Bone mineral density at menopause does not predict breast cancer incidence

The Association between Bone Mineral Density and Risk of Mortality: A Prospective Cohort Study of 233,397 Taiwanese

PURPOSE

Osteoporosis is an important public health challenge given its high prevalence in western populations and the prevalence has shown an upward trend in recent decades in Asia. However, epidemiological evidence on the association between bone mineral density (BMD) and mortality risk in the Asian population is sparse.

METHODS

The Cox proportional hazards model and cause-specific hazard models were used to investigate the association of BMD with the risk of all-cause mortality and cause-specific mortality.

RESULTS

The present study comprised of 3,332,207 person-years with a median follow-up of 14.6 years. 27,508 participants (15,967 men and 11,541 women) died among 233,397 participants (112,348 men and 121,049 women) during the follow-up period. Compared to those with normal BMD level, both men and women with low BMD had a significantly higher risk of all-cause, cardiovascular disease (CVD), and cancer mortality after adjusting for the covariates. [For men with osteoporosis: all-cause: 1.37 (1.27-1.49); CVD: 1.28 (1.08-1.52); cancer: 1.29 (1.12-1.49); For women with osteoporosis: all-cause: 1.72 (1.63-1.82); CVD: 1.85 (1.64-2.08); cancer: 1.47 (1.35-1.61)]. The P for interactions for BMD with sex were significant for all-cause and CVD mortality. The adverse effects of BMD on the risk of all-cause and CVD were higher in women than in men [men vs. women: all-cause: 1.37 (1.27-1.49) vs. 1.72 (1.63-1.82); CVD: 1.28 (1.08-1.52) vs. 1.85 (1.64-2.08)]. In the nonlinear dose-response analyses, the association between BMD increments and all-cause mortality risk shows an L-shaped pattern in men and a similar U-shaped trend in women (P for non-linear association: <0.001). Likewise, a similar L-shaped association was observed between BMD levels and cancer mortality risk in men.

CONCLUSIONS

Low BMD had an increased risk of all-cause, CVD, and cancer mortality in both men and women. Women had a stronger positive association between low BMD and an increased risk of all-cause and CVD mortality compared to men.

Breast Cancer and Bone Mineral Density in a U.S. Cohort of Middle-Aged Women: Associations with Phosphate Toxicity

Breast cancer is associated with phosphate toxicity, the toxic effect from dysregulated phosphate metabolism that can stimulate tumorigenesis. Phosphate toxicity and dysregulated phosphate metabolism are also associated with bone mineral abnormalities, including excessive bone mineral loss and deposition. Based on shared associations with dysregulated phosphate metabolism and phosphate toxicity, a hypothesis proposed in the present mixed methods-grounded theory study posits that middle-aged women with incidence of breast cancer had a greater magnitude of changes in bone mineral density over time compared with women who remained cancer-free. To test this hypothesis, a mixed-effects model was used to analyze the associations of breast cancer incidence with spinal bone mineral density changes in the U.S. Study of Women's Health Across the Nation. Compared with women in the cohort who remained cancer-free, women who self-reported breast cancer had higher bone mineral density at baseline, but had more rapid losses in bone mineral density during follow-up visits. These findings agree with the hypothesis that a greater magnitude of changes in bone mineral density over time is associated with breast cancer in a cohort of middle-aged women. The findings also have implications for studies investigating dysregulated phosphate metabolism and phosphate toxicity as causative factors of bone metastasis in metastatic breast cancer. Additionally, the authors previously found increased breast cancer risk associated with high dietary phosphate intake in the same cohort of middle-aged women, and more studies should investigate a low-phosphorus diet to reduce bone mineral abnormalities and tumorigenesis in breast cancer patients.

Mendelian randomization analyses of associations between breast cancer and bone mineral density

The purpose of this study was to verify whether there is a causal relationship between breast cancer and bone mineral density (BMD). Summary statistics for exposures and outcomes were obtained from corresponding genome-wide association studies. The bidirectional and multivariate mediated Mendelian randomization (MR) analyses were performed. In the bidirectional MR analysis, breast cancer might reduce the BMD of the heel (HE-BMD) (FDR = 1.51 × 10^-4) as might its ER+ subtype (FDR = 1.51 × 10^-4). From BMD to breast cancer, no significant association was found (FDR > 0.05). The mediating MR analysis showed that Higher free testosterone (FT) only mediated the causal relationship between breast cancer and HE-BMD by 2.9%; both ER+ type and FT were independent factors of HE-BMD (ER+: P = 0.021; FT: P = 6.88 × 10^-6). Higher FT could increase the risk of breast cancer (FDR = 1.21 × 10^-3) as could total testosterone (TT) (FDR = 5.81 × 10^-3). Similarly, higher FT could increase the risk of ER+ subtype (FDR = 2.51 × 10^-6) as could TT (FDR = 5.55 × 10^-4). These results indicate that BMD is not a risk factor for breast cancer but breast cancer and its ER+ subtype are risk factors for BMD loss. Furthermore, higher FT and TT levels are associated with both an increased incidence of breast cancer and increased bone density.

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.

Evaluation of baseline fracture risk in younger postmenopausal women with breast cancer using different risk assessment methods

OBJECTIVE

Controversy exists about the impact of bone mineral density (BMD) and fracture risk in newly diagnosed patients with breast cancer (BC). It is presumed that there are differences in BMD between women with BC and healthy controls. BMD is therefore considered as a potential marker to predict BC risk. This study was conducted to investigate the association of BMD, trabecular bone score (TBS) and fracture risk in younger postmenopausal women with hormone responsive BC.

METHODS

Overall, 343 women were examined. Women with BC were matched to a control group of the general population. Forty-nine women and fifty-nine controls were included in the final analysis. All subjects underwent dual energy x-ray absorptiometry (DXA) of the lumbar spine, femoral neck, and the total hip to evaluate bone mineral density. The 10-year fracture risk for a major osteoporotic fracture was assessed using the FRAX-score and the TBS-adjusted FRAX-Score, respectively.

RESULTS

Lumbar and femoral neck BMD were similar in BC patients and controls. No difference was found for TBS of the spine (1.38 ± 0.1 vs.1.36 ± 0.09) in the BC and the control group, respectively (p = 0.19). The 10- year probability for a major osteoporotic fracture (MoF) or femoral neck (FN) fracture was 6.1 (± 2.6%) and 0.9 (± 1.2%) in the BC group vs. 6.7 (± 3.5%) (p = 0.33) and 0.9 (± 1.1%) (p = 0.73) in the control group.

CONCLUSION

Postmenopausal women younger than 60 years with breast cancer do not show any differences in baseline BMD, TBS, or TBS adjusted FRAX in comparison to controls.

High Bone Mineral Density of the Lumbar Spine Is Positively Associated with Breast Cancer

Objective

The objective of this study was to verify possible associations between bone mineral density (BMD) and breast cancer in recently diagnosed women in the Brazilian Mid-west region, considering the menopausal status of patients.

Methods

A case-control study was conducted with 142 cases of breast cancer and 234 controls matched by for age, body mass index (BMI), and menopausal status (pre- and postmenopause), performed in a university hospital in the Brazilian Mid-west. Lumbar spine (L1–L4), femoral neck, and total femur BMD were measured by the dual-energy X-ray absorptiometry (DXA) method. For association, a logistic regression analysis was used.

Results

Women in the highest lumbar spine BMD quartile presented had a higher chance of developing breast cancer (OR = 2.31; 1.02–5.25; p = 0.045), after adjusting for the confounding variables. Nonetheless, there were no statistically significant differences in the association between pre- and postmenopause in that quartile and breast cancer.

Conclusions

High lumbar spine BMD was positively associated with breast cancer in the total sample. In evaluating the BMD of the femoral neck and total femur, such an association was not observed.

Relationship between bone mineral density and the risk of breast cancer: a systematic review and dose-response meta-analysis of ten cohort studies

Purpose

The evidence from recent epidemiological studies investigating the relationship between bone mineral density (BMD) and the risk of breast cancer (BC) remains inconsistent.

Materials and methods

The PubMed, EMBASE, and Web of Science databases were comprehensively searched by two independent authors to identify related cohort studies from the inception of the databases through January 31, 2018. Similarly, two researchers separately extracted the data from the selected studies, and any differences were resolved by discussion. Summarized relative risks (RRs) and 95% CIs were summarized via inverse variance weighted random-effects meta-analysis. Heterogeneity among studies was assessed with the I² statistic.

Results

Ten studies with 1,522 BC patients among 81,902 participants were included in this meta-analysis. Compared to the participants with the lowest BMD at the lumbar spine, those with the highest BMD had a significantly lower RR for BC (RR =0.75; 95% CI =0.60–0.93; I²=23.0%). In the subgroup analyses, although the directions of the results were consistent with those of the main findings, not all showed statistical significance. We failed to detect an association between BMD at the femoral neck or total hip and the risk of BC (RR =0.94; 95% CI =0.66–1.33; I²=72.5%). Furthermore, the results of the dose–response analysis did not show a significant association between BMD at the lumbar spine, femoral neck, or total hip and the risk of BC. Funnel plot and statistical analyses showed no evidence of publication bias.

Conclusion

There is no relationship between BMD and the risk of BC. More prospective cohort studies are warranted to further investigate this issue.

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.

Does adjuvant chemotherapy change bone mineral density and related serum biomarkers in women with breast cancer?

Background:

The primary objective of this study was to assess BMD change in Iranian females with breast cancer.

Methods:

A sample of 73 female breast cancer patients treated with adjuvant chemotherapy either alone or followed by radiotherapy between March 2013 and February 2016 were considered for this study. Bone mineral density (BMD) change was evaluated by measuring z-score of lumbar spine, femoral neck (right and left side) as well as biochemical measurements. With respect to WHO categorization for the treatment of osteoporosis, patients were categorized as normal BMD, osteopenic and all analysis was done separately.

Results:

In women with normal BMD, lumbar spine and femoral neck (right side) z-score decreased significantly by 15.7 and 39%, respectively (p<0.05). In osteoporosis group, there was no BMD change in any of the lumbar or femoral neck z-scores. However, in osteopenic patients, femoral neck BMD decreased significantly by 40.9% after 8 months (p=0.003). The level of all measured biomedical markers such as Ca, Alb, P and vitamin OHD decreased significantly in a follow-up visit in both osteoporosis and normal BMD.

Conclusion:

Our results revealed that adjuvant chemotherapy led to unfavorable effects on lumbar spine and femoral neck means z-score during 8 months. Also, unfavorable changes in biochemical markers appeared in all groups.

Multimorbidity in women with and without osteoporosis: results from a large US retrospective cohort study 2004-2009

To determine the incidence of comorbidities in women with and without osteoporosis, incidence rates per 1,000 person-years were calculated using electronic health records from an integrated healthcare system. The overall comorbidity burden and health service utilization were greater in women with osteoporosis than in the controls.

INTRODUCTION

This retrospective cohort study describes the incidence of an array of comorbidities in women with and without osteoporosis (OP).

METHODS

Using electronic health records from an integrated healthcare system, we identified 22,414 women aged 55-89 years with OP and 22,414 age-matched controls without OP. Incidence rates (IRs) per 1,000 person-years (P-Y) were calculated and 95% confidence intervals (CI) were estimated.

RESULTS

Women with OP had significantly more comorbidities, medications, hospitalizations, and outpatient visits than the controls. Most cardiac comorbidity rates were 20-25% lower in the OP cohort than in the control cohort. Hypertension had the largest rate difference; the IR was 42.0 per 1,000 P-Y (95% CI 40.2-44.0) in the OP cohort compared to 94.0 (95% CI 90.7-97.4) in the control cohort. Rates for cerebrovascular disease were similar for both cohorts at 26 per 1,000 P-Y. Bronchitis, sinusitis, and cystitis were each 55 per 1,000 P-Y in the OP cohort, whereas they ranged from 28 to 34 per 1,000 P-Y in the controls. The OP cohort had decreased incidence of ovarian, uterine, colorectal, and liver cancers and increased incidence of lung cancer, breast cancer, and multiple myeloma, compared to the non-OP cohort. Falls, depression, vision, and musculoskeletal issues were higher for the OP cohort than the controls.

CONCLUSIONS

This study demonstrates the high disease burden in women with OP. This knowledge may help guide the clinical management of this population and may aid in the interpretation of adverse events in randomized clinical trials of OP therapies.

Association between bone mineral density and incidence of breast cancer

Introduction

Previous studies have suggested an inverse relationship between bone mineral density (BMD) and breast cancer incidence. The primary objective of this study was to assess whether BMD is associated with risk of subsequent breast cancer occurrence in the female population of southern Israel.

Methods

The electronic medical charts of women who underwent BMD at the Soroka Medical Center (SMC) between February 2003 and March 2011 were screened for subsequent breast cancer diagnoses. Women were divided by tertiles of BMD at 3 skeletal sites: lumbar spine (LS, L1–4), total hip (TH) and femoral neck (FN). The incidence of breast cancer was calculated.

Results

Of 15268 women who underwent BMD testing, 86 were subsequently diagnosed with breast cancer. Most women in the study were older than 50 years (94.2% and 92.7%, respectively; p = 0.597). Women who subsequently developed breast cancer had a higher mean body-mass index (BMI) (30.9±5.5 vs. 29.1±5.7 p = 0.004) and the mean BMD Z-score was significantly higher than in those without breast cancer for all 3 skeletal sites (LS: 0.36±1.58 vs. −0.12±1.42, p = 0.002; TH: 0.37±1.08 vs. 0.03±1.02, p = 0.002; FN: 0.04±0.99 vs. −0.18±0.94; p = 0.026). Women in the highest Z-score tertiles at the FN and TH had a higher chance of developing breast cancer compared to the lowest tertile; odds ratio of 2.15, 2.02, respectively (P = 0.004 and 0.01 respectively). No association was found between the BMD Z-score and the stage, histology, grade or survival from breast cancer.

Conclusions

This study provides additional support for an inverse association between BMD and the risk of breast cancer.

Does anastrozole affect bone resorption similarly in early and late postmenopausal women?

The aim of this study was to determine whether the bone-resorption response to anastrozole differed according to initial patient age in postmenopausal women with breast cancer in a cross-sectional study. Second-morning void urines were collected for measurement of urinary cross-linked N-telopeptide of type I collagen (uNTx, corrected for creatinine and log-transformed) from postmenopausal women, 99 with breast cancer on anastrozole (ABC), 88 with newly diagnosed breast cancer (NDBC), and 137 community-dwelling healthy control (HC) women. Bone mineral density (BMD) was also measured at the lumbar spine (LS, L2-L4) and the femoral neck (FN) in the ABC group. uNTx (nanomole bone collagen equivalents/millimole creatinine) levels increased with age in HC subjects. In patients <70 years, anastrozole treatment led to a significant increase in uNTx compared with age-related HC subjects (1.74 vs. 1.55, P < 0.005). Patients >70 years showed no such increase compared to HC (1.72 vs. 1.69, nonsignificant); however, NDBC women >70 years had uNTx levels significantly lower than HC women (1.59 vs. 1.69, P < 0.05). There was no difference in uNTx levels above and below the age of 70 years in NDBC women (1.56 vs. 1.59, nonsignificant). ABC women were more likely to have a positive LS BMD z score than age-matched controls. Anastrozole treatment increases bone turnover more in younger postmenopausal women with breast cancer than in older women compared to healthy controls. Higher LS BMD in ABC patients may help protect against fracture.

Fracture risk prediction using BMD and clinical risk factors in early postmenopausal women: sensitivity of the WHO FRAX tool

The aim of this prospective study was (1) to identify significant and independent clinical risk factors (CRFs) for major osteoporotic (OP) fracture among peri- and early postmenopausal women, (2) to assess, in this population, the discriminatory capacity of FRAX and bone mineral density (BMD) for the identification of women at high risk of fracture, and (3) to assess whether adding risk factors to either FRAX or BMD would improve discriminatory capacity. The study population included 2651 peri- and early postmenopausal women [mean age (+/- SD): 54 +/- 4 years] with a mean follow-up period of 13.4 years (+/-1.4 years). At baseline, a large set of CRFs was recorded, and vertebral BMD was measured (Lunar, DPX) in all women. Femoral neck BMD also was measured in 1399 women in addition to spine BMD. Women with current or past OP treatment for more than 3 months at baseline (n = 454) were excluded from the analyses. Over the follow-up period, 415 women sustained a first low-energy fracture, including 145 major OP fractures (108 wrist, 44 spine, 20 proximal humerus, and 13 hip). In Cox multivariate regression models, only 3 CRFs were significant predictors of a major OP fracture independent of BMD and age: a personal history of fracture, three or more pregnancies, and current postmenopausal hormone therapy. In the subsample of women who had a hip BMD measurement and who were not receiving OP therapy (including hormone-replacement therapy) at baseline, mean FRAX value was 3.8% (+/-2.4%). The overall discriminative value for fracture, as measured by the area under the Receiver Operating Characteristic (ROC) curve (AUC), was equal to 0.63 [95% confidence interval (CI) 0.56-0.69] and 0.66 (95% CI 0.60-0.73), respectively, for FRAX and hip BMD. Sensitivity of both tools was low (ie, around 50% for 30% of the women classified as the highest risk). Adding parity to the predictive model including FRAX or using a simple risk score based on the best predictive model in our population did not significantly improve the discriminatory capacity over BMD alone. Only a limited number of clinical risk factors were found associated with the risk of major OP fracture in peri- and early postmenopausal women. In this population, the FRAX tool, like other risk scores combining CRFs to either BMD or FRAX, had a poor sensitivity for fracture prediction and did not significantly improve the discriminatory value of hip BMD alone.

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.