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

Bone health in breast cancer

Early breast cancer is among the most common cancers worldwide. Recent advances continue to improve outcomes and increase long-term survivorship. However, therapeutic modalities are deleterious for patients' bone health. While antiresorptive therapy may partially negate this, consequent reduction in rates of fragility fractures remains unproven. Selective prescription of bisphosphonates or denosumab may be an amicable middle ground. Recent evidence also suggests a possible role of osteoclast inhibitors as adjuvant therapy, but the evidence is modest at best. In this narrative clinical review, we explore the impact of various adjuvant modalities on bone mineral density and fragility fracture rates of early breast cancer survivors. We also review optimal patient selection for antiresorptive agents, their impact on rates of fragility fractures, and the possible role of these agents as adjuvant therapy.

The influence of age, menstrual state and body mass index on the relation between osteopenia and osteoporosis associated with breast cancer

Osteoporosis and body mass index (BMI) have been reported to be associated with breast cancer. The correlation between other types of bone loss and breast cancer requires further illustrative evidence. Effect of age and menstrual state on the relationship of osteoporosis, osteopenia and BMI with breast cancer was evaluated in this study. Two hundred breast cancer patients and 200 breast cancer-free patients were included in a case-control study. Bone mineral density (BMD) and BMI were determined in all subjects. Postmenopause was the most frequent menstrual state. osteopenia was found to be significant in breast cancer patients and osteoporosis was significant in another group of women. There was no significant difference between breast cancer patients and control women in terms of age and menstrual status. Obesity was common in all subjects. In conclusion, bone loss rates are significantly low in breast cancer patients relative to healthy women. There was no significant impact of age, menstrual status or BMI on the development of osteopenia or osteoporosis in breast cancer patients. In addition, BMD analytical results may identify the appropriate treatment for bone loss. A routine check-up of osteopenia or osteoporosis is highly recommended for breast cancer patients.Impact StatementWhat is already known on this subject? Breast cancer may be associated with a wide variety of human body parameters. These parameters can include age, body mass index (BMI), obesity and menstrual status. There is also a correlation between osteoporosis and breast cancer.What do the results of this study add? Osteopenia is the most frequent form of bone loss among women with breast cancer. In contrast, osteoporosis as the worst stage of bone loss is unusual in these patients. Factors such as age, menstruation and BMI have no effect on the development of breast cancer.What are the implications of these findings for clinical practice and/or further research? Identification of the type of bone loss in women with breast cancer is essential to determine the appropriate type of therapy.

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.

Effect of platelet-derived growth factor (PDGF-BB) and bone morphogenic protein 2 (BMP-2) transfection of rBMSCs compounded with platelet-rich plasma on adipogenic differentiation

The aim of this study was to inhibit adipogenic differentiation by transfecting two growth factors, platelet-derived growth factor (PDGF-BB) and bone morphogenic protein 2 (BMP-2), into modified rat bone marrow mesenchymal stem cells (rBMSCs) and then compounded with platelet-rich plasma (PRP). To achieve rBMSCs, the osteoporosis model of rats was established, and then the rBMSCs from the rats were isolated and identified. Co-transfection of rBMSCs with PDGF-BB-GFP and BMP-2 and detection of PDGF-BB/BMP-2 expression in transfected BMSCs was assessed by qRT-PCR and western blot, respectively. Moreover, the effect of the two growth factors transfection of rBMSCs on adipogenic differentiation was evaluated by oil red O staining and western blot, respectively. Finally, construction of the two growth factors transfection of rBMSCs compounded with PRP and detection of adipogenic differentiation were assessed by oil red O staining, CCK-8, and western blot, respectively. In vitro studies revealed that the two growth factors transfection of rBMSCs compounded with PRP promoted cell viability and inhibited adipogenic differentiation and could be promising for inhibiting adipogenic differentiation.

Risk of osteoporosis and fracture in long-term breast cancer survivors

Purpose

High incidence of osteoporosis has been reported in breast cancer patients due to early menopause triggered by adjuvant treatment and temporary ovarian function suppression. In this study, we sought to determine whether long-term breast cancer survivors had an elevated risk of low bone density compared to the general population.

Methods

Long-term breast cancer survivors who had been treated for more than 5 years were selected for this study. Data were obtained from medical records and using a questionnaire from the Korea National Health and Nutrition Examination Survey (KNHANES). An age-matched non-cancer control group was selected from the KNHANES records. Incidence of fracture and bone mineral density (BMD) were compared between the two groups.

Results

In total, 74 long-term breast cancer survivors and 296 non-cancer controls were evaluated. The incidence of fracture did not differ between the two groups (P=0.130). No differences were detected in lumbar BMD (P=0.051) following adjustment for body mass index, while hip BMD was significantly lower in breast cancer survivors (P=0.028). Chemotherapy and endocrine treatment were not related to low BMD in breast cancer survivors. In more than half of the survivors, the 10-year risk of osteoporotic fracture was less than 1%.

Conclusion

Long-term breast cancer survivors had low bone density but a comparable risk of fracture compared to non-cancer age-matched controls. Further studies on the factors related to low bone density in long-term breast cancer survivors are required.

Vitamin D Inhibition of TRPV5 Expression During Osteoclast Differentiation

BACKGROUND

Vitamin D is an important steroid that can regulate bone metabolism including osteoclast (OC) differentiation. Transient receptor potential cation channel subfamily V member 5 (TRPV5), is a calcium channel protein involved in OC differentiation. However, the impact of vitamin D on TRPV5 expression during OC differentiation is not clear.

OBJECTIVES

To determine if 1,25-dihydroxyvitamin D3 (1,25(OH)₂D₃) regulates the expression of TRPV5 during OC differentiation.

METHODS

Bone marrow mononuclear macrophage (BMMs) were induced to differentiate into OC with or without treatment with 10 nM 1,25(OH)₂D₃. The expression levels of vitamin D receptor (VDR) and TRPV5 were examined. The expression of several OC markers, including tartrate resistant acid phosphatase (TRAP), carbonic anhydrase II (Ca II), cathepsin K (CTSK), and vacuolar-type H⁺-ATPase (V-ATPase) were also detected.

RESULTS

We found that the VDR was expressed in murine bone marrow-derived macrophages at the early stage of OC differentiation. TRPV5 expression was increased during OC differentiation, which was down-regulated by 1,25(OH)₂D₃ after a prolonged exposure. The 1,25(OH)₂D₃ and TRPV5 inhibitors inhibited OC differentiation.

CONCLUSIONS

1,25(OH)₂D₃ can inhibit TRPV5 expression as well as TRPV5 inhibitors during OC differentiation. This suggests that 1,25(OH)₂D₃ may suppress OC differentiation by inhibiting TRPV5 expression.

Sensitivity and Specificity of Computed Tomography in the Evaluation of Bone Mineral Density in Mexican Patients with Breast Cancer

Introduction Breast cancer (BC) is the most frequently reported cancer among women - reported in 2012 as 25% of all cancers. BC has been related to the increased life and activity of osteoclasts, conferring a higher risk for osteoporosis/osteopenia. This study aimed to determine a cut-off point in Hounsfield units (HU) as well as the sensitivity and specificity of computed axial tomography (CT) in the diagnosis of osteoporosis/osteopenia in Mexican women with BC. Material and methods We included 108 patients with a histopathological diagnosis of BC treated at the ABC Medical Center in Mexico City. All patients were subjected to both dual X-ray densitometry and CT. The receiver operating characteristic (ROC) curve was used to identify the cutoff point and sensitivity and specificity were calculated, as were confidence intervals for the diagnoses of osteoporosis/osteopenia. Results The mean age was 58.49 ± 11.01 years. The cutoff point with the highest sensitivity (82%) and specificity (68%) was <157 HU for osteoporosis/osteopenia in patients with BC. Conclusions Women with BC are exposed to several risk factors for osteoporosis/osteopenia. The CT obtained for the general evaluation of these patients can also be used to evaluate bone mineral density, avoiding additional examinations and exposure to radiation, as well as the cost it confers, offering an earlier diagnosis of osteoporosis/osteopenia for its control.

Bone Metastasis of Breast Cancer

Bone is the most common site of metastasis for breast cancer. Bone metastasis significantly affects both quality of life and survival of the breast cancer patient. Clinically, complications secondary to bone metastasis include pain, pathologic fractures, spinal cord compression, and hypercalcemia of malignancy. Because bone metastasis is extremely common in patients with metastatic breast cancer, clinical management of bone metastases is an important and challenging aspect of treatment in the metastatic setting.The skeleton is a metabolically active organ system that undergoes continuous remodeling throughout life. A delicate balance of the bone-forming osteoblasts and bone-resorbing osteoclasts in the dynamic microenvironment of the skeleton maintains normal bone remodeling and integrity. The presence of metastatic lesions in bone disrupts the normal bone microenvironment and upsets the fine balance between the key components. The changes in the bone microenvironment then create a vicious cycle that further promotes bone destruction and tumor progression.Various therapeutic options are available for bone metastases of breast cancer. Treatment can be tailored for each patient and, often requires multiple therapeutic interventions. Commonly used modalities include local therapies such as surgery, radiation therapy and radiofrequency ablation (RFA) together with systemic therapies such as endocrine therapy, chemotherapy, monoclonal antibody-based therapy, bone-enhancing therapy and radioisotope therapy. Despite the use of various therapeutic modalities, bone metastases eventually become resistant to therapy, and disease progresses.In this chapter, we describe the clinical picture and biological mechanism of bone metastases in breast cancer. We also discuss known risk factors as well as detection and assessment of bone metastases. We present therapeutic options for bone metastasis using a multidisciplinary approach. Further, we describe future directions for bone metastasis management, focusing on novel bone-specific targeted therapies.

Correlation between severe infection and breast cancer metastases in the EORTC 10994/BIG 1-00 trial: Investigating innate immunity as a tumour suppressor in breast cancer

BACKGROUND

Breast cancer cells which express an innate immune signature regulated by interferon regulatory factor 7 (IRF7) have reduced metastatic potential. Infections can induce interferon signalling and may activate an anti-tumour immune response. We investigated whether 'severe infection' can be a clinical surrogate of this phenomenon and/or the presence of high levels of the IRF7 signature at diagnosis before neo-adjuvant chemotherapy (NACT) is associated with a reduced distant relapse risk, specifically in bones.

METHODS

Clinical data of the European Organisation for Research and Treatment of Cancer 10994/BIG 1-00 phase III trial which randomised 1856 patients treated with NACT between 2001 and 2006, were used. Severe infection was febrile neutropenia or any other grade III-IV infective adverse event during NACT. The IRF7 signature was calculated from gene expression data available for 160 patients on a pre-NACT biopsy. Cox models for distant relapse-free interval (DRFI) investigated the effect of the severe infection and IRF7. Fine and Gray models studied the occurrence of bone metastases as first distant relapse.

RESULTS

Median follow-up was 4.8 years. No association between severe infection and DFRI was observed in the entire population (n = 1615 eligible patients) hazard ratio [(HR] = 0.99, 90% CI, confidence interval [CI] = 0.81-1.20). For IRF7 (N = 160), a trend towards an association with DRFI was observed (HR = 0.89 for a 50 unit increase, 90% CI = 0.78-1.02, p = 0.081). Higher levels of the IRF7 signature were significantly associated with a decreased bone metastases risk: (HR = 0.76 for a 50 unit increase, 95% CI, 0.62-0.94, p = 0.012).

CONCLUSIONS

In this study it was shown that severe infection during NACT was not associated with decreased DRFI while high expression of the IRF7 gene signature was significantly associated with reduced bone relapse. This result may be useful for future adjuvant bisphosphonate/denosumab use.

Adjuvant Endocrine Therapy and Bone Health in Breast Cancer

Breast cancer is one of the most common malignancies of women. The majority of breast cancers express estrogen and/or progesterone receptors, permitting anticancer targeting strategies to reduce estrogen signaling in the cancer cells and thereby lowering the risk of breast cancer recurrence. The development of the selective estrogen receptor modulator (SERM) tamoxifen marked a significant milestone in breast cancer care that transcended older estrogen ablative strategies such as oophorectomy and ovarian irradiation. An unintended benefit of tamoxifen in postmenopausal women was bone density preservation. The third generation of aromatase inhibitors (AIs) have demonstrated superior efficacy to tamoxifen in improving disease-free survival in postmenopausal women. However, the AIs significantly increase bone resorption, reduce bone mineral density, and increase the risk of fracture above that of tamoxifen. As a consequence of this, clinical oncologists have assumed a larger role in the screening and treatment of the skeletal complications of breast cancer therapies. The key features of managing bone health in women with early stage breast cancer receiving adjuvant endocrine therapy are reviewed here.

Periodontal health, perceived oral health, and dental care utilization of breast cancer survivors

OBJECTIVES

This population-based analysis examined the prevalence of periodontal diseases along with the self-perceived oral health and patterns of dental care utilization of breast cancer survivors in the United States.

METHODS

Data from the 1999-2004 National Health and Nutrition Surveys were utilized, examining information from 3,354 women between 50 and 85 years of age. Primary outcomes were gingivitis and periodontitis, self-perceived oral health, and dental care utilization. Logistic regression analyses were used to estimate relationships of breast cancer diagnosis and primary outcomes while controlling for confounding factors.

RESULTS

Breast cancer survivors were more likely to be older than 55 years, white, nonsmokers, have higher levels of education and income, and a higher prevalence of osteoporosis. Breast cancer survivors were significantly less likely to have dental insurance (P = 0.04). Utilization of dental services and reason for last dental visit did not significantly differ between groups. A history of a breast cancer diagnosis did not increase the odds of gingivitis [odds ratio (OR):  1.32; 95 percent confidence interval (CI): 0.53-3.63], periodontitis (OR: 1.82; 95 percent CI:  0.89-4.01), or poor self-perceived oral health (OR: 0.89; 95 percent CI: 0.61-1.33) after adjusting for age, race, education, dental care utilization, and smoking status.

CONCLUSIONS

In this sample, a history of breast cancer does not significantly impact periodontal health, self-perceived oral health, and dental care utilization. However, efforts should be made to assure that breast cancer survivors have dental insurance.

Skeletal manifestations of treatment of breast cancer

Breast cancer and osteoporosis are common diagnoses in women. Breast cancer survival has improved due to earlier detection and improved treatments. As most breast cancers are estrogen receptor positive, treatment is often aimed at altering the hormonal environment. Both pre and postmenopausal women undergoing these therapies are at risk for bone loss. The patient's health care team ought to have an awareness of the potential for breast cancer treatments to accelerate bone loss. Women with early stage breast cancer are treated with curative intent and, therefore, maintaining bone health is important and is part of the survivorship care to ensure an optimal quality of life.

The management of osteoporosis in breast cancer survivors

Breast cancer is a common diagnosis and the majority of women treated will be cured. Women with early stage breast cancer may be at increased risk for osteoporosis due to anticancer therapies. Chemotherapy induced amenorrhea and the use of anti-estrogens can promote bone loss; thus, the management of bone health in women with breast cancer is an important component of survivorship care. Osteoporosis is considered a "silent" disease as there are often no discrete warning signs, until a fracture occurs; therefore, clinicians must be cognizant of the underlying risk for osteoporosis and co-morbid conditions and/or medications that accelerate risk of fracture. Breast cancer therapies that effect bone, screening for bone loss and interventions to mitigate the treatment toxicities are reviewed.

Potential implications of adjuvant endocrine therapy for the oral health of postmenopausal women with breast cancer

Current adjuvant treatment modalities for breast cancer that express the estrogen receptor or progesterone receptor include adjuvant anti-estrogen therapies, and tamoxifen and aromatase inhibitors. Bone, including the jaw, is an endocrine-sensitive organ, as are other oral structures. This review examines the potential links between adjuvant anti-estrogen treatments in postmenopausal women with hormone receptor positive breast cancer and oral health. A search of PubMed, EMBASE, CENTRAL, and the Web of Knowledge was conducted using combinations of key terms "breast," "cancer," "neoplasm," "Tamoxifen," "Aromatase Inhibitor," "chemotherapy," "hormone therapy," "alveolar bone loss," "postmenopausal bone loss," "estrogen," "SERM," "hormone replacement therapy," and "quality of life." We selected articles published in peer-reviewed journals in the English. The authors found no studies reporting on periodontal diseases, alveolar bone loss, oral health, or oral health-related quality of life in association with anti-estrogen breast cancer treatments in postmenopausal women. Periodontal diseases, alveolar bone density, tooth loss, and conditions of the soft tissues of the mouth have all been associated with menopausal status supporting the hypothesis that the soft tissues and bone of the oral cavity could be negatively affected by anti-estrogen therapy. As a conclusion, the impact of adjuvant endocrine breast cancer therapy on the oral health of postmenopausal women is undefined. The structures of the oral cavity are influenced by estrogen; therefore, anti-estrogen therapies may carry the risk of oral toxicities. Oral health care for breast cancer patients is an important but understudied aspect of cancer survivorship.

Selecting a comparison group for 5-year oral and pharyngeal cancer survivors: two methods

BACKGROUND

To assess potential long-term consequences of cancer treatment, studies that include comparison groups are needed. These comparison groups should be selected in a way that allows the subtle long-range effects of cancer therapy to be detected and distinguishes them from the effects of aging and other risk factors. The purpose of this investigation was to test two methods of recruiting a comparison group for 5-year oral and pharyngeal cancer survivors (peer-nominated and listed sample) with emphasis on feasibility and the quality of the match.

METHODS

Participants were drawn from a pool of 5-year survivors treated at a large Southeastern hospital. A peer-nominated sample was solicited from the survivors. A listed sample matched on sex, age, and zip code was purchased. Telephone interviews were conducted by a professional call center.

RESULTS

The following represent our key findings: The quality of matching between survivors and listed sample was better than that between survivors and peer-nominated group in age and sex. The quality of matching between the two methods on other key variables did not differ except for education, with the peer method providing a better match for the survivors than the listed sample. The yield for the listed sample method was greater than for the peer-nominated method. The cost per completed interview was greater for the peer-nominated method than the listed sample.

CONCLUSION

This study not only documents the methodological challenges in selecting a comparison group for studies examining the late effects of cancer treatment among older individuals but also documents challenges in matching groups that potentially have disproportionate levels of comorbidities and at-risk health behaviors.

Cancer therapy and osteoporosis: approach to evaluation and management

The incidences of osteoporosis and cancer increase with age, and these two diagnoses are often made in the same individual. Both increasing age and hypogonadism associated with aging, as well as cancer therapies, can lead to loss of bone mass and increased risk for fragility fractures. Advancing age carries an association with increased incidence of cancers. Thus, cancer and its therapies may predispose an individual to osteoporosis and its associated morbidity and mortality. Prevention of bone loss and its consequent fractures is critical in the care of aging patients. This article reviews the mechanisms of bone metabolism and the principles of management of bone health in the older population with a history of cancer.

Dual focal adhesion kinase/Pyk2 inhibitor has positive effects on bone tumors: implications for bone metastases

BACKGROUND

Lytic bone metastases occur frequently in cancer patients and present major clinical issues including lack of effective therapies. The mechanism of lytic bone metastases involves interactions between tumor cells, bone matrix, and bone cells. Both focal adhesion kinase (FAK) and Pyk2 are implicated in the biology and physiology of bone and cancer.

METHODS

The efficacy of PF-562,271 was evaluated using MDA-MB-231 cells implanted in the tibia of nude rats. The drug was administered orally at a dose of 5 mg/kg, 7 days per week for 28 days. Serum and urine biomarkers, imaging, and histologic techniques were deployed to monitor tumor take rate, disease progression, and response to therapy.

RESULTS

The compound was well tolerated. Both compound-treated groups demonstrated significant and similar increases in osteocalcin and cancellous bone parameters. Radiographic evaluation of tumor-bearing tibiae revealed tumor expansion in nontreated rats compared with a decrease in tumor growth and signs of bone healing in rats treated with PF-562,271. Tartrate-resistant acid phosphatase and fluorescent in situ hybridization analysis revealed that the majority of bone resorption at the tumor site was performed by osteoclasts of rat origin.

CONCLUSIONS

The oral administration of PF-562,271 at a dose of 5 mg/kg suppressed the growth and local spread of intratibial tumors and restored tumor-induced bone loss. The unique ability of PF-562,271 to both curb tumor growth and safely increase bone formation may be an effective therapy for many cancer patients with bone metastases and cancer-associated osteoporosis.

Osteoclast precursors display dynamic metabolic shifts toward accelerated glucose metabolism at an early stage of RANKL-stimulated osteoclast differentiation

Mature osteoclasts have an increased citric acid cycle and mitochondrial respiration to generate high ATP production and ultimately lead to bone resorption. However, changes in metabolic pathways during osteoclast differentiation have not been fully illustrated. We report that glycolysis and oxidative phosphorylation characterized by glucose and oxygen consumption as well as lactate production were increased during receptor activator of nuclear factor-kappaB ligand (RANKL)-induced osteoclastogenesis from RAW264.7 and bone marrow-derived macrophage cells. Cell proliferation and differentiation varied according to glucose concentrations (0 to 100 mM). Maximal cell growth occurred at 20 mM glucose concentration and differentiation occurred at 5 mM concentration. Despite the similar growth rates exhibited when cultured cells were exposed to either 5 mM or 40 mM glucose, their differentiation was markedly decreased in high glucose concentrations. This finding suggests the possibility that osteoclastogenesis could be regulated by changes in metabolic substrate concentrations. To further address the effect of metabolic shift on osteoclastogenesis, we exposed cultured cells to pyruvate, which is capable of promoting mitochondrial respiration. Treatment of pyruvate synergistically increased osteoclastogenesis through the activation of RANKL-stimulated signals (ERK and JNK). We also found that osteoclastogenesis was retarded by blocking ATP production with either the inhibitors of mitochondrial complexes, such as rotenone and antimycin A, or the inhibitor of ATP synthase, oligomycin. Taken together, these results indicate that glucose metabolism during osteoclast differentiation is accelerated and that a metabolic shift towards mitochondrial respiration allows high ATP production and induces enhanced osteoclast differentiation.

[Osteoporosis in cancer survivors]

The detection of late sequelae in survivors of cancer has become increasingly important as developments in diagnostic and therapeutic methods have led to a more and long-term survival rates in tumoral patients. Osteoporosis is one of such problem that has been increasingly identified in patients with cancer. Significant bone loss and increased risk of fractures have been described in these patients. Medical problems associated with the malignancy or caused by the oncologic treatment are the main factors involved in bone loss. Therefore, patients at risk for bone loss should be undergo preventive or therapeutic interventions at an early enough stage to prevent fractures.

Exercise effects on bone mineral density in women with breast cancer receiving adjuvant chemotherapy

PURPOSE/OBJECTIVES

To test the effects of aerobic and resistance exercise on changes in bone mineral density (BMD) in women newly diagnosed with stage I-III breast cancer receiving chemotherapy.

DESIGN

Randomized clinical trial.

SETTING

Two National Cancer Institute-designated cancer centers in metropolitan areas.

SAMPLE

66 women with stage I-III breast cancer beginning adjuvant chemotherapy.

METHODS

Participants were randomized to aerobic or resistance exercise and usual care. At the beginning of chemotherapy and at six months, patients completed exercise testing and BMD assessment of the lumbar spine by dual energy x-ray absorptionetry.

MAIN RESEARCH VARIABLES

BMD, aerobic capacity, and muscle strength.

FINDINGS

The average decline in BMD was -6.23% for usual care, -4.92% for resistance exercise, and -0.76% for aerobic exercise. Aerobic exercise preserved BMD significantly better compared to usual care. Premenopausal women demonstrated significantly greater declines in BMD than postmenopausal women. Aerobic capacity increased by almost 25% for women in the aerobic exercise group and 4% for resistance exercise. Participants in the usual care group showed a 10% decline in aerobic capacity.

CONCLUSIONS

The data suggest that weight-bearing aerobic exercise attenuates declines in BMD and that aerobic and resistance exercise improve aerobic capacity and muscle strength at a time when women generally show marked declines in functional ability.

IMPLICATIONS FOR NURSING

Exercise may prevent or at least minimize bone loss observed during chemotherapy and may prevent or delay the long-term effects of osteoporosis.

Endocrine Effects of Breast Cancer Treatment

OBJECTIVES

To discuss long-term physical effects of treatment for breast cancer including effects on reproductive, bone, sexual health, and related women's issues.

DATA SOURCES

Research articles, abstracts, literature reviews.

CONCLUSION

Long-term effects of treatment have become increasingly prevalent in breast cancer survivors. The most common are effects on reproductive, bone, and sexual health.

IMPLICATIONS FOR NURSING PRACTICE

Long-term effects of treatment can have a significant negative impact on the long-term health and QOL of women with breast cancer. Oncology nurses are well-positioned to anticipate and address the reproductive and endocrine consequences of breast cancer treatment.

Bone integrity and bone metastases in breast cancer

Individuals with a history of early-stage breast cancer may be at increased risk of osteoporosis related to adjuvant therapy, and those with metastatic breast cancer may experience skeletal-related complications from the cancer affecting the bone. Maintaining bone strength is critical in the care of both early- and late-stage breast cancer patients because fractures are associated with morbidity and mortality. This article reviews the maintenance of bone integrity in women with breast cancer.