrogen/Progestin Interventions Study

Introduction

Mammographic breast density is a strong independent risk factor for breast cancer. We hypothesized that demonstration of an association between mammographic breast density and bone mineral density (BMD) would suggest a unifying underlying mechanism influencing both breast density and BMD.

Methods

In a cross-sectional analysis of baseline data from the Postmenopausal Estrogen/Progestin Interventions Study (PEPI), participants were aged 45 to 64 years and were at least 1 year postmenopausal. Mammographic breast density (percentage of the breast composed of dense tissue), the outcome, was assessed with a computer-assisted percentage-density method. BMD, the primary predictor, was measured with dual-energy X-ray absorptiometry. Women quitting menopausal hormone therapy to join PEPI were designated recent hormone users.

Results

The mean age of the 594 women was 56 years. The average time since menopause was 5.6 years. After adjustment for age, body mass index, and cigarette smoking, in women who were not recent hormone users before trial enrollment (n = 415), mammographic density was positively associated with total hip (P = 0.04) and lumbar (P = 0.08) BMD. Mammographic density of recent hormone users (n = 171) was not significantly related to either total hip (P = 0.51) or lumbar (P = 0.44) BMD. In participants who were not recent hormone users, mammographic density was 4% greater in the highest quartile of total hip BMD than in the lowest. In participants who were not recent hormone users, mammographic density was 5% greater in the highest quartile of lumbar spine BMD than in the lowest.

Conclusion

Mammographic density and BMD are positively associated in women who have not recently used postmenopausal hormones. A unifying biological mechanism may link mammographic density and BMD. Recent exogenous postmenopausal hormone use may obscure the association between mammographic density and BMD by having a persistent effect on breast tissue.

Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer

PURPOSE

Cancer survivors are at increased risk for several comorbid conditions, and many seek lifestyle change to reduce dysfunction and improve long-term health. To better understand the impact of cancer on adult survivors' health and health behaviors, a review was conducted to determine (1) prevalent physical health conditions, (2) persistent lifestyle changes, and (3) outcomes of previous lifestyle interventions aimed at improving health within this population.

METHODS

Relevant studies from 1966 and beyond were identified through MEDLINE and PubMed searches.

RESULTS

Cancer survivors are at increased risk for progressive disease but also for second primaries, osteoporosis, obesity, cardiovascular disease, diabetes, and functional decline. To improve overall health, survivors frequently initiate diet, exercise, and other lifestyle changes after diagnosis. However, those who are male, older, and less educated are less likely to adopt these changes. There also is selective uptake of messages, as evidenced by findings that only 25% to 42% of survivors consume adequate amounts of fruits and vegetables, and approximately 70% of breast and prostate cancer survivors are overweight or obese. Several behavioral interventions show promise for improving survivors' health-related outcomes. Oncologists can play a pivotal role in health promotion, yet only 20% provide such guidance.

CONCLUSION

With 64% of cancer patients surviving > 5 years beyond diagnosis, oncologists are challenged to expand their focus from acute care to managing the long-term health consequences of cancer. Although more research is needed, opportunities exist for oncologists to promote lifestyle changes that may improve the length and quality of life of their patients.

Baseline bone mineral density of the total lumbar spine may predict for chemotherapy-induced ovarian failure

Age at treatment and the total cumulative dose of cyclophosphamide are established predictors of chemotherapy-induced ovarian failure in premenopausal women with breast cancer. In a prospective trial of 49 women receiving adjuvant chemotherapy, we sought to identify whether other factors including family history of osteoporosis, lifestyle factors, reproductive hormones, bone turnover markers, or bone mineral density (BMD) of the hip or total spine measured before (baseline) and 6 months after chemotherapy increased the risk of ovarian failure. Univariate logistic regression analyses were used to identify the variables related to the risk of ovarian failure, and a multivariate logistic regression model was used to find the best of predictors of ovarian failure among the variables. In the multivariate model a higher total spine BMD at baseline (OR=6.0, p=0.02, 95% CI 1.4-27.3), and a 10% change in estradiol (E2) from baseline to six months (OR=0.80, p=0.02, 95% CI 0.67-0.97) were predictive of ovarian failure adjusted for age. In particular, as total spine BMD at baseline increases by 0.1 g/cm2 the odds of developing chemotherapy-induced ovarian failure increases by 6-fold. The multivariate model provides a good fit to the data (GOF p-value=0.8852), and provides excellent discrimination between those women who will and will not develop ovarian failure (Area under ROC=0.9487). If confirmed in larger data sets, using baseline spinal BMD to identify women who are at higher risk of developing ovarian failure independent of their age would be of value.

Strategies for managing breast cancer risk after the menopause

Postmenopausal women in Western societies are conscious of breast cancer as a potential cause of death and ill health, which they wish to avoid with the advice of their doctors. Yet many factors that predispose women to the development of cancer will have been laid down before the menopause, in their genetic makeup or during their adolescent years. Even in middle age it is important to take account of the intrinsic level of risk, and to give women advice tailored to their own individual risk level. This results from their family history, previous diseases such as benign breast disease, and previous treatment for breast cancer or Hodgkin's disease. For those at the highest level of risk, strategies will include regular screening, prophylactic mastectomy, and the use of chemoprevention agents, such as tamoxifen. These women should avoid hormone replacement therapy (HRT) and control their menopausal symptoms and osteoporosis through the use of other agents now available - venlafaxine for menopausal symptoms and bisphosphonates for osteoporosis. Raloxifene is an agent under trial that may be valuable for breast cancer control as well as for osteoporosis. Women at standard population risk will require less robust preventive strategies, which will include screening and lifestyle modification. Their decisions regarding HRT should now be modified by recent evidence of associated risks. Recent studies show that tibolone causes less mammographic density and has a lower relative risk of breast cancer than combined estrogen/progestogen preparations. There is limited evidence that controlling obesity, participating in exercise and adopting a diet low in fats and high in fruit and vegetables will alter risk at this age. These precautions will, however, reduce the risk of other diseases common in this age group, such as hypertension, heart disease, stroke, and type 2 diabetes mellitus. Alcohol, even in small amounts, is a risk factor for breast cancer. Given the cardioprotective effect of moderate alcohol intake, advice on alcohol must reflect the individual relative risk of cardiovascular disease and breast cancer. Personal risk assessment is relevant for all women. Screening and a healthy lifestyle are worthwhile approaches for all, with the more aggressive approaches such as chemoprevention and prophylactic surgery reserved for those who have substantially elevated levels of risk. Once the menopause has passed, screening is probably the most effective evidence-based tool for breast cancer control by early diagnosis.

Clinical management of osteoporosis in women with a history of breast carcinoma

Osteoporosis is a skeletal disorder that is characterized by low bone mass and compromised bone strength. Fractures are the clinically important consequence of osteoporosis and result not only in disability but also in excess mortality. Women who have a history of breast carcinoma may represent a unique population for whom screening and treatment for osteoporosis should be modified. A review of the English literature was performed that included original, review, consensus, and statement articles that were identified through Medline or National Institutes of Health-related links. According to the literature, osteoporosis constitutes a major public health problem. Approximately 55% of the U.S. population > or = 50 years of age has low bone mass (osteopenia or osteoporosis). Annually, > 200,000 women in the U.S. are diagnosed with breast carcinoma. Due to the high prevalence rates of both low bone mass and breast carcinoma in women, these two diseases commonly coexist in the same individuals. Women with a history of breast carcinoma may be at increased risk of developing bone loss and fragility fractures as a consequence of antineoplastic therapies. The majority of women treated for early-stage breast carcinoma do not develop recurrences, as a result of recent advances in therapy. Ensuring the diagnosis, prevention, and treatment of long-term toxicities and comorbid conditions like osteoporosis in breast carcinoma survivors is a serious concern and is of increasing importance. In this article, the authors address the evaluation and treatment of osteoporosis in women who have a history of early-stage breast carcinoma.

Bone mineral density and adjuvant therapy in breast cancer survivors

Compared to mean values from a US database, premenopausal breast cancer survivors (BCS) had significantly higher whole body bone mineral density (BMD) compared to age and ethnicity matched referents; higher whole body BMD was present in all premenopausal BCS, including those who received chemotherapy, tamoxifen+chemotherapy, or no adjuvant therapy. Postmenopausal BCS who had received no adjuvant therapy also had higher whole body BMD compared to similarly aged women. In contrast, hip and lumbar spine BMD values in BCS were similar to those of the population-based database.

Diet and cancer prevention

Dietary effects are presumed to underlie many of the large international differences in incidence seen for most cancers. Apart from alcohol and a few micronutrients, however, the role of specific nutritional factors remains ill-defined. The evidence for a role of energy balance, physical inactivity, and obesity has strengthened, while for dietary fat it has weakened. Phytochemicals such as folate, lycopene and flavonoids are still the subject of active research. As the mechanisms underlying human carcinogenesis are better understood, dietary research will focus increasingly on intermediate markers such as the insulin-like growth factors and potentially carcinogenic metabolites.

A second-stage genome scan for QTLs influencing BMD variation

Low bone mineral density (BMD) is a major risk factor for osteoporotic fracture. To identify genomic regions harboring quantitative trait loci (QTLs) contributing to BMD variation, we performed a two-stage genome screen. The first stage involved genotyping of a sample of 53 pedigrees with 630 individuals using 400 microsatellite markers spaced at approximately 10-cM intervals throughout the genome. Ten genomic regions with multi- and/or two-point LOD scores greater than 1.5 were observed. In the present second-stage study, 60 microsatellite markers, with a mean spacing of about 5 cM, were genotyped in these regions in an expanded sample of 79 pedigrees that contained 1816 subjects. Each pedigree was ascertained through a proband with extreme BMD at the hip or spine. BMD at the spine (L1-4), hip (the femoral neck, trochanter, and intertrochanteric region), and wrist (the ultradistal region) was measured by dual-energy X-ray absorptiometry (DXA) and was adjusted for age, sex, height, and weight. Two-point and multipoint linkage analyses were performed for each BMD site using statistical genetic methods that are implemented in the computer package SOLAR. Several regions (7q11, 10q26, 12q13, and 12q24) achieved LOD scores in excess of 1 in the second-stage followup study. The current results replicate some of our previous linkage findings and also highlight some of the difficulties facing microsatellite linkage mapping for complex human diseases.

Risk factors for low bone mineral density and the 6-year rate of bone loss among premenopausal and perimenopausal women

Risk factors that are associated with lower bone mineral density (BMD) may not necessarily be associated with increased bone loss among premenopausal and perimenopausal women. We determined risk factors for lower premenopausal and perimenopausal BMD while simultaneously determining risk factors for increased 6-year rate of bone loss among women aged 24-50 years within a population-based prospective cohort study. BMD of the lumbar spine and femoral neck, reported as t scores, were measured five times within the 6-year study among 614 women who were between the ages of 24 and 44 in 1992/1993. Rates of bone loss were calculated from the repeated BMD measurements. Risk factors for lower BMD over time at the lumbar spine included history of any fracture ( P=0.005). The major risk factor for lower BMD over time at the femoral neck was family history of osteoporosis ( P<0.002). The major protective factor for greater BMD over time at both skeletal sites was additional body weight ( P<0.0001). Other protective factors for greater BMD over time at the femoral neck were modest alcohol consumption ( P=0.0002) and high-school sports participation ( P=0.002). Risk factors for greater bone loss at either skeletal site included postmenopausal status ( P<0.0001 at the lumbar spine; P=0.01 at the femoral neck), and the reporting of a reproductive cancer ( P<0.0001 at the lumbar spine; P=0.0008 at the femoral neck). Body weight was protective against bone loss at both skeletal sites ( P<0.0001). Baseline age, calcium intake, smoking, and current physical activity were not associated with BMD or bone loss. The understanding of the relative importance of risk factors for both low BMD and bone loss may assist in the identification of women at greater risk for subsequent low postmenopausal BMD.

Estrogen metabolites and the risk of breast cancer in older women

BACKGROUND

Women who metabolize a large proportion of their estrogen via the 16alpha hydroxylation pathway could be at a higher risk of breast cancer. The objective of this study was to test the hypothesis that serum concentrations of 2-hydroxyestrone (2-OHE1) and 16alpha-hydroxyestrone (16alpha-OHE1), as well as their ratio, predict the risk of breast cancer in older women.

METHODS

We performed a case-cohort study of 272 women with confirmed incident breast cancer and 291 controls chosen randomly from the cohort. Estrogen metabolites were measured in serum collected at the baseline examination and stored at -120 degrees C. Incident breast cancers were confirmed by medical records and pathology reports during an average follow-up of 8.7 years.

RESULTS

Mean concentrations of 2-OHE1 and 16alpha-OHE1, adjusted for age and body mass index, were 3% to 4% higher in cases compared with controls: 2-OHE1 was 176 pg/mL and 169 pg/mL and 16alpha-OHE1 was 233 pg/mL and 226 pg/mL in cases and controls, respectively. There was, however, no difference in the ratio of 2-OHE1 to 16alpha-OHE1. The risk of breast cancer in women with the highest quartile of this ratio compared with those in the lowest quartile was 1.17 (95% confidence interval = 0.73-1.87).

CONCLUSION

The study results do not support the hypothesis that the ratio of 2-OHE1 to 16alpha-OHE1 predicts breast cancer risk.

Osteopenia and osteoporosis in women with breast cancer

Osteopenia and osteoporosis are prevalent in women. Epidemiologic studies show that the risk of breast cancer is greater in postmenopausal women with higher bone mineral density (BMD). Standard treatments for breast cancer such as adjuvant chemotherapy or hormonal therapy can increase bone loss, and hence may increase the risk of osteoporosis. Premenopausal women treated with standard adjuvant chemotherapy frequently develop permanent ovarian failure, or early menopause. Ovarian failure is associated with accelerated bone loss, and bisphosphonates may mitigate this bone loss in women treated with adjuvant chemotherapy. Tamoxifen preserves BMD in postmenopausal women; however, in premenopausal women tamoxifen may increase bone loss. Anastrazole, an aromatase inhibitor, is approved for adjuvant treatment of postmenopausal women with early-stage, estrogen receptor-positive breast cancer. With a follow-up duration of less than 5 years, anastrazole-treated women experience increased fractures relative to those treated with tamoxifen. The management of osteopenia and osteoporosis in women with breast cancer generally does not differ from women without breast cancer. Adequate dietary calcium and vitamin D intake, encouraging weight-bearing exercise, and counseling about the relationship between smoking and alcohol and bone loss are all prudent recommendations for overall health and may lessen bone loss and the risk of subsequent osteoporosis. BMD should be measured in women with chemotherapy-induced ovarian failure, and in those on aromatase inhibitors. Bisphosphonates reduce the bone loss associated with chemotherapy-induced ovarian failure, and clinical trials evaluating third-generation bisphosphonates in women with chemotherapy-induced ovarian failure are underway. As many women with breast cancer will be long-term survivors, increasing recognition of maintaining skeletal health is important.

The effects of adjuvant chemotherapy on bone density in postmenopausal women with early breast cancer

PURPOSE

Adjuvant chemotherapy for breast cancer can have adverse effects on bone. We investigated the effects of adjuvant chemotherapy on bone mineral density in postmenopausal women with early-stage breast cancer.

METHODS

We performed a chart review of all our breast center patients who had spine or hip bone density measured by dual-energy X-ray absorptiometry at our institution after treatment for stage I or II breast cancer. Patients who had other causes of metabolic bone disease were excluded. Multivariate regression analysis was used to adjust for confounding factors. Results were expressed as age-adjusted standard deviation units (Z scores).

RESULTS

Of the 130 eligible women, 36 (28%) received adjuvant chemotherapy and 94 (72%) did not. Mean adjusted bone density scores in both the hip (0.65 SD units; 95% confidence interval [CI]: 0.32 to 0.98 SD units; P = 0.0002) and spine (0.60 SD units; 95% CI: 0.01 to 1.19 SD units; P = 0.05) were significantly lower in patients who had received adjuvant chemotherapy compared with those who had not.

CONCLUSION

Women who were postmenopausal when they developed breast cancer and who received adjuvant chemotherapy had lower bone density than those who did not. Whether this effect is caused by adjuvant chemotherapy remains to be determined.

Bone mineral density and the risk of breast cancer: the Rotterdam Study

Estrogens play an important role in the development of breast cancer, but studies on serum levels of estrogens have shown inconsistent results. Bone mineral density is considered to be a marker for lifetime estrogen exposure. Some studies have suggested that a higher bone mass is associated with an increase in breast cancer risk. We investigated the association between bone mineral density (BMD), as measured at the lumbar spine and femoral neck, and the risk of breast cancer in women age 55 or older in the Rotterdam Study, a population-based cohort study in the Netherlands. Information on baseline lumbar spine and femoral neck BMD, as measured by DEXA (Lunar DPX-L), and cancer incidence was available for 3,107 women. The Rotterdam Cancer Registry provided information on follow-up of incident cancer. After an average follow-up time of 6.5 years, 74 new cases of breast cancer occurred. Z-scores of lumbar spine and femoral neck BMD were divided into tertiles and risk estimates for breast cancer were computed by the Cox proportional hazards model, using the middle tertile as a reference. Breast cancer risk in the upper tertile of lumbar spine BMD was doubled compared to the reference after adjustment for age, body mass index, and age at menopause (hazards ratio = 2.1 [1.1-3.7]), whereas risk estimates for women in the lower tertile did not significantly differ from the reference (hazards ratio = 1.5 [0.8-2.9]). Women with either a low intertrochanteric or femoral neck BMD appeared to have a somewhat decreased breast cancer risk, although this was not statistically significant. The results of this study suggest that in elderly women an association between especially lumbar spine BMD and incident breast cancer exists. Stimulating effects of estrogen on both trabecular bone and mammary cells may be responsible.