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Adams A, Jakob T, Huth A, Monsef I, Ernst M, Kopp M, Caro-Valenzuela J, Wöckel A, Skoetz N. Bone-modifying agents for reducing bone loss in women with early and locally advanced breast cancer: a network meta-analysis. Cochrane Database Syst Rev 2024; 7:CD013451. [PMID: 38979716 PMCID: PMC11232105 DOI: 10.1002/14651858.cd013451.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
BACKGROUND Bisphosphonates and receptor activator of nuclear factor-kappa B ligand (RANKL)-inhibitors are amongst the bone-modifying agents used as supportive treatment in women with breast cancer who do not have bone metastases. These agents aim to reduce bone loss and the risk of fractures. Bisphosphonates have demonstrated survival benefits, particularly in postmenopausal women. OBJECTIVES To assess and compare the effects of different bone-modifying agents as supportive treatment to reduce bone mineral density loss and osteoporotic fractures in women with breast cancer without bone metastases and generate a ranking of treatment options using network meta-analyses (NMAs). SEARCH METHODS We identified studies by electronically searching CENTRAL, MEDLINE and Embase until January 2023. We searched various trial registries and screened abstracts of conference proceedings and reference lists of identified trials. SELECTION CRITERIA We included randomised controlled trials comparing different bisphosphonates and RANKL-inihibitors with each other or against no further treatment or placebo for women with breast cancer without bone metastases. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed the risk of bias of included studies and certainty of evidence using GRADE. Outcomes were bone mineral density, quality of life, overall fractures, overall survival and adverse events. We conducted NMAs and generated treatment rankings. MAIN RESULTS Forty-seven trials (35,163 participants) fulfilled our inclusion criteria; 34 trials (33,793 participants) could be considered in the NMA (8 different treatment options). Bone mineral density We estimated that the bone mineral density of participants with no treatment/placebo measured as total T-score was -1.34. Evidence from the NMA (9 trials; 1166 participants) suggests that treatment with ibandronate (T-score -0.77; MD 0.57, 95% CI -0.05 to 1.19) may slightly increase bone mineral density (low certainty) and treatment with zoledronic acid (T-score -0.45; MD 0.89, 95% CI 0.62 to 1.16) probably slightly increases bone mineral density compared to no treatment/placebo (moderate certainty). Risedronate (T-score -1.08; MD 0.26, 95% CI -0.32 to 0.84) may result in little to no difference compared to no treatment/placebo (low certainty). We are uncertain whether alendronate (T-score 2.36; MD 3.70, 95% CI -2.01 to 9.41) increases bone mineral density compared to no treatment/placebo (very low certainty). Quality of life No quantitative analyses could be performed for quality of life, as only three studies reported this outcome. All three studies showed only minimal differences between the respective interventions examined. Overall fracture rate We estimated that 70 of 1000 participants with no treatment/placebo had fractures. Evidence from the NMA (16 trials; 19,492 participants) indicates that treatment with clodronate or ibandronate (42 of 1000; RR 0.60, 95% CI 0.39 to 0.92; 40 of 1000; RR 0.57, 95% CI 0.38 to 0.86, respectively) decreases the number of fractures compared to no treatment/placebo (high certainty). Denosumab or zoledronic acid (51 of 1000; RR 0.73, 95% CI 0.52 to 1.01; 55 of 1000; RR 0.79, 95% CI 0.56 to 1.11, respectively) probably slightly decreases the number of fractures; and risedronate (39 of 1000; RR 0.56, 95% CI 0.15 to 2.16) probably decreases the number of fractures compared to no treatment/placebo (moderate certainty). Pamidronate (106 of 1000; RR 1.52, 95% CI 0.75 to 3.06) probably increases the number of fractures compared to no treatment/placebo (moderate certainty). Overall survival We estimated that 920 of 1000 participants with no treatment/placebo survived overall. Evidence from the NMA (17 trials; 30,991 participants) suggests that clodronate (924 of 1000; HR 0.95, 95% CI 0.77 to 1.17), denosumab (927 of 1000; HR 0.91, 95% CI 0.69 to 1.21), ibandronate (915 of 1000; HR 1.06, 95% CI 0.83 to 1.34) and zoledronic acid (925 of 1000; HR 0.93, 95% CI 0.76 to 1.14) may result in little to no difference regarding overall survival compared to no treatment/placebo (low certainty). Additionally, we are uncertain whether pamidronate (905 of 1000; HR 1.20, 95% CI 0.81 to 1.78) decreases overall survival compared to no treatment/placebo (very low certainty). Osteonecrosis of the jaw We estimated that 1 of 1000 participants with no treatment/placebo developed osteonecrosis of the jaw. Evidence from the NMA (12 trials; 23,527 participants) suggests that denosumab (25 of 1000; RR 24.70, 95% CI 9.56 to 63.83), ibandronate (6 of 1000; RR 5.77, 95% CI 2.04 to 16.35) and zoledronic acid (9 of 1000; RR 9.41, 95% CI 3.54 to 24.99) probably increases the occurrence of osteonecrosis of the jaw compared to no treatment/placebo (moderate certainty). Additionally, clodronate (3 of 1000; RR 2.65, 95% CI 0.83 to 8.50) may increase the occurrence of osteonecrosis of the jaw compared to no treatment/placebo (low certainty). Renal impairment We estimated that 14 of 1000 participants with no treatment/placebo developed renal impairment. Evidence from the NMA (12 trials; 22,469 participants) suggests that ibandronate (28 of 1000; RR 1.98, 95% CI 1.01 to 3.88) probably increases the occurrence of renal impairment compared to no treatment/placebo (moderate certainty). Zoledronic acid (21 of 1000; RR 1.49, 95% CI 0.87 to 2.58) probably increases the occurrence of renal impairment while clodronate (12 of 1000; RR 0.88, 95% CI 0.55 to 1.39) and denosumab (11 of 1000; RR 0.80, 95% CI 0.54 to 1.19) probably results in little to no difference regarding the occurrence of renal impairment compared to no treatment/placebo (moderate certainty). AUTHORS' CONCLUSIONS When considering bone-modifying agents for managing bone loss in women with early or locally advanced breast cancer, one has to balance between efficacy and safety. Our findings suggest that bisphosphonates (excluding alendronate and pamidronate) or denosumab compared to no treatment or placebo likely results in increased bone mineral density and reduced fracture rates. Our survival analysis that included pre and postmenopausal women showed little to no difference regarding overall survival. These treatments may lead to more adverse events. Therefore, forming an overall judgement of the best ranked bone-modifying agent is challenging. More head-to-head comparisons, especially comparing denosumab with any bisphosphonate, are needed to address gaps and validate the findings of this review.
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Affiliation(s)
- Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Tina Jakob
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Alessandra Huth
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Institute of Public Health, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Moritz Ernst
- Cochrane Haematology, Institute of Public Health, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marco Kopp
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia Caro-Valenzuela
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Achim Wöckel
- Department of Gynaecology and Obstetrics, University Hospital of Würzburg, Würzburg, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Institute of Public Health, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Wong PK, Chen W. Cancer survivorship and bone health. THE LANCET. HEALTHY LONGEVITY 2024; 5:e168-e169. [PMID: 38335984 DOI: 10.1016/s2666-7568(24)00022-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Affiliation(s)
- Peter Kk Wong
- Department of Rheumatology, Westmead Hospital, Sydney, NSW 2145, Australia; Westmead Clinical School, Faculty of Medicine and Health Sciences, The University of Sydney, NSW, Australia; Rural Medical School, Coffs Harbour, Faculty of Medicine, University of New South Wales, NSW, Australia.
| | - Weiwen Chen
- Department of Endocrinology, St Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia; Healthy Ageing Theme, The Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW, Australia
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Abstract
Individuals with cancer face unique risk factors for osteoporosis and fractures. Clinicians must consider the additive effects of cancer-specific factors, including treatment-induced bone loss, and premorbid fracture risk, utilizing FRAX score and bone mineral densitometry when available. Pharmacologic therapy should be offered as per cancer-specific guidelines, when available, or local general osteoporosis guidelines informed by clinical judgment and patient preferences. Our objective was to review and summarize the epidemiologic burden of osteoporotic fracture risk and fracture risk assessment in adults with cancer, and recommended treatment thresholds for cancer treatment-induced bone loss, with specific focus on breast, prostate, thyroid, gynecological, multiple myeloma, and hematopoietic stem cell transplant. This narrative review was informed by PubMed searches to July 25, 2022, that combined terms for cancer, stem cell transplantation, fracture, bone mineral density (BMD), trabecular bone score, FRAX, Garvan nomogram or fracture risk calculator, QFracture, prediction, and risk factors. The literature informs that cancer can impact bone health in numerous ways, leading to both systemic and localized decreases in BMD. Many cancer treatments can have detrimental effects on bone health. In particular, hormone deprivation therapies for hormone-responsive cancers such as breast cancer and prostate cancer, and hematopoietic stem cell transplant for hematologic malignancies, adversely affect bone turnover, resulting in osteoporosis and fractures. Surgical treatments such as hysterectomy with bilateral salpingo-oophorectomy for gynecological cancers can also lead to deleterious effects on bone health. Radiation therapy is well documented to cause localized bone loss and fractures. Few studies have validated the use of fracture risk prediction tools in the cancer population. Guidelines on cancer-specific treatment thresholds are limited, and major knowledge gaps still exist in fracture risk and fracture risk assessment in patients with cancer. Despite the limitations of current knowledge on fracture risk assessment and treatment thresholds in patients with cancer, clinicians must consider the additive effects of bone damaging factors to which these patients are exposed and their premorbid fracture risk profile. Pharmacologic treatment should be offered as per cancer-specific guidelines when available, or per local general osteoporosis guidelines, in accordance with clinical judgment and patient preferences.
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Affiliation(s)
- Carrie Ye
- University of Alberta, Edmonton, Canada.
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Wang Y, Jing F, Wang H. Role of Exemestane in the Treatment of Estrogen-Receptor-Positive Breast Cancer: A Narrative Review of Recent Evidence. Adv Ther 2022; 39:862-891. [PMID: 34989983 DOI: 10.1007/s12325-021-01924-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/14/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Breast cancer (BC) is the most common type of cancer diagnosed among women worldwide with an estimated 2.3 million new cases every year. Almost two-thirds of all patients with BC have estrogen receptor-positive (ER+) tumors. In this review, the clinical evidence of exemestane in different treatment settings in ER+ BC is presented and summarized. SEARCH STRATEGY A search strategy with the keywords "breast cancer [MeSH Terms]" AND "exemestane [Title/Abstract]" was devised and a search was performed in PubMed. RESULTS The efficacy of exemestane in different treatment settings has been established by numerous clinical studies. Exemestane is recommended as an adjuvant treatment in postmenopausal women previously treated with tamoxifen in trials comparing 5 years of tamoxifen with 2-3 years of tamoxifen combined with 2-3 years of exemestane, which proved that treatment with exemestane provided better survival outcomes. Similarly, exemestane could be considered as a safe treatment option for neoadjuvant treatment, prevention of chemotherapy, and treatment of advanced BC either alone or in combination with other targeted therapy drugs in both pre- and postmenopausal women. CONCLUSION Exemestane could be considered as a reasonable therapeutic option in the treatment of ER+ BC at any stage in pre- and postmenopausal women.
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Sestak I, Blake G, Patel R, Cuzick J, Howell A, Coleman R, Eastell R. Off-treatment bone mineral density changes in postmenopausal women receiving anastrozole for 5 years: 7-year results from the IBIS-II prevention trial. Br J Cancer 2021; 124:1373-1378. [PMID: 33495601 PMCID: PMC8039042 DOI: 10.1038/s41416-020-01228-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 12/01/2020] [Accepted: 12/10/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Anastrozole has been associated with substantial accelerated bone mineral density (BMD) loss during active treatment. METHODS One thousand four hundred and ten women were included in a BMD substudy and stratified into three strata according to their baseline T-score at spine or femoral neck. The primary objective of this analysis was to investigate whether DXA BMD at the spine and hip changed two years after treatment cessation (between years 5 and 7) in those who did not receive risedronate. RESULTS Five- and seven-year BMD data were available for a total of 528 women who did not receive risedronate. In women with normal BMD at baseline, an increase in BMD at the lumbar spine after anastrozole withdrawal was observed 1.25% (95% CI 0.73 to 1.77) (P = 0.0004), which was larger than in those on placebo (0.14% (-0.29 to 0.56))). At the hip, BMD remained unchanged between years 5 and 7 for those previously on anastrozole but continued to a decrease in those who had been randomised to placebo (-1.35% (-1.70 to -0.98)). CONCLUSIONS These are the first results reporting BMD changes after stopping anastrozole in a breast cancer prevention setting. Our results show that the negative effects of anastrozole on BMD in the preventive setting are partially reversible.
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Affiliation(s)
- Ivana Sestak
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Glen Blake
- School of Biomedical Engineering & Imaging Sciences, King's College London, St Thomas' Hospital, London, SE1 7EH, UK
| | - Raj Patel
- Imperial College London, London, SW7 2AZ, UK
| | - Jack Cuzick
- Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
| | - Anthony Howell
- Division of Cancer Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Robert Coleman
- Department of Oncology and Metabolism, University of Sheffield, Western Bank, Sheffield, S10 2TN, UK
| | - Richard Eastell
- Department of Oncology and Metabolism, University of Sheffield, Western Bank, Sheffield, S10 2TN, UK
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Mandó P, Hirsch I, Waisberg F, Ostinelli A, Luca R, Pranevicene B, Ferreyra Camacho A, Enrico D, Chacon M. Appraising the quality of meta-analysis for breast cancer treatment in the adjuvant setting: A systematic review. Cancer Treat Res Commun 2021; 27:100358. [PMID: 33957603 DOI: 10.1016/j.ctarc.2021.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Breast cancer is the tumor with highest incidence in women worldwide and adjuvant treatment is extremely important to achieve disease control. Given the relevance of systematic reviews, their rigor should be warranted to avoid biased conclusions. Our objective was to investigate the methodological quality of meta-analysis of early breast cancer adjuvant treatment. MATERIAL AND METHODS Comprehensive searches were performed using electronic databases from 1/1/2007 to 11/12/2018. All studies identified as a systematic review with meta-analysis investigating the efficacy of breast cancer adjuvant treatments were included. Two reviewers independently assessed titles and abstracts, then full-texts for eligibility. Quality was assessed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) version 2 tool. RESULTS Of 950 citations retrieved, 66 studies (7.0%) were deemed eligible. Methodological quality was highly variable, median AMSTAR score 8.5 (IQR 7-9.5) and range 0-16. There was a weak positive correlation between journal impact factor and AMSTAR score (r = 0.17) and citation rate and AMSTAR score (r = 0.16). Cochrane Systematic Reviews were of higher quality than reviews from other journals. Overall confidence was critically low for 61 (92.4%) studies, and the least well-reported domains were the statement of conflict of interest and funding source for the included studies (4.6%), the report of a pre-defined study protocol (15.2%), and the description of details of excluded studies (6.1%). CONCLUSIONS Our findings reinforce concerns about the design, conduction and interpretation of meta-analysis in current literature. Methodological quality should be carefully considered and journal editors, decision makers and readers in general, must follow a critical approach to this studies.
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Affiliation(s)
- Pablo Mandó
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; CEMIC, Galvan 4102, Ciudad de Buenos Aires, CP 1431, Argentina.
| | - Ian Hirsch
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Hospital General de Agudos Teodoro Álvarez, Juan Felipe Aranguren 2701, Ciudad de Buenos Aires, CP1406, Argentina
| | - Federico Waisberg
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Alexis Ostinelli
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
| | - Romina Luca
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Belen Pranevicene
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Augusto Ferreyra Camacho
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Diego Enrico
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina
| | - Matías Chacon
- Argentine Association of Clinical Oncology, Gorostiaga 2450, Ciudad de Buenos Aires, CP1426, Argentina; Instituto Alexander Fleming, Cramer 1180, Ciudad de Buenos Aires, CP1426, Argentina
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Walsh EM, Smith KL, Stearns V. Management of hormone receptor-positive, HER2-negative early breast cancer. Semin Oncol 2020; 47:187-200. [PMID: 32546323 PMCID: PMC7374796 DOI: 10.1053/j.seminoncol.2020.05.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 12/24/2022]
Abstract
The majority of breast cancers are diagnosed at an early stage and are hormone receptor (HR)-positive and human epidermal growth factor receptor 2 (HER2)-negative. Significant advances have been made in the management of early stage HR-positive, HER2-negative breast cancer, resulting in improved survival outcomes. In this review, we discuss important factors to consider in the management of this disease. In particular, we discuss the role of adjuvant endocrine therapy, specific endocrine therapy agents, the duration of adjuvant endocrine therapy, treatment-related side effects, and the role of genomic assays and other biomarkers when considering treatment recommendations for individuals with HR-positive, HER2-negative early breast cancer. Finally, we address emerging data to individualize therapeutic decision-making and provide future considerations.
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Affiliation(s)
- Elaine M Walsh
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Karen L Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD
| | - Vered Stearns
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD.
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Jakob T, Monsef I, Kuhr K, Adams A, Maurer C, Wöckel A, Skoetz N. Bone-modifying agents for the prevention of bone loss in women with early or locally advanced breast cancer: a systematic review and network meta-analysis. Hippokratia 2019. [DOI: 10.1002/14651858.cd013451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tina Jakob
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematological Malignancies; University of Cologne; Kerpener Str. 62 Cologne Germany
| | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematological Malignancies; University of Cologne; Kerpener Str. 62 Cologne Germany
| | - Kathrin Kuhr
- Faculty of Medicine and University Hospital Cologne, Institute of Medical Statistics and Computational Biology; University of Cologne; Kerpener Str. 62 Cologne Germany 50937
| | - Anne Adams
- Faculty of Medicine and University Hospital Cologne, Institute of Medical Statistics and Computational Biology; University of Cologne; Kerpener Str. 62 Cologne Germany 50937
| | - Christian Maurer
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; University of Cologne; Kerpener Str. 62 Cologne Germany 50937
| | - Achim Wöckel
- University Hospital of Würzburg; Department of Gynaecology and Obstetrics; Josef-Schneider-Straße 2 Würzburg Germany 97080
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Cancer; University of Cologne; Kerpener Str. 62 Cologne Germany 50937
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Pedersini R, Amoroso V, Maffezzoni F, Gallo F, Turla A, Monteverdi S, Ardine M, Ravanelli M, Vassalli L, Rodella F, Formenti AM, Dalla Volta A, Simoncini EL, Giustina A, Maroldi R, Berruti A. Association of Fat Body Mass With Vertebral Fractures in Postmenopausal Women With Early Breast Cancer Undergoing Adjuvant Aromatase Inhibitor Therapy. JAMA Netw Open 2019; 2:e1911080. [PMID: 31560383 PMCID: PMC6777242 DOI: 10.1001/jamanetworkopen.2019.11080] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Aromatase inhibitors induce a profound depletion in serum estrogen levels. Postmenopausal obese women receiving aromatase inhibitor therapy may be at increased risk of bone fractures owing to the detrimental association of adiposity with bone quality and the loss of the protective effect of estrogens on bone mineral density. OBJECTIVE To determine whether fat body mass (FBM), as measured by dual-energy x-ray absorptiometry, is associated with vertebral fracture prevalence in postmenopausal women undergoing adjuvant aromatase inhibitor therapy for breast cancer. DESIGN, SETTING, AND PARTICIPANTS In this single-center, cross-sectional study, 556 postmenopausal women with early-stage breast cancer were consecutively enrolled from October 15, 2013, to June 30, 2018, and stratified according to whether they were aromatase inhibitor-naive or aromatase inhibitor-treated for at least 2 years. The database was locked on December 31, 2018, and data analysis was completed on February 28, 2019. Eligible patients in both groups had normal renal function, no metabolic diseases, and no previous or current treatment with antiosteoporotic drugs or glucocorticoids. Previous chemotherapy, but not tamoxifen, was permitted. Data were gathered once, at baseline. MAIN OUTCOMES AND MEASURES Vertebral fracture prevalence associated with FBM in aromatase inhibitor-naive and aromatase inhibitor-treated patients. RESULTS Of the 556 women enrolled, the mean age was 63.0 years (95% CI, 62.2-63.8 years). The 195 aromatase inhibitor-treated patients were older than the 361 aromatase inhibitor-naive patients (mean age, 66.1 vs 61.3 years; P < .001), had a higher body mass index (mean, 26.4 vs 25.3; P = .009), were less likely to engage in physical activity (65.3% vs 73.7%; P = .03), and were less likely to consume alcoholic beverages (68.4% vs 80.9%; P = .001). Among the aromatase inhibitor-naive patients, the vertebral fracture prevalence was higher in the subgroup with FBM below the median value than in those with high FBM, but the difference was not statistically significant (19.2% vs 13.3%; P = .13). Conversely, the proportion of vertebral fractures in the aromatase inhibitor-treated group was 20.0% in patients with low FBM vs 33.3% in patients with high FBM (P = .04). An opposite trend in the association of FBM with vertebral fracture prevalence according to aromatase inhibitor group was shown by multivariable analysis in the propensity score-matched sample: odds ratio, 0.38 (95% CI, 0.12-1.19) and 1.94 (95% CI, 0.67-5.64) in the aromatase inhibitor-naive and aromatase inhibitor-treated groups, respectively (odds ratio for the interaction, 5.77 [95% CI, 1.08-30.81]; P for interaction term = .03). CONCLUSIONS AND RELEVANCE Fat body mass may be associated with fragility-related fractures in patients with breast cancer who undergo aromatase inhibitor therapy. If these data are confirmed, obesity could be included in the algorithm for assessing fracture risk and selecting patients to receive bone resorption inhibitors.
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Affiliation(s)
- Rebecca Pedersini
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Vito Amoroso
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Filippo Maffezzoni
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Fabio Gallo
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Antonella Turla
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Sara Monteverdi
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Mara Ardine
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Marco Ravanelli
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Lucia Vassalli
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Filippo Rodella
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Anna Maria Formenti
- Division of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - Alberto Dalla Volta
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | | | - Andrea Giustina
- Division of Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - Roberto Maroldi
- Radiology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
| | - Alfredo Berruti
- Medical Oncology Unit, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Brescia, Italy
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Bouvard B, Confavreux CB, Briot K, Bonneterre J, Cormier C, Cortet B, Hannoun-Lévi JM, Hennequin C, Javier RM, Kerbrat P, Lespessailles E, Lesur A, Mayeur D, Paccou J, Trémollières F, Vieillard MH, Debiais F. French recommendations on strategies for preventing and treating osteoporosis induced by adjuvant breast cancer therapies. Joint Bone Spine 2019; 86:542-553. [PMID: 31352137 DOI: 10.1016/j.jbspin.2019.07.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2019] [Indexed: 01/12/2023]
Abstract
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.
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Affiliation(s)
| | - Cyrille B Confavreux
- Université de Lyon, Service de rhumatologie, Centre Hospitalier Lyon Sud, Hospices civils de Lyon, 69310 Pierre Bénite, France
| | - Karine Briot
- Service de rhumatologie, Hôpital Cochin 74014 Paris, France
| | - Jacques Bonneterre
- Département de cancérologie sénologique, Centre Oscar Lambret, 59000 Lille, France
| | | | - Bernard Cortet
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | | | - Christophe Hennequin
- Service de cancérologie et radiothérapie, Hôpital Saint Louis, 75010 Paris, France
| | - Rose-Marie Javier
- Service de rhumatologie, CHU de Strasbourg, 67000 Strasbourg, France
| | - Pierre Kerbrat
- Service d'oncologie, Centre Eugène Marquis, 35042 Rennes, France
| | | | - Anne Lesur
- Service d'oncologie, Institut Alexis Vautrin, 54519 Vandoeuvre-Les-Nancy, France
| | - Didier Mayeur
- Centre hospitalier de Versailles, 78150 Le Chesnay, France
| | - Julien Paccou
- Service de rhumatologie, CHU de Lille, 59037 Lille, France
| | | | - Marie-Hélène Vieillard
- Service de rhumatologie, CHU de Lille, 59037 Lille, France; Département des soins de support, Centre Oscar Lambret, 59000 Lille, France
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11
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Wöckel A, Festl J, Stüber T, Brust K, Krockenberger M, Heuschmann PU, Jírů-Hillmann S, Albert US, Budach W, Follmann M, Janni W, Kopp I, Kreienberg R, Kühn T, Langer T, Nothacker M, Scharl A, Schreer I, Link H, Engel J, Fehm T, Weis J, Welt A, Steckelberg A, Feyer P, König K, Hahne A, Baumgartner T, Kreipe HH, Knoefel WT, Denkinger M, Brucker S, Lüftner D, Kubisch C, Gerlach C, Lebeau A, Siedentopf F, Petersen C, Bartsch HH, Schulz-Wendtland R, Hahn M, Hanf V, Müller-Schimpfle M, Henscher U, Roncarati R, Katalinic A, Heitmann C, Honegger C, Paradies K, Bjelic-Radisic V, Degenhardt F, Wenz F, Rick O, Hölzel D, Zaiss M, Kemper G, Budach V, Denkert C, Gerber B, Tesch H, Hirsmüller S, Sinn HP, Dunst J, Münstedt K, Bick U, Fallenberg E, Tholen R, Hung R, Baumann F, Beckmann MW, Blohmer J, Fasching P, Lux MP, Harbeck N, Hadji P, Hauner H, Heywang-Köbrunner S, Huober J, Hübner J, Jackisch C, Loibl S, Lück HJ, von Minckwitz G, Möbus V, Müller V, Nöthlings U, Schmidt M, Schmutzler R, Schneeweiss A, Schütz F, Stickeler E, Thomssen C, Untch M, Wesselmann S, Bücker A, Buck A, Stangl S. Interdisciplinary Screening, Diagnosis, Therapy and Follow-up of Breast Cancer. Guideline of the DGGG and the DKG (S3-Level, AWMF Registry Number 032/045OL, December 2017) - Part 2 with Recommendations for the Therapy of Primary, Recurrent and Advanced Breast Cancer. Geburtshilfe Frauenheilkd 2018; 78:1056-1088. [PMID: 30581198 PMCID: PMC6261741 DOI: 10.1055/a-0646-4630] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 06/20/2018] [Indexed: 12/29/2022] Open
Abstract
Purpose The aim of this official guideline coordinated and published by the German Society for Gynecology and Obstetrics (DGGG) and the German Cancer Society (DKG) was to optimize the screening, diagnosis, therapy and follow-up care of breast cancer. Method The process of updating the S3 guideline published in 2012 was based on the adaptation of identified source guidelines. They were combined with reviews of evidence compiled using PICO (Patients/Interventions/Control/Outcome) questions and with the results of a systematic search of literature databases followed by the selection and evaluation of the identified literature. The interdisciplinary working groups took the identified materials as their starting point and used them to develop suggestions for recommendations and statements, which were then modified and graded in a structured consensus process procedure. Recommendations Part 2 of this short version of the guideline presents recommendations for the therapy of primary, recurrent and metastatic breast cancer. Loco-regional therapies are de-escalated in the current guideline. In addition to reducing the safety margins for surgical procedures, the guideline also recommends reducing the radicality of axillary surgery. The choice and extent of systemic therapy depends on the respective tumor biology. New substances are becoming available, particularly to treat metastatic breast cancer.
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Affiliation(s)
- Achim Wöckel
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Jasmin Festl
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Tanja Stüber
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | - Katharina Brust
- Universitätsfrauenklinik Würzburg, Universität Würzburg, Würzburg, Germany
| | | | - Peter U. Heuschmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | - Steffi Jírů-Hillmann
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
| | | | - Wilfried Budach
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Ina Kopp
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | | | - Thorsten Kühn
- Frauenklinik, Klinikum Esslingen, Esslingen, Germany
| | - Thomas Langer
- Office des Leitlinienprogrammes Onkologie, Berlin, Germany
| | - Monika Nothacker
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Germany
| | - Anton Scharl
- Frauenklinik, Klinikum St. Marien Amberg, Amberg, Germany
| | | | - Hartmut Link
- Praxis für Hämatologie und Onkologie, Kaiserslautern, Germany
| | - Jutta Engel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Tanja Fehm
- Universitätsfrauenklinik Düsseldorf, Düsseldorf, Germany
| | - Joachim Weis
- Stiftungsprofessur Selbsthilfeforschung, Tumorzentrum/CCC Freiburg, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Anja Welt
- Innere Klinik (Tumorforschung), Westdeutsches Tumorzentrum, Universitätsklinikum Essen, Essen, Germany
| | | | - Petra Feyer
- Klinik für Strahlentherapie und Radioonkologie, Vivantes Klinikum, Neukölln Berlin, Germany
| | - Klaus König
- Berufsverband der Frauenärzte, Steinbach, Germany
| | | | | | - Hans H. Kreipe
- Institut für Pathologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Wolfram Trudo Knoefel
- Klinik für Allgemein-, Viszeral- und Kinderchirurgie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Michael Denkinger
- AGAPLESION Bethesda Klinik, Geriatrie der Universität Ulm, Ulm, Germany
| | - Sara Brucker
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Diana Lüftner
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Campus Benjamin Franklin, Universitätsklinikum Charité, Berlin, Germany
| | - Christian Kubisch
- Institut für Humangenetik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Gerlach
- III. Medizinische Klinik und Poliklinik, uct, Interdisziplinäre Abteilung für Palliativmedizin, Universitätsmedizin der Johannes Gutenberg Universität, Mainz, Germany
| | - Annette Lebeau
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Cordula Petersen
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Markus Hahn
- Universitätsfrauenklinik Tübingen, Tübingen, Germany
| | - Volker Hanf
- Frauenklinik Nathanstift, Klinikum Fürth, Fürth, Germany
| | | | | | - Renza Roncarati
- Frauenselbsthilfe nach Krebs – Bundesverband e. V., Bonn, Germany
| | - Alexander Katalinic
- Institut für Sozialmedizin und Epidemiologie, Universitätsklinikum Schleswig-Holstein, Lübeck, Germany
| | - Christoph Heitmann
- Ästhetisch plastische und rekonstruktive Chirurgie, Camparihaus München, München, Germany
| | | | - Kerstin Paradies
- Konferenz Onkologischer Kranken- und Kinderkrankenpflege, Hamburg, Germany
| | - Vesna Bjelic-Radisic
- Universitätsfrauenklinik, Abteilung für Gynäkologie, Medizinische Universität Graz, Graz, Austria
| | - Friedrich Degenhardt
- Klinik für Frauenheilkunde und Geburtshilfe, Medizinische Hochschule Hannover, Hannover, Germany
| | - Frederik Wenz
- Klinik für Strahlentherapie und Radioonkologie, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Oliver Rick
- Klinik Reinhardshöhe Bad Wildungen, Bad Wildungen, Germany
| | - Dieter Hölzel
- Tumorregister München, Institut für medizinische Informationsverarbeitung, Biometrie und Epidemiologie, Ludwig-Maximilians-Universität München, München, Germany
| | - Matthias Zaiss
- Praxis für interdisziplinäre Onkologie & Hämatologie, Freiburg, Germany
| | | | - Volker Budach
- Klinik für Radioonkologie und Strahlentherapie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Denkert
- Institut für Pathologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Gerber
- Universitätsfrauenklinik am Klinikum Südstadt, Rostock, Germany
| | - Hans Tesch
- Centrum für Hämatologie und Onkologie Bethanien, Frankfurt, Germany
| | | | - Hans-Peter Sinn
- Pathologisches Institut, Universität Heidelberg, Heidelberg, Germany
| | - Jürgen Dunst
- Klinik für Strahlentherapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | - Karsten Münstedt
- Frauenklinik Offenburg, Ortenau Klinikum Offenburg-Gengenbach, Offenburg, Germany
| | - Ulrich Bick
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eva Fallenberg
- Klinik für Radiologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Reina Tholen
- Deutscher Verband für Physiotherapie, Referat Bildung und Wissenschaft, Köln, Germany
| | - Roswita Hung
- Frauenselbsthilfe nach Krebs, Wolfsburg, Germany
| | - Freerk Baumann
- Centrum für Integrierte Onkologie Köln, Uniklinik Köln, Köln, Germany
| | - Matthias W. Beckmann
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jens Blohmer
- Klinik für Gynäkologie incl. Brustzentrum, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Fasching
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael P. Lux
- Frauenklinik, Universitätsklinikum Erlangen, CCC Erlangen-EMN, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Nadia Harbeck
- Brustzentrum, Frauenklinik, Universität München (LMU), München, Germany
| | - Peyman Hadji
- Klinik für Gynäkologie und Geburtshilfe, Krankenhaus Nordwest, Frankfurt, Germany
| | - Hans Hauner
- Lehrstuhl für Ernährungsmedizin, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | | | | | - Jutta Hübner
- Klinik für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Christian Jackisch
- Klinik für Gynäkologie und Geburtshilfe, Sana Klinikum Offenbach, Offenbach, Germany
| | | | | | | | - Volker Möbus
- Klinik für Gynäkologie und Geburtshilfe, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Volkmar Müller
- Klinik und Poliklinik für Gynäkologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Nöthlings
- Institut für Ernährungs- und Lebensmittelwissenschaften, Rheinische Friedrich-Wilhelms Universität Bonn, Bonn, Germany
| | - Marcus Schmidt
- Klinik und Poliklinik für Geburtshilfe und Frauengesundheit, Universitätsmedizin der Johannes Gutenberg-Universität Mai, Germany nz, Mainz
| | - Rita Schmutzler
- Zentrum Familiärer Brust- und Eierstockkrebs, Universitätsklinikum Köln, Köln, Germany
| | - Andreas Schneeweiss
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Florian Schütz
- Nationales Centrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Elmar Stickeler
- Klinik für Gynäkologie und Geburtsmedizin, Uniklinik RWTH Aachen, Aachen, Germany
| | | | - Michael Untch
- Klinik für Geburtshilfe und Gynäkologie, Helios Klinikum Berlin-Buch, Berlin, Germany
| | | | - Arno Bücker
- Klinik für Diagnostische und Interventionelle Radiologie am UKS, Universität des Saarlandes, Homburg, Germany
| | - Andreas Buck
- Nuklearmedizinische Klinik und Poliklinik des Universitätsklinikums Würzburg, Würzburg, Germany
| | - Stephanie Stangl
- Institut für Klinische Epidemiologie und Biometrie (IKE-B), Universität Würzburg, Würzburg, Germany
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12
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Hadji P, Stoetzer O, Decker T, Kurbacher CM, Marmé F, Schneeweiss A, Mundhenke C, Distelrath A, Fasching PA, Lux MP, Lüftner D, Janni W, Muth M, Kreuzeder J, Quiering C, Grischke EM, Tesch H. The impact of mammalian target of rapamycin inhibition on bone health in postmenopausal women with hormone receptor-positive advanced breast cancer receiving everolimus plus exemestane in the phase IIIb 4EVER trial. J Bone Oncol 2018; 14:010-10. [PMID: 30515367 PMCID: PMC6263089 DOI: 10.1016/j.jbo.2018.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/31/2023] Open
Abstract
Background Breast cancer and its treatments are associated with a detrimental effect on bone health. Here we report the results of an exploratory analysis assessing changes in levels of biomarkers of bone metabolism in patients enrolled in the phase IIIb 4EVER study. Methods The 4EVER trial investigated everolimus in combination with exemestane in postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative locally advanced or metastatic breast cancer. In this prespecified exploratory analysis, changes in biomarkers of bone turnover were assessed in patients from baseline to weeks 4, 12, and 24. The serum bone markers assessed were procollagen type 1 N-terminal propeptide (P1NP), C-terminal cross-linking telopeptide of type 1 collagen (CTX), osteocalcin, parathyroid hormone (PTH), and 25-hydroxyvitamin D (25-OH-vitamin D). On-treatment changes in bone markers over time were described per subgroup of interest and efficacy outcomes. Results Bone marker data were available for 241 of 299 enrolled patients. At the final assessment, P1NP, osteocalcin, PTH, 25-OH-vitamin D (all P < 0.001), and CTX (P = 0.036) were significantly decreased from baseline values per the Wilcoxon signed-rank test. At the last assessment (24 weeks or earlier), levels of serum CTX and PTH were significantly lower (P = 0.009 and P = 0.034, respectively) among patients with vs. without prior antiresorptive treatment (ART). Serum CTX levels were significantly lower (P < 0.001), and 25-OH-vitamin D concentrations significantly higher (P = 0.029), at the last postbaseline assessment in patients receiving concomitant ART vs. those without ART. Changes from baseline in PTH and 25-OH-vitamin D concentrations to the final assessment were significantly smaller in patients with prior ART. Lower baseline serum concentrations of osteocalcin and PTH were associated with clinical response (partial vs. non-response) at 24 weeks. High serum levels of CTX and P1NP at baseline were risk factors for progression at 12 weeks. Conclusions These exploratory analyses support use of everolimus plus exemestane for the treatment of postmenopausal women with hormone receptor-positive, human epidermal growth factor receptor 2-negative advanced breast cancer, and add to the body of evidence suggesting a potentially favorable impact of everolimus on bone turnover. Trial registration NCT01626222. Registered 22 June 2012, https://clinicaltrials.gov/ct2/show/NCT01626222.
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Key Words
- 25-OH-vitamin D, 25-hydroxyvitamin D
- Art, antiresorptive therapy
- BSAP, bone-specific alkaline phosphatase
- Bone health
- Bone marker
- Breast cancer
- CI, confidence interval
- CR, complete response
- CTX, C-terminal cross-linking telopeptide of type 1 collagen
- Everolimus
- HER2-negative, human epidermal growth factor receptor 2-negative
- HR, hazard ratio
- HR +, hormone receptor-positive
- Hormone receptor-positive
- Mammalian target of rapamycin
- NSAI, non-steroidal aromatase inhibitor
- OR, overall response
- ORR, overall response rate
- ORR24w, overall response rate within the first 24 weeks of treatment
- P1NP, procollagen type 1 N-terminal peptide
- PFS, progression-free survival
- PR, partial response
- PTH, parathyroid hormone
- SD, standard deviation
- SRE, skeletal-related event
- mTOR, mammalian target of rapamycin
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Affiliation(s)
- Peyman Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, North West Hospital, Steinbacher Hohl 2-26, 60488 Frankfurt am Main, Germany.,Philipps University of Marburg, Steinbacher Hohl 2-26, 60488 Marburg Frankfurt, Germany
| | - Oliver Stoetzer
- Haematology and Oncology, Outpatient Cancer Care Center, Munich, Germany
| | | | | | - Frederik Marmé
- Department of Obstetrics and Gynecology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Christoph Mundhenke
- Department of Obstetrics and Gynecology, University Hospital Kiel, Kiel, Germany
| | - Andrea Distelrath
- Praxisgemeinschaft für Onkologie und Urologie, Facharztzentrum am Meer, Friedrich-Paffrath-Str. 98, 26389 Wilhelmshaven, Germany
| | - Peter A Fasching
- Department of Obstetrics and Gynaecology, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Michael P Lux
- Department of Obstetrics and Gynaecology, University Hospital Erlangen, Comprehensive Cancer Center Erlangen-EMN, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Diana Lüftner
- Medical Department for Haematology, Oncology, and Tumor Immunology, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Wolfgang Janni
- Department of Gynecology and Obstetrics, University Hospital Ulm, Ulm, Germany
| | | | | | | | - Eva-Marie Grischke
- Department of Obstetrics and Gynecology, University of Tuebingen, Germany
| | - Hans Tesch
- Department of Oncology, Bethanien Hospital, Frankfurt am Main, Germany
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13
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Exercise for improving bone health in women treated for stages I–III breast cancer: a systematic review and meta-analyses. J Cancer Surviv 2017. [DOI: 10.1007/s11764-017-0622-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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14
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Hadji P, Aapro MS, Body JJ, Gnant M, Brandi ML, Reginster JY, Zillikens MC, Glüer CC, de Villiers T, Baber R, Roodman GD, Cooper C, Langdahl B, Palacios S, Kanis J, Al-Daghri N, Nogues X, Eriksen EF, Kurth A, Rizzoli R, Coleman RE. Management of Aromatase Inhibitor-Associated Bone Loss (AIBL) in postmenopausal women with hormone sensitive breast cancer: Joint position statement of the IOF, CABS, ECTS, IEG, ESCEO IMS, and SIOG. J Bone Oncol 2017; 7:1-12. [PMID: 28413771 PMCID: PMC5384888 DOI: 10.1016/j.jbo.2017.03.001] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Several guidelines have been reported for bone-directed treatment in women with early breast cancer (EBC) for averting fractures, particularly during aromatase inhibitor (AI) therapy. Recently, a number of studies on additional fracture related risk factors, new treatment options as well as real world studies demonstrating a much higher fracture rate than suggested by randomized clinical controlled trials (RCTs). Therefore, this updated algorithm was developed to better assess fracture risk and direct treatment as a position statement of several interdisciplinary cancer and bone societies involved in the management of AI-associated bone loss (AIBL). PATIENTS AND METHODS A systematic literature review identified recent advances in the management of AIBL. Results with individual agents were assessed based on trial design, size, follow-up, and safety. RESULTS Several fracture related risk factors in patients with EBC were identified. Although, the FRAX algorithm includes fracture risk factors (RF) in addition to BMD, it does not seem to adequately address the effects of AIBL. Several antiresorptive agents can prevent and treat AIBL. However, concerns regarding compliance and long-term safety remain. Overall, the evidence for fracture prevention is strongest for denosumab 60 mg s.c. every 6 months. Additionally, recent studies as well as an individual patient data meta-analysis of all available randomized trial data support additional anticancer benefits from adjuvant bisphosphonate treatment in postmenopausal women with a 34% relative risk reduction in bone metastasis and 17% relative risk decrease in breast cancer mortality that needs to be taken into account when advising on management of AIBL. CONCLUSIONS In all patients initiating AI treatment, fracture risk should be assessed and recommendation with regard to exercise and calcium/vitamin D supplementation given. Bone-directed therapy should be given to all patients with a T-score<-2.0 or with a T-score of <-1.5 SD with one additional RF, or with ≥2 risk factors (without BMD) for the duration of AI treatment. Patients with T-score>-1.5 SD and no risk factors should be managed based on BMD loss during the first year and the local guidelines for postmenopausal osteoporosis. Compliance should be regularly assessed as well as BMD on treatment after 12 - 24 months. Furthermore, because of the decreased incidence of bone recurrence and breast cancer specific mortality, adjuvant bisphosphonates are recommended for all postmenopausal women at significant risk of disease recurrence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - John Kanis
- Catholic University of Australia, Melbourne, Australia and University of Sheffield, UK
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Pedersini R, Monteverdi S, Mazziotti G, Amoroso V, Roca E, Maffezzoni F, Vassalli L, Rodella F, Formenti AM, Frara S, Maroldi R, Berruti A, Simoncini E, Giustina A. Morphometric vertebral fractures in breast cancer patients treated with adjuvant aromatase inhibitor therapy: A cross-sectional study. Bone 2017; 97:147-152. [PMID: 28104509 DOI: 10.1016/j.bone.2017.01.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 12/27/2016] [Accepted: 01/14/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The impact of long-term adjuvant therapy with aromatase inhibitors (AIs) on vertebral fracture (VF) risk is still unclear. OBJECTIVE In this cross-sectional study, we explored the prevalence and determinants of VFs in breast cancer (BC) patients before and during AI therapy. Each woman underwent a dual-energy X-ray absorptiometry (DXA) to evaluate bone mineral density (BMD) and identify VFs by a quantitative morphometric approach. Blood samples were collected to measure serum hormone and calcium levels. RESULTS We consecutively included 263 postmenopausal women with hormone receptor-positive early BC. One-hundred-sixty-nine women were AI-naïve, and 94 were AI-treated. AI-treated patients had lower BMD at total hip (p=0.01) and lumbar spine (p=0.03), higher serum vitamin D (p<0.001) and parathyroid hormone (p=0.006) values as compared to AI-naïve patients. The prevalence of VFs was 18.9% in AI-naïve patients, and 31.2% in those assessed during AI therapy (odds ratio 1.90, 95% CI 1.1-3.5, p=0.03). In AI-naïve patients, VFs were associated with older age (p=0.002) and lower BMD values at femoral neck (p=0.04) and total hip (p=0.007), whereas VFs occurred without association with any parameter analyzed in AI-treated patients. In AI-treated group, the prevalence of VFs was not significantly different between patients with osteoporosis and those with normal BMD (36.7% vs. 20.0%; p=0.31). CONCLUSIONS In women with early BC, AI therapy is associated with high prevalence of radiological VFs, which were shown to be independent of BMD values during the adjuvant treatment. These findings may be clinically relevant since they may lead to a change in management of AI-induced skeletal fragility. Specifically, the results of this study provide a rationale for performing a morphometric evaluation of VFs in all women undergoing treatment with AIs.
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Affiliation(s)
- Rebecca Pedersini
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy; Breast Unit, Spedali Civili Hospital, Brescia, Italy
| | - Sara Monteverdi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy; Breast Unit, Spedali Civili Hospital, Brescia, Italy
| | - Gherardo Mazziotti
- Endocrine and Bone Unit, Department of Medicine, ASST "Carlo Poma", Mantova, Italy
| | - Vito Amoroso
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy.
| | - Elisa Roca
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy
| | - Filippo Maffezzoni
- Department of Molecular and Translational Medicine, University of Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Radiology Unit, Brescia, Italy
| | - Lucia Vassalli
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy; Breast Unit, Spedali Civili Hospital, Brescia, Italy
| | - Filippo Rodella
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy; Breast Unit, Spedali Civili Hospital, Brescia, Italy
| | - Anna Maria Formenti
- Department of Molecular and Translational Medicine, University of Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Radiology Unit, Brescia, Italy
| | - Stefano Frara
- Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
| | - Roberto Maroldi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Radiology Unit, Brescia, Italy
| | - Alfredo Berruti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Spedali Civili Hospital, Medical Oncology Unit, Brescia, Italy
| | | | - Andrea Giustina
- Endocrinology, San Raffaele Vita-Salute University, Milan, Italy
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Abstract
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.
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Affiliation(s)
- Gregory A Clines
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA,
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17
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Hadji P. Cancer Treatment-Induced Bone Loss in women with breast cancer. BONEKEY REPORTS 2015; 4:692. [PMID: 26029361 PMCID: PMC4440228 DOI: 10.1038/bonekey.2015.60] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 03/25/2015] [Indexed: 01/16/2023]
Abstract
Osteoporosis is one of the most frequent diseases in postmenopausal women, leading to an increased fracture risk due to the physiologic loss of the bone protective effects of estrogen. Hereby, several risk factors for fracture such as prevalent fracture, low bone mineral density (BMD), age, low body mass index, family history, tendency to falls, smoking, use of SSRIs, glucocorticoid use etc. have been identified. In addition, the further reduction in endogenous estrogens with chemotherapy (CHT), GnRH analoga or aromatase inhibitors (AIs) continuously increases fracture risk. Breast cancer (BC) on the other hand is the most frequent cancer type in women. Recent reports indicate a continuous increased incidence, whereas mortality, due to early diagnosis and treatment improvements, is decreasing. Dependent on specific tumor characteristics, radiation, CHT, antibody treatment as well as endocrine treatment have been included into the adjuvant clinical treatment setting. Some but not all of these cancer-specific treatments interfere with bone turnover, leading to an accelerated bone loss referred to as cancer treatment-induced bone loss (CTIBL). Whereas CHT leads to an unspecific increase in bone resorption, AI reduces residual serum endogenous estrogen level and is associated with a decrease in BMD and increased fracture risk. Independent of the type of AI administered, bone loss is 2-3-fold increased compared with healthy, age-matched postmenopausal controls. Therefore, several guidelines have emerged to help managing CTIBL in women with BC including strategies to identify and treat those at highest risk for fractures. This review summarizes the current knowledge on CTIBL and fracturing risk and indicates preventative strategies.
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Affiliation(s)
- Peyman Hadji
- Department of Bone Oncology, Krankenhaus Nordwest, Endocrinology and Reproductive Medicine, Philipps University of Marburg, Frankfurt, Germany
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18
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Freedman O, Fletcher G, Gandhi S, Mates M, Dent S, Trudeau M, Eisen A. Adjuvant endocrine therapy for early breast cancer: a systematic review of the evidence for the 2014 Cancer Care Ontario systemic therapy guideline. Curr Oncol 2015; 22:S95-S113. [PMID: 25848344 PMCID: PMC4381796 DOI: 10.3747/co.22.2326] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Cancer Care Ontario's Program in Evidence-Based Care (pebc) recently created an evidence-based consensus guideline on the systemic treatment of early breast cancer. The evidence for the guideline was compiled using a systematic review to answer the question "What is the optimal systemic therapy for patients with early-stage, operable breast cancer, when patient and disease factors are considered?" The question was addressed in three parts: cytotoxic chemotherapy, endocrine treatment, and her2 (human epidermal growth factor receptor 2)-targeted therapy. METHODS For the systematic review, the literature in the medline and embase databases was searched for the period January 2008 to May 2014. The Standards and Guidelines Evidence directory of cancer guidelines and the Web sites of major oncology guideline organizations were also searched. The basic search terms were "breast cancer" and "systemic therapy" (chemotherapy, endocrine therapy, targeted agents, ovarian suppression), and results were limited to randomized controlled trials (rcts), guidelines, systematic reviews, and meta-analyses. RESULTS Several hundred documents that met the inclusion criteria were retrieved. Meta-analyses from the Early Breast Cancer Trialists' Collaborative Group encompassed many of the rcts found. Several additional studies that met the inclusion criteria were retained, as were other guidelines and systematic reviews. SUMMARY The results of the systematic review constitute a comprehensive compilation of high-level evidence, which was the basis for the 2014 pebc guideline on systemic therapy for early breast cancer. The review of the evidence for systemic endocrine therapy (adjuvant tamoxifen, aromatase inhibitors, and ovarian ablation and suppression) is presented here; the evidence for chemotherapy and her2-targeted treatment-and the final clinical practice recommendations-are presented separately in this supplement.
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Affiliation(s)
| | - G.G. Fletcher
- Program in Evidence-Based Care, Cancer Care Ontario; and Department of Oncology, McMaster University, Hamilton, ON
| | - S. Gandhi
- Sunnybrook Health Science Centre, Toronto, ON
| | - M. Mates
- Cancer Centre of Southeastern Ontario, Kinston General Hospital, and Queen’s University, Kingston, ON
| | - S.F. Dent
- The Ottawa Hospital Cancer Centre and University of Ottawa, Ottawa, ON
| | | | - A. Eisen
- Durham Regional Cancer Centre, Oshawa, ON
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19
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Kalder M, Hadji P. Breast cancer and osteoporosis - management of cancer treatment-induced bone loss in postmenopausal women with breast cancer. Breast Care (Basel) 2014; 9:312-7. [PMID: 25759610 PMCID: PMC4322683 DOI: 10.1159/000368843] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The incidence of breast cancer (BC) in postmenopausal women is continuously rising. Due to early diagnosis and various treatment designs, the long-term clinical outcome has improved. Frequent settings are chemotherapy as well as endocrine treatment. Both have proven to interfere with bone health resulting in cancer treatment-induced bone loss (CTIBL). Whereas chemotherapy is associated with increased bone resorption, aromatase inhibitor (AI) therapy reduces residual estrogen and is associated with decreased bone mineral density. Independent of the AI administered, the loss of bone mineral density is twice as high compared to healthy postmenopausal women. As a consequence of CTIBL, both chemotherapy and AI treatment can lead to a significantly increased fracture risk. Therefore, several guidelines have emerged for the management of CTIBL in women with BC, including strategies to identify and treat those at high risk for fractures. Further research on tracking guideline adherence examining the feasibility and practicability of guideline implementation to bridge the gap between determined scientific best evidence and applied best practice is needed to adjust these guidelines in the future.
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Affiliation(s)
- Matthias Kalder
- Department of Obstetrics and Gynecology, Philipps University of Marburg, Germany
| | - Peyman Hadji
- Department of Bone Oncology, Endocrinology and Reproductive Medicine, Hospital Nordwest, Frankfurt/M., Germany
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20
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Effect of aromatase inhibition on serum levels of sclerostin and dickkopf-1, bone turnover markers and bone mineral density in women with breast cancer. J Cancer Res Clin Oncol 2014; 140:1671-80. [DOI: 10.1007/s00432-014-1726-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 05/28/2014] [Indexed: 12/19/2022]
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21
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Goss PE, Hershman DL, Cheung AM, Ingle JN, Khosla S, Stearns V, Chalchal H, Rowland K, Muss HB, Linden HM, Scher J, Pritchard KI, Elliott CR, Badovinac-Crnjevic T, St Louis J, Chapman JAW, Shepherd LE. Effects of adjuvant exemestane versus anastrozole on bone mineral density for women with early breast cancer (MA.27B): a companion analysis of a randomised controlled trial. Lancet Oncol 2014; 15:474-82. [PMID: 24636210 DOI: 10.1016/s1470-2045(14)70035-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment of breast cancer with aromatase inhibitors is associated with damage to bones. NCIC CTG MA.27 was an open-label, phase 3, randomised controlled trial in which women with breast cancer were assigned to one of two adjuvant oral aromatase inhibitors-exemestane or anastrozole. We postulated that exemestane-a mildly androgenic steroid-might have a less detrimental effect on bone than non-steroidal anastrozole. In this companion study to MA.27, we compared changes in bone mineral density (BMD) in the lumbar spine and total hip between patients treated with exemestane and patients treated with anastrozole. METHODS In MA.27, postmenopausal women with early stage hormone (oestrogen) receptor-positive invasive breast cancer were randomly assigned to exemestane 25 mg versus anastrozole 1 mg, daily. MA.27B recruited two groups of women from MA.27: those with BMD T-scores of -2·0 or more (up to 2 SDs below sex-matched, young adult mean) and those with at least one T-score (hip or spine) less than -2·0. Both groups received vitamin D and calcium; those with baseline T-scores of less than -2·0 also received bisphosphonates. The primary endpoints were percent change of BMD at 2 years in lumbar spine and total hip for both groups. We analysed patients according to which aromatase inhibitor and T-score groups they were allocated to but BMD assessments ceased if patients deviated from protocol. This study is registered with ClinicalTrials.gov, NCT00354302. FINDINGS Between April 24, 2006, and May 30, 2008, 300 patients with baseline T-scores of -2·0 or more were accrued (147 allocated exemestane, 153 anastrozole); and 197 patients with baseline T-scores of less than -2·0 (101 exemestane, 96 anastrozole). For patients with T-scores greater than -2·0 at baseline, mean change of bone mineral density in the spine at 2 years did not differ significantly between patients taking exemestane and patients taking anastrozole (-0·92%, 95% CI -2·35 to 0·50 vs -2·39%, 95% CI -3·77 to -1·01; p=0·08). Respective mean loss in the hip was -1·93% (95% CI -2·93 to -0·93) versus -2·71% (95% CI -4·32 to -1·11; p=0·10). Likewise for those who started with T-scores of less than -2·0, mean change of spine bone mineral density at 2 years did not differ significantly between the exemestane and anastrozole treatment groups (2·11%, 95% CI -0·84 to 5·06 vs 3·72%, 95% CI 1·54 to 5·89; p=0·26), nor did hip bone mineral density (2·09%, 95% CI -1·45 to 5·63 vs 0·0%, 95% CI -3·67 to 3·66; p=0·28). Patients with baseline T-score of -2·0 or more taking exemestane had two fragility fractures and two other fractures, those taking anastrozole had three fragility fractures and five other fractures. For patients who had baseline T-scores of less than -2·0 taking exemestane, one had a fragility fracture and four had other fractures, whereas those taking anastrozole had five fragility fractures and one other fracture. INTERPRETATION Our results demonstrate that adjuvant treatment with aromatase inhibitors can be considered for breast cancer patients who have T-scores less than -2·0. FUNDING Canadian Cancer Society Research Institute, Pfizer, Canadian Institutes of Health Research.
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Affiliation(s)
- Paul E Goss
- Massachusetts General Hospital, Boston, MA, USA.
| | | | | | | | | | - Vered Stearns
- Johns Hopkins Oncology Centre, School of Medicine, Baltimore, MD, USA
| | | | | | - Hyman B Muss
- University of North Carolina/Lineberger Comp Cancer Center, Chapel Hill, NC, USA
| | | | | | | | | | | | | | | | - Lois E Shepherd
- NCIC Clinical Trials Group, Queen's University, Kingston, ON, Canada
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22
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Kalder M, Hans D, Kyvernitakis I, Lamy O, Bauer M, Hadji P. Effects of Exemestane and Tamoxifen treatment on bone texture analysis assessed by TBS in comparison with bone mineral density assessed by DXA in women with breast cancer. J Clin Densitom 2014; 17:66-71. [PMID: 23562130 DOI: 10.1016/j.jocd.2013.03.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 03/04/2013] [Indexed: 12/19/2022]
Abstract
We performed an analysis of a substudy of the randomized Tamoxifen Exemestane Adjuvant Multinational trial to determine the effects of exemestane (EXE) and tamoxifen (TAM) adjuvant treatment on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry compared with the trabecular bone score, a novel grey-level texture measurement that correlates with 3-dimensional parameters of bone texture in postmenopausal women with hormone receptor-positive breast cancer for the first time. In total, 36 women were randomized to receive TAM (n = 17) or EXE (n = 19). Patients receiving TAM showed a mean increase of BMD in lumbar spine from baseline of 1.0%, 1.5%, and 1.9% and in trabecular bone score of 2.2%, 3.5%, and 3.3% at 6-, 12-, and 24-mo treatment, respectively. Conversely, patients receiving EXE showed a mean decrease from baseline in lumbar spine BMD of -2.3%, -3.6%, and -5.3% and in trabecular bone score of -0.9%, -1.7%, and -2.3% at 6-, 12-, and 24-mo treatment, respectively. Changes in trabecular bone score from baseline at spine were also significantly different between EXE and TAM: p = 0.05, 0.007, and 0.006 at 6, 12, and 24 mo, respectively. TAM induced an increase in BMD and bone texture analysis, whereas EXE resulted in decreases. The results were independent from each other.
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Affiliation(s)
- Matthias Kalder
- Department of Gynecology, Gynecological Endocrinology and Oncology, Philipps University of Marburg, Marburg, Germany.
| | - Didier Hans
- Center of Bone Diseases, Department of Bone and Joints, Lausanne University Hospital, Lausanne, Switzerland
| | - Ioannis Kyvernitakis
- Department of Gynecology, Gynecological Endocrinology and Oncology, Philipps University of Marburg, Marburg, Germany
| | - Olivier Lamy
- Center of Bone Diseases, Department of Bone and Joints, Lausanne University Hospital, Lausanne, Switzerland
| | - Martina Bauer
- Department of Gynecology, Gynecological Endocrinology and Oncology, Philipps University of Marburg, Marburg, Germany
| | - Peyman Hadji
- Department of Gynecology, Gynecological Endocrinology and Oncology, Philipps University of Marburg, Marburg, Germany
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23
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Impact of BMI on serum estradiol and bone turnover markers in postmenopausal women with hormone-sensitive early breast cancer treated with anastrozole. J Cancer Res Clin Oncol 2013; 140:159-66. [DOI: 10.1007/s00432-013-1557-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 11/19/2013] [Indexed: 01/09/2023]
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24
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Abstract
Cancer is a major risk factor for bone loss and fractures. This is due both to direct effects of cancer cells on the skeleton and to deleterious effects of cancer-specific therapies on bone cells. Marked improvements in survival for many cancers mean that strategies to limit bone loss and reduce fracture risk must be incorporated into the care plans for nearly all patients with cancer. The vast majority of effort thus far has focused on bone loss in patients with breast and prostate cancers, with comparatively few studies in other malignancies. Antiresorptive therapies have proven nearly universally effective for limiting bone loss in cancer patients, although few studies have been powered sufficiently to include fractures as primary endpoints, and patients are frequently neither identified nor treated according to published guidelines. Nonpharmacologic approaches to limit falls, particularly in elderly patients, are also likely important adjunctive measures for most cancer patients.
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Affiliation(s)
- Matthew T Drake
- Division of Endocrinology, Department of Medicine, College of Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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25
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Bone effects of mammalian target of rapamycin (mTOR) inhibition with everolimus. Crit Rev Oncol Hematol 2013; 87:101-11. [DOI: 10.1016/j.critrevonc.2013.05.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 05/22/2013] [Accepted: 05/31/2013] [Indexed: 01/28/2023] Open
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26
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Winters-Stone KM, Dobek J, Nail LM, Bennett JA, Leo MC, Torgrimson-Ojerio B, Luoh SW, Schwartz A. Impact + resistance training improves bone health and body composition in prematurely menopausal breast cancer survivors: a randomized controlled trial. Osteoporos Int 2013; 24:1637-46. [PMID: 22996743 PMCID: PMC3856427 DOI: 10.1007/s00198-012-2143-2] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 09/05/2012] [Indexed: 02/07/2023]
Abstract
UNLABELLED Our randomized controlled trial in prematurely menopausal breast cancer survivors showed that impact + resistance training prevented increases in percentage of body fat compared with controls and also improved BMD at the hip and prevented BMD loss at the spine among exercise-trained women who were menopausal for >1 year. INTRODUCTION Cancer treatment-related menopause worsens bone health and body composition in breast cancer survivors (BCS). We investigated whether impact + resistance training could improve bone mineral density (BMD), reduce bone turnover, build muscle, and decrease fat mass in BCS with premature menopause. METHODS We conducted a randomized controlled trial in 71 BCS (mean age, 46.5 years) within 5 years of treatment-related menopause. Women were randomly assigned to one of two groups: (1) impact + resistance training (prevent osteoporosis with impact + resistance (POWIR)) or (2) exercise placebo (FLEX) 3×/week for 1 year. Outcomes were hip and spine BMD (in grams per square centimeter) and body composition (percent body fat (%BF) and lean and fat mass (in kilograms)) by DXA and bone turnover markers (serum osteocalcin (in nanograms per milliliter) and urinary deoxypryrodinoline (in nanomoles per milliliter). RESULTS There were no significant group × time interactions for bone outcomes when using an intent-to-treat approach on the full sample. In analyses restricted to BCS who were menopausal for ≥1 year, POWIR increased BMD at the hip and slowed BMD loss at the spine compared with FLEX (femoral neck-POWIR, 0.004 ± 0.093 g/cm(2) vs. FLEX, -0.010 ± 0.089 g/cm(2); p < 0.01; spine-POWIR, -0.003 ± 0.114 g/cm(2) vs. FLEX, -0.020 ± 0.110 g/cm(2); p = 0.03). POWIR prevented increases in %BF (POWIR, 0.01 % vs. FLEX, 1.3 %; p < 0.04). Women with attendance to POWIR at ≥64 % had better improvements in %BF than women attending less often (p < 0.03). CONCLUSION Impact + resistance training may effectively combat bone loss and worsening body composition from premature menopause in BCS.
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Affiliation(s)
- K M Winters-Stone
- School of Nursing, Oregon Health & Science University, Portland, OR, USA.
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27
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Gnant M, Baselga J, Rugo HS, Noguchi S, Burris HA, Piccart M, Hortobagyi GN, Eakle J, Mukai H, Iwata H, Geberth M, Hart LL, Hadji P, El-Hashimy M, Rao S, Taran T, Sahmoud T, Lebwohl D, Campone M, Pritchard KI. Effect of everolimus on bone marker levels and progressive disease in bone in BOLERO-2. J Natl Cancer Inst 2013; 105:654-63. [PMID: 23425564 DOI: 10.1093/jnci/djt026] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Breast Cancer Trials of Oral Everolimus 2 (BOLERO-2), a phase III study in postmenopausal women with estrogen receptor-positive breast cancer progressing despite nonsteroidal aromatase inhibitor therapy, showed statistically significant benefits with adding everolimus to exemestane. Moreover, in preclinical studies, mammalian target of rapamycin inhibition was associated with decreased osteoclast survival and activity. Exploratory analyses in BOLERO-2 evaluated the effect of everolimus on bone marker levels and progressive disease in bone. METHODS Patients were treated with exemestane (25mg/day) and randomized (2:1) to everolimus (10mg/day; combination) or placebo (exemestane only). Exploratory endpoints included changes in bone turnover marker levels vs baseline and progressive disease in bone, defined as unequivocal progression of a preexisting bone lesion or the appearance of a new bone lesion. RESULTS Baseline disease characteristics were well balanced between arms (N = 724); baseline bisphosphonate use was not (43.9% combination vs 54.0% exemestane only). At a median of 18 months of follow-up, median progression-free survival (primary endpoint) was statistically significantly longer with the combination vs exemestane only (Cox proportional hazard ratio = 0.45, 95% confidence interval = 0.38 to 0.54; log-rank, 1-sided P < .0001). Bone marker levels at 6 and 12 weeks increased with exemestane only, as expected, but decreased with the combination. The cumulative incidence rate of progressive disease in bone was lower in the combination arm. Bone-related adverse events occurred with similar frequency in both arms (3.3% combination vs 4.2% exemestane only). CONCLUSION These exploratory analyses suggest that everolimus has beneficial effects on bone turnover and progressive disease in bone in patients receiving exemestane for hormone receptor-positive breast cancer progressing during/after nonsteroidal aromatase inhibitor therapy.
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Affiliation(s)
- Michael Gnant
- Department of Surgery and Comprehensive Cancer Center, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
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28
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Zhang Y, Simondsen K, Kolesar JM. Exemestane for primary prevention of breast cancer in postmenopausal women. Am J Health Syst Pharm 2012; 69:1384-8. [PMID: 22855103 DOI: 10.2146/ajhp110585] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The benefits and risks of exemestane for the primary prevention of breast cancer are discussed and compared with other breast cancer chemoprevention therapies. SUMMARY Selective estrogen-receptor modulators (SERMs) are the current mainstay for primary prevention of breast cancer. As an alternative, exemestane, an aromatase inhibitor, has been evaluated for breast cancer prevention in postmenopausal women. A study of 4560 high-risk postmenopausal women taking exemestane 25 mg daily for a median of three years found a 65% relative reduction in the annual occurrence of invasive breast cancer compared with placebo (0.19% versus 0.55%; hazard ratio, 0.35; 95% confidence interval [CI], 0.18-0.70; p = 0.002) and a 53% reduction in invasive plus noninvasive breast cancer (0.35% versus 0.77%; hazard ratio, 0.47; 95% CI, 0.27-0.79; p = 0.04). Adverse effects from exemestane are generally mild, with the most common being diarrhea, joint pain, and menopausal-related symptoms. Importantly, exemestane did not increase the risks of endometrial cancers, thromboembolism, cardiovascular events, or cataracts. However, joint stiffness and arthralgia were more common when compared with tamoxifen or raloxifene. Ongoing clinical trials with other aromatase inhibitors are underway to evaluate the benefits and long-term skeletal risks. CONCLUSION Exemestane 25 mg daily taken for at least three years is a new option for the prevention of breast cancer in high-risk postmenopausal women. Indirectly compared with SERMs, exemestane has a similar frequency of bothersome adverse effects without the risk of thromboembolic events or endometrial cancer, though an increased risk of osteoporosis is of concern.
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Affiliation(s)
- Yang Zhang
- University of Wisconsin--Madison, Madison, WI 53792, USA
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29
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Abstract
Aromatase inhibitors are well-established therapies in the neoadjuvant, adjuvant and metastatic settings for breast cancer. In adjuvant trials, this class of drugs has shown preventative properties by decreasing the rate of contralateral breast cancer. Recently, the National Cancer Institute of Canada Clinical Trials Group MAP.3 study evaluated exemestane as a breast cancer prevention agent for women with specified higher risks of developing breast cancer. We review the history of exemestane and evaluate the available evidence of its use for breast cancer prevention.
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Affiliation(s)
- Jennifer Keating Litton
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1354, Houston, TX 77030, USA
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Winters-Stone KM, Schwartz AL, Hayes SC, Fabian CJ, Campbell KL. A prospective model of care for breast cancer rehabilitation: Bone health and arthralgias. Cancer 2012; 118:2288-99. [DOI: 10.1002/cncr.27465] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Cheung AM, Tile L, Cardew S, Pruthi S, Robbins J, Tomlinson G, Kapral MK, Khosla S, Majumdar S, Erlandson M, Scher J, Hu H, Demaras A, Lickley L, Bordeleau L, Elser C, Ingle J, Richardson H, Goss PE. Bone density and structure in healthy postmenopausal women treated with exemestane for the primary prevention of breast cancer: a nested substudy of the MAP.3 randomised controlled trial. Lancet Oncol 2012; 13:275-84. [PMID: 22318095 DOI: 10.1016/s1470-2045(11)70389-8] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Exemestane can prevent breast cancer in postmenopausal women. Because of potential widespread use, we examined the safety of exemestane on bone health. METHODS In this nested safety substudy of the MAP.3 trial (a randomised, placebo-controlled, double-blind trial of exemestane 25 mg a day for the primary prevention of breast cancer), we included postmenopausal women from five centres who were eligible to participate in MAP.3, not osteoporotic, not receiving drugs for bone-related disorders, with baseline lumbar spine, total hip, and femoral neck T-scores above -2·0. The primary endpoint was percent change from baseline to 2 years in total volumetric bone mineral density (BMD) at the distal radius by high-resolution peripheral quantitative CT. The primary analysis was per protocol using a non-inferiority margin. This analysis was done earlier than originally planned because of the impending announcement of MAP.3 results and subsequent unmasking of patients to treatment assignment. This study is registered with ClinicalTrials.gov, number NCT01144468, and has been extended to 5 years of unmasked follow-up. FINDINGS 351 women (176 given exemestane, 175 given placebo; median age 61·3 years [IQR 59·2-64·9]) met our inclusion criteria and completed baseline assessment. At the time of clinical cutoff, 242 women had completed 2-year follow-up (124 given exemestane, 118 given placebo). From baseline to 2 years, the mean percent change in total volumetric BMD at the distal radius was -6·1% (95% CI -7·0 to -5·2) in the exemestane group and -1·8% (-2·4 to -1·2) in the placebo group (difference -4·3%, 95% CI -5·3 to -3·2; p<0·0001). The lower limit of the 95% CI was lower than our non-inferiority margin of negative 4% (one-sided test for non-inferiority p=0·70), meaning the hypothesis that exemestane was inferior could not be rejected. At the distal tibia, the mean percent change in total volumetric BMD from baseline to 2 years was -5·0% (95% CI -5·5 to -4·4) in the exemestane group and -1·3% (-1·7 to -1·0) in the placebo group (difference -3·7%, 95% CI -4·3 to -3·0; p<0·0001). The mean percent change in cortical thickness was -7·9% (SD 7·3) in the exemestane group and -1·1% (5·7) in the placebo group at the distal radius (difference -6·8%, 95% CI -8·5 to -5·0; p<0·0001) and -7·6% (SD 5·9) in the exemestane group and -0·7% (4·9) in the placebo group at the distal tibia (difference -6·9%, -8·4 to -5·5; p<0·0001). Decline in areal BMD, as measured by dual-energy x-ray absorptiometry, in the exemestane group compared with the placebo group occurred at the lumbar spine (-2·4% [95% CI -3·1 to -1·7] exemestane vs -0·5% [-1·1 to 0·2] placebo; difference -1·9%, 95% CI -2·9 to -1·0; p<0·0001), total hip (-1·8% [-2·3 to -1·2] exemestane vs -0·6% [-1·1 to -0·1] placebo; difference -1·2%, -1·9 to -0·4; p=0·004), and femoral neck (-2·4% [-3·2 to -1·7] exemestane vs -0·8% [-1·5 to 0·1] placebo; difference -1·6%, -2·7 to -0·6; p=0·002). INTERPRETATION 2 years of treatment with exemestane worsens age-related bone loss in postmenopausal women despite calcium and vitamin D supplementation. Women considering exemestane for the primary prevention of breast cancer should weigh their individual risks and benefits. For women taking exemestane, regular bone monitoring plus adequate calcium and vitamin D supplementation are important. To assess the effect of our findings on fracture risk, long-term follow-up is needed. FUNDING Canadian Breast Cancer Research Alliance (Canadian Institutes of Health Research/Canadian Cancer Society).
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Affiliation(s)
- Angela M Cheung
- University Health Network, University of Toronto, Toronto, ON, Canada.
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Litton JK, Arun BK, Brown PH, Hortobagyi GN. Aromatase inhibitors and breast cancer prevention. Expert Opin Pharmacother 2012; 13:325-31. [DOI: 10.1517/14656566.2012.651459] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kittaneh M, Glück S. Exemestane in the adjuvant treatment of breast cancer in postmenopausal women. Breast Cancer (Auckl) 2011; 5:209-26. [PMID: 22084574 PMCID: PMC3201097 DOI: 10.4137/bcbcr.s6234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Exemestane is an irreversible inhibitor of the aromatase enzyme, which is a key component in the production of estrogen. The majority of breast cancers are sensitive to the proliferative effects of estrogen. Exemestane is approved for the adjuvant treatment of postmenopausal women with breast cancer after 2 to 3 years of tamoxifen therapy, based on a 32% improvement in disease-free survival compared with 5 years of tamoxifen alone (P < 0.001). Exemestane has also shown clinical benefits as an upfront therapy. The safety profile of exemestane shares some side effects with tamoxifen (hot flashes and arthralgia), but is not associated with an increased risk of endometrial cancer or thromboembolic events. This review will discuss in detail the efficacy and safety of exemestane in early breast cancer.
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Affiliation(s)
- Muaiad Kittaneh
- University of Miami, Leonard M. Miller School of Medicine, 1475 NW 12th Avenue, Suite 3310, Miami, Florida, USA
| | - Stefan Glück
- University of Miami, Leonard M. Miller School of Medicine, 1475 NW 12th Avenue, Suite 3310, Miami, Florida, USA
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