Debilitating musculoskeletal pain and stiffness with letrozole and exemestane: associated tenosynovial changes on magnetic resonance imaging

Adverse Event Profiles of the Third-Generation Aromatase Inhibitors: Analysis of Spontaneous Reports Submitted to FAERS

The third-generation aromatase inhibitors (AIs), represented by letrozole, anastrozole, and exemestane, have been used as a standard first-line adjuvant therapy for postmenopausal breast cancer patients with positive hormone receptor. However, their safety in the real world has not been systematically analyzed. We used the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS) to investigate adverse event (AE) profiles of the three AIs, covering the period from Q1 2004 to Q3 2023. The time-to-event onset profiles and cumulative incidence were analyzed by Weibull shape parameter test and Kaplan-Meier method, respectively. The disproportionality analysis was utilized to assess drug toxicity risk. Based on the FAERS database, 18,035, 8242, and 7011 reports listing letrozole, anastrozole, and exemestane as primary suspected drugs were extracted, respectively. AEs associated with anastrozole displayed the latest onset (p < 0.0001); meanwhile, WSP test showed that all three AIs had early failure-type profiles. At the preferred term level, we acquired 95, 59, and 42 significant signals associated with letrozole, anastrozole, and exemestane, which involved 18, 13, and 15 system organ classes, respectively. The three AIs all reported that their strongest AE signal was trigger finger. Neutropenia was the most frequent AE for letrozole, while the highest occurrences of anastrozole and exemestane were arthralgia. We also found that interstitial lung disease, a rare but serious AE, showed strong signal intensity in all three AIs. Additionally, letrozole was also associated with lots of other rare but serious AEs in hematologic, respiratory, and hepatic systems, which were not recorded in the instructions. Our analysis of safety warning signals of the third-generation AIs from the FAERS database provided reference for clinical safe and rational drug use.

The role of exercise in aromatase inhibitor-induced arthralgia

Aromatase inhibitors are prescribed in breast cancer due to their associated lower rate of cancer recurrence compared to tamoxifen. However, aromatase inhibitor-induced arthralgia (AIIA) is one of the leading causes of treatment nonadherence, increasing the risk of cancer recurrence. The pathophysiology of AIIA is poorly understood, and although current recommendations for AIIA include lifestyle changes and analgesics depending on the severity of symptoms, there is no established effective treatment. The aim of this study is to explore the presentation and mechanism of AIIA and investigate the feasibility and efficacy of different exercise interventions (aerobic, resistance, aerobic and resistance combined, and yoga or tai chi) in patients with AIIA to guide the development of formal exercise prescription guidelines. Findings indicate that a mixed-modality regimen of aerobic and resistance exercises is feasible and safe and may serve the most benefit in improving joint pain, functionality, and quality of life. More specifically, the weekly regimen should consist of 150 min of aerobic exercise with two sessions of at least six resistance exercises, 8 to 12 repetitions, three sets each. Supplementary yoga and tai chi may be recommended twice a week depending on a patient's target symptoms. Yoga was associated with improved physical functionality, whereas tai chi was related to improvements in mental health. However, the feasibility and impact of combined aerobic and resistance exercise protocols with yoga or tai chi in our target population were not investigated in this review. The use of large, randomized controlled trials is recommended for future studies.

Progressive relaxation training in patients with breast cancer receiving aromatase inhibitor therapy-randomized controlled trial

BACKGROUND

Aromatase inhibitors have positive impacts on the disease-free life of patients with breast cancer. However, their side effects, especially arthralgia, may be experienced by many patients. This study sought to assess the efficacy of Progressive Relaxation Exercises on the prevalent side effects of Aromatase Inhibitors in patients with breast cancer.

MATERIALS AND METHODS

This clinical trial was conducted with single-blind randomization at a physiotherapy department in a local hospital. Patients who received Aromatase Inhibitor were assigned at random to either the study or control group. The study group (n = 22) performed a Progressive Relaxation Exercises program four days a week for six weeks, while the control group (n = 22) received advice on relaxation for daily life. Data was collected before the intervention and after six weeks. The study's primary endpoint was the Brief Pain Inventory, which was used to measure pain severity. Secondary endpoints included assessments of quality of life and emotional status, which were measured using the Functional Assessment of Chronic Illness Therapy and Hospital Anxiety and Depression scales, respectively.

RESULTS

The study group exhibited a significant reduction in Pain Severity (p = 0.001) and Pain Interference (p = 0.012) sub-scores. Reduction in Pain Severity (p<0.001) and Patient Pain Experience (p = 0.003) sub-scores was also noted between the groups. Quality of Life and Emotional Status showed no significant variation both within and between the groups (p>0.05).

CONCLUSION

The study demonstrated that Progressive Relaxation Exercises caused a significant reduction in pain scores among Breast Cancer patients receiving Aromatase Inhibitors. While a decrease in pain during the 6-week period is valuable data, it is necessary to monitor the long-term effects of relaxation techniques.

Aromatase inhibitor-induced arthralgia ameliorated by Mediterranean diet and active lifestyle guided by continuous glucose monitoring: a case report and review of the literature

Aromatase inhibitors (AIs) are a cornerstone adjuvant treatment of many hormone receptor-positive breast cancers, and nearly half of women taking aromatase inhibitors suffer from AI-induced arthralgia (AIA), also known as AI-associated musculoskeletal syndrome (AIMSS), for which there are limited evidence-based treatments. Pharmacologic management and complementary methods including supplements, exercise, physical therapy, yoga, acupuncture, and massage have all shown mixed results. Comprehensive diet and lifestyle strategies are understudied in AIA/AIMSS despite their disease-modifying effects across many chronic conditions. Here we report a case of a woman with stage 2 estrogen and progesterone receptor-positive invasive ductal carcinoma on adjuvant anastrozole whose AI-induced arthralgia was durably controlled through a Mediterranean plant-forward diet and daily physical activity guided by continuous glucose monitoring. We posit that diet and a lifestyle inclusive of daily physical activity constitute a low-cost, low-risk, and potentially high-reward strategy for controlling common AI-induced musculoskeletal symptoms and that more investigation in this arena, including well-designed randomized trials, is warranted.

The role of aromatase inhibitors in slim women with breast cancer-related lymphoedema: a reflective case series

BACKGROUND

This case series follows the reflective processes undertaken, when five slim women presented with reactive oedemas of the forearm and hand, that did not respond to usual therapy.

AIM

To raise awareness about Aromatase Inhibitor (AI), Letrozole.

METHODS

Possible causes, including Cyclin-Dependent Kinase 4 and 6 (CDK4/6) inhibitors, Ribociclib and Axillary Web Syndrome, were explored and reviewed, and potential effective treatment options were then sought. New cases presented, which discounted each theory, until Letrozole was suspected.

RESULTS

Inflammatory oedemas were explained by the mechanisms-of-action relating to Aromatase Inhibitor Associated Musculoskeletal Syndrome (AIMSS), the severity of which, especially for slim women with oestrogen deprivation, causes almost 50% of women to cease treatment within 6 months; risking disease reoccurrence.

CONCLUSION

Permissions were gained, a table was collated and sent to referring consultants, requesting risk/benefit analysis of Letrozole with a medication review. If non-responsive, inflammatory oedemas present in clinic, AIs should be considered as a trigger.

Aromatase Inhibitor Musculoskeletal Syndrome and Bone Loss: a Review of the Current Literature

PURPOSE OF REVIEW

The study aims to review the literature regarding musculoskeletal complications of aromatase inhibitors and treatment options for these complications.

RECENT FINDINGS

Aromatase inhibitors are common medications to treat hormone receptor-positive breast cancer in postmenopausal women and have been shown to improve survival and prevent disease recurrence. However, 20-60% patients stop treatment prematurely due to side effects. Side effects include joint stiffness and pain, tendonitis, tendon tears, muscle pain, and carpal tunnel syndrome known as aromatase inhibitor musculoskeletal syndrome (AIMSS) as well as bone loss. Proposed mechanisms of AIMSS include decreased estrogen levels, inflammation, and genetic factors. Switching aromatase inhibitors, exercise, non-steroidal anti-inflammatory medications, duloxetine, acupuncture, prednisone, and bisphosphonates are some treatment options for this syndrome and will be discussed in more detail in this review. Aromatase inhibitors are important in the treatment of hormone receptor-positive breast cancer in postmenopausal women. As we study the incidence of side effects of these medications including bone loss and AIMSS and determine the mechanisms of these symptoms and possible treatment options, we will decrease the incidence of patients discontinuing treatment prematurely and improve symptoms, quality of life, and survival in this patient population.

Incidence and Treatment Efficacy of Trigger Finger in the Breast Cancer Population on Aromatase Inhibitors

BACKGROUND

Trigger finger is a common hand complaint of the general population. Limited literature exists implicating a low-estrogen state in patients on aromatase inhibitor (AI) therapy for breast cancer who develop trigger finger. The authors' objective was to determine the incidence and treatment outcomes of this population.

METHODS

A single-center retrospective chart review was conducted on patients with a diagnosis of breast cancer on AI who developed trigger finger from 2010 to 2019. The total population of patients during this time served as our population, and patients with breast cancer not on AI with trigger finger served as our control. Primary outcomes included total number of injections and need for surgery. Secondary outcomes included risk factors for surgery. χ2 analysis and logistical regression model determined the significance of primary and secondary outcomes, respectively.

RESULTS

In all, 192 patients of a population size of 664 751 met our study group criteria. The study group showed a higher incidence of trigger finger (5.1% vs 1.3%; P < .001) compared with our population. Patients treated with AI for breast cancer had both higher incidence of trigger finger (5.1% vs 1.5%, P < .001) and injections (77.1% vs 66.5%, P < .001) compared with patients not on AI therapy. Independent risk factors requiring surgical treatment were found in patients with diabetes (odds ratio [OR], 3.54; P = .01) and in patients with concomitant radiation therapy (OR, 3.17; P = .02).

CONCLUSIONS

This study demonstrates for the first time the incidence, treatment outcomes, and surgical risk factors of trigger finger in patients on AI therapy for breast cancer.

Rheumatic aspects of arthralgias associated with aromatase inhibitor therapy (analysis of a clinical case series)

Objective: to describe the rheumatic aspects of arthralgia associated with aromatase inhibitor therapy in a clinical case series.Material and methods. The article presents a series of clinical cases – 16 patients (mean age 61±14 years) with histologically verified breast cancer (BC) and the onset of musculoskeletal pathology during hormone therapy with aromatase inhibitors (letrozole, anastrozole, exemestane). The laboratory and instrumental examination data, including ultrasound, joint X-rays, general and immunological blood tests with the determination of rheumatoid factor (RF), antibodies to cyclic citrullinated peptide (ACCP), CRP and antinuclear factor (ANF) are presented. The detected musculoskeletal pathology was compared with valid classification and/or diagnostic criteria for rheumatic diseases.Results and discussion. In 10 (63%) cases, musculoskeletal pathology debuted in the first 3 months of therapy with aromatase inhibitors and in all patients it was represented by inflammatory manifestations, including clinically significant synovitis (n=13), tenosynovitis (n=12), enthesitis (n=5), morning stiffness in the joints >30 min (n=6) and inflammatory rhythm lower back pain (n=1). In 15 (94%) patients, ultrasound showed signs of synovitis (with increased vascularization in 5 cases), tenosynovitis in 15 (94%), and erosions in 1 (6%). X-rays showed osteoarthritis in 12 patients, and chronic erosive arthritis in 2. Increased ESR >30 mm/h and CRP level >5 mg/l were present in 6 (38%) and 7 (44%) patients, respectively; ANF (Hеp2) titer 1/160 was found in 8 (53%) out 15 examined patients. RF and ACCP were not detected in any case. During rheumatological examination, the following were diagnosed: polymyalgia rheumatica (n=1), undifferentiated arthritis (n=6), psoriatic arthritis (n=1), rheumatoid arthritis (n=1), recurrent proliferative synovitis of the knee joints with a pronounced exudative component (n=3), inflammatory lesions of periarticular tissues (n=4).Conclusion. Based on the obtained data, it can be assumed that arthralgias induced by breast cancer hormone therapy may be a manifestation of inflammatory diseases of the musculoskeletal system. Given the heterogeneity of manifestations of musculoskeletal pathology in such patients, a complete rheumatological examination is necessary to establish the diagnosis and conduct adequate therapy.

Mat Pilates improves lower and upper body strength and flexibility in breast cancer survivors undergoing hormone therapy: a randomized controlled trial (HAPiMat study)

PURPOSE

To evaluate the effects of 24 weeks of Mat Pilates in breast cancer survivors (BCS) undergoing hormone therapy on lower and upper body muscle strength parameters and flexibility.

MATERIALS AND METHODS

Forty-three BCS (≥40 years) with confirmed breast cancer stage 0-III undergoing hormone therapy were included. Participants were randomized into Mat Pilates (three times/week, 60 min session) or control group (relaxation activities every two weeks). The difficulty and number of exercise repetitions were increased over the weeks. Assessments were performed at three times points (baseline, 12 weeks, and 24 weeks). The generalized estimating equations (GEE) model was used to compare each outcome measure during the analysis of intention to treat (ITT) and "Per protocol analysis" (PPA).

RESULTS

The Pilates group presented significantly increased (p < 0.05) isometric flexor-extensor PT, and concentric and eccentric flexor PT and mechanical work (MW) after the intervention. Most of the upper body strength parameters, time to achieve maximal force (TF_max), maximal force (F_max), and rapid force index (RFI) and right-left upper and lower body flexibility (p < 0.05) also improved.

CONCLUSIONS

From our findings, we conclude that 24 and 12-weeks of Mat Pilates induced strength and flexibility gains for lower and upper body, respectively.Implications for rehabilitationMat Pilates can be adapted to the fitness level of breast cancer survivors, with a great variety of exercises that can be performed using a mat only or a few pieces of equipment.Patients can practice at home to gain different health benefits (i.e., increasing strength, flexibility, and functional capacity level), which could positively impact on quality of life.Mat Pilates performed three times per week with systematized increments in exercise level, load, and volume throughout the intervention was effective to improve hip extensor-flexor muscles peak torque and mechanical work at different muscle contractions, as well as upper and lower body flexibility.Mat Pilates was also able to improve right-left shoulder abductor and trunk extensor muscles strength parameters after 12 weeks of intervention, as well as both surgery and non-surgery sides of the upper body.

Office-Based Open Trigger Finger Release Has a Low Complication Rate

Purpose

Open trigger finger release is generally performed in the operating room in an outpatient setting. Its complication rate widely varies between 1% and 43%. Our goal was to determine whether performing this surgery in the clinic is a safe and viable alternative to performing this surgery in the operating room.

Methods

All open trigger finger releases performed at our clinic between 2015 and 2019 were retrospectively reviewed. Each surgery was performed by the same fellowship-trained hand surgeon using a standard open technique with an Esmarch tourniquet and without the use of epinephrine. Five hundred twenty seven finger releases were performed in 514 patients. Complications were defined as signs or symptoms requiring further treatment.

Results

There were 33 documented complications in the 527 fingers (6.3%). The most common complications were minor wound complications, including 17 (3.2%) with localized cellulitis, 2 (0.4%) with a superficial infection, 4 (0.8%) with stitch abscesses, and 5 (0.9%) with wound dehiscence. All minor complications resolved quickly with oral antibiotics and supportive care. Five patients (0.9%) required further operative management. Of these 5, 2 (0.4%) had a deep infection, 1 had chronic dehiscence, and 2 (0.4%) required flexor tenosynovectomy for persistent pain and stiffness.

Conclusions

Patients who undergo open trigger finger release surgery in the clinic have complication rates similar to reported complication rates of surgery performed in the operating room.

Clinical relevance

Performing open trigger finger surgery in the office is safe. We continue to perform this surgery during the coronavirus disease 2019 pandemic, when access to operating rooms and personal protective equipment is limited.

Aromatase inhibitor–associated musculoskeletal pain: An overview of pathophysiology and treatment modalities

Since their introduction into clinical use in the 1970s, aromatase inhibitors have been a cornerstone of therapy for estrogen-receptor positive breast cancer in postmenopausal women. Unfortunately, this therapy leads to estrogen depletion in the body, which can lead to unpleasant side effects such as menopausal symptoms like hot flashes, insomnia, slightly increased risk of ischemic heart disease, accelerated bone loss leading to higher osteoporosis risk, and most significantly, arthralgias. The joint pain induced by aromatase inhibitor therapy is frequently cited as the leading cause of premature discontinuation; approximately 50% of patients will report new onset or worsening joint pain 1 year after therapy initiation, approximately 30% of patients discontinue therapy after 1 year, and only 50%–68% of patients remain fully compliant with therapy after 3 years. This article will describe risk factors for aromatase inhibitor–associated musculoskeletal syndrome, including genetic predispositions correlated with an increased risk of this syndrome, explain the currently understood pathophysiology, and give an overview of effective treatment options in managing this syndrome.

Aromatase Inhibitor-Induced Carpal Tunnel Syndrome and Stenosing Tenosynovitis: A Systematic Review

BACKGROUND

Although aromatase inhibitors are the first-line treatment in postmenopausal women with hormone receptor-positive breast cancer, there is increasing evidence that they can induce carpal tunnel syndrome and stenosing tenosynovitis. This systematic review summarizes the risk factors, incidence, and management for patients with aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis compared to tamoxifen or placebo.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-guided systematic review of PubMed/MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials was conducted (to March 19, 2020), supplemented with Google Scholar, Plastic and Reconstructive Surgery, and The Journal of Hand Surgery. Two reviewers independently completed the primary and secondary screens and the quality appraisal.

RESULTS

This study reviewed 577 abstracts and included 19 studies. Risk factors for aromatase inhibitor-induced carpal tunnel syndrome or stenosing tenosynovitis included hormone replacement therapy before trial entry, history of musculoskeletal symptoms, age younger than 60 years, prior chemotherapy, and body mass index greater than 25 kg/m2. The incidence can be increased up to 10 times compared to tamoxifen. Patient discontinuation of aromatase inhibitor treatment because of carpal tunnel syndrome and stenosing tenosynovitis was reported. Nonsurgical management led to complete resolution of carpal tunnel syndrome symptoms in up to 67 percent of cases. Although most aromatase inhibitor-induced stenosing tenosynovitis original studies were low quality, all recommended surgical release for symptom resolution.

CONCLUSIONS

This study provides current knowledge of the associated risk factors, management options, and quality of literature for aromatase inhibitor-induced carpal tunnel syndrome and stenosing tenosynovitis. Early recognition can prevent self-discontinuation of an aromatase inhibitor and long-term sequelae of poorly treated carpal tunnel syndrome and stenosing tenosynovitis.

Pain in the Cancer Survivor

Recent decades have demonstrated significant strides in cancer screening, diagnostics and therapeutics. As such there have been dramatic changes in survival following a diagnosis of cancer.

Shear wave elastography detects novel imaging biomarkers of aromatase inhibitor-induced joint pain: a pilot study

Aim

To determine whether differences in joint and tendon stiffness as measured by ultrasound shear wave elastography are present in breast cancer patients with aromatase inhibitor-associated arthralgias compared to age-comparable healthy control women.

Methods

Postmenopausal women with stage I–III breast cancer who were taking adjuvant aromatase inhibitors and complained of joint pain were enrolled (n = 6). Postmenopausal women with no history of breast cancer, hormone treatment, or joint pain served as controls (n = 7). All subjects had bilateral hands and wrists evaluated by gray-scale and power Doppler ultrasound, and shear wave elastography ultrasound.

Results

Patients with AI-associated arthralgias had significantly stiffer tendons than controls in the 1^st extensor compartment (long axis; p = 0.001), 4^th extensor compartment (long axis; p = 0.014), 3^rd metacarpophalangeal joint (p = 0.002), the pooled values of the extensor compartments, both long (p = 0.044) and short axes (p = 0.035), and the pooled values for the metacarpophalangeal joints (p = 0.002). On ultrasound, the patients (but not controls) presented with hyperemia and increased tenosynovial fluid in the flexor and extensor tendon sheaths, and the median nerves were symptomatic and bifid; however, these differences were not statistically significant.

Conclusions

This is the first study to identify increased tendon stiffness as a putative physiological characteristic of aromatase inhibitor–associated arthralgias. Future studies should determine whether increased tendon stiffness is a risk factor for the development of aromatase inhibitor–associated arthralgias, or a result of aromatase inhibitor treatment.

Aromatase and CDK4/6 Inhibitor-Induced Musculoskeletal Symptoms: A Systematic Review

BACKGROUND

Treatment with aromatase inhibitors (AIs) is fundamental in women with hormone receptor-positive breast cancer in the adjuvant as well as the metastatic setting. Even though it is considered to be a well-tolerated therapy, aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) is the most common adverse event encountered by breast cancer patients. CDK4/6 inhibitors have emerged as a new treatment strategy in metastatic hormone receptor-positive breast cancer. However, the impact of CDK4/6 inhibitors on musculoskeletal symptoms caused by AIs is not well-defined.

OBJECTIVES

This systematic review aims to identify the frequency of joint symptoms induced by treatment with AIs and CDK4/6 inhibitors in the metastatic setting.

SEARCH STRATEGY

Eligible articles were identified by a search of existing literature for the period 2005/01/01-2021/01/01; The algorithm consisted of a predefined combination of the following keywords "breast", "cancer", "aromatase inhibitors", "CDK4/6", "phase III".

SELECTION CRITERIA

This study was performed in accordance with PRISMA guidelines. All randomized controlled Phase III trials (RCTs) evaluating the administration of third-generation aromatase inhibitors (AIs) and CDK4/6 inhibitors in postmenopausal women in the metastatic setting were considered eligible for this review.

DATA COLLECTION

Overall, 16 randomized control trials (RCTs) were retrieved, of which nine studies explored the administration of AIs in the metastatic setting and seven studies investigated the combination of CDK4/6 inhibitors and AIs. Arthralgia was reported in 1-47% of patients treated with AIs and 5.8-33.3% of patients treated with CDK4/6 inhibitors. Myalgias occurred in 2-23.7% of patients receiving AIs compared with 4.8-11.9% of patients treated with CDK4/6 inhibitors. The incidence of back pain was 7-32.9% vs. 2.9-8.5% in postmenopausal women with metastatic disease treated with AIs and CDK4/6 inhibitors, respectively. Bone pain was reported in 7-32.9% of postmenopausal women treated with AIs and 2.9-8.5% of women treated with CDK4/6 inhibitors.

CONCLUSIONS

AI treatment-induced musculoskeletal syndrome is an adverse event affecting over one-third (20-47%) of postmenopausal patients treated with AIs that often leads to treatment discontinuation. Data from RCTs provide evidence that the incidence of musculoskeletal symptoms is relatively decreased upon CDK4/6 inhibitor administration. CDK4/6 inhibitors may provide a protective role against AIMSS development.

Aromatase Inhibitor-Associated Musculoskeletal Syndrome: Understanding Mechanisms and Management

Aromatase inhibitors (AIs) are a key component in the chemoprevention and treatment of hormone receptor-positive (HR+) breast cancer. While the addition of AI therapy has improved cancer-related outcomes in the management of HR+ breast cancer, AIs are associated with musculoskeletal adverse effects known as the aromatase inhibitor-associated musculoskeletal syndrome (AIMSS) that limit its tolerability and use. AIMSS is mainly comprised of AI-associated bone loss and arthralgias that affect up to half of women on AI therapy and detrimentally impact patient quality of life and treatment adherence. The pathophysiology of AIMSS is not fully understood though has been proposed to be related to estrogen deprivation within the musculoskeletal and nervous systems. This review aims to characterize the prevalence, risk factors, and clinical features of AIMSS, and explore the syndrome's underlying mechanisms and management strategies.

Aromatase Inhibitors-Induced Musculoskeletal Disorders: Current Knowledge on Clinical and Molecular Aspects

Aromatase inhibitors (AIs) have radically changed the prognosis of hormone receptor positive breast cancer (BC) in post-menopausal women, and are a mainstay of the adjuvant therapy for BC after surgery in place of, or following, Tamoxifen. However, AIs aren't side effect-free; frequent adverse events involve the musculoskeletal system, in the form of bone loss, AI-associated arthralgia (AIA) syndrome and autoimmune rheumatic diseases. In this narrative review, we reported the main clinical features of these three detrimental conditions, their influence on therapy adherence, the possible underlying molecular mechanisms and the available pharmacological and non-pharmacological treatments. The best-known form is the AIs-induced osteoporosis, whose molecular pathway and therapeutic possibilities were extensively investigated in the last decade. AIA syndrome is a high prevalent joint pain disorder which often determines a premature discontinuation of the therapy. Several points still need to be clarified, as a universally accepted diagnostic definition, the pathogenetic mechanisms and satisfactory management strategies. The association of AIs therapy with autoimmune diseases is of the utmost interest. The related literature has been recently expanded, but many issues remain to be explored, the first being the molecular mechanisms.

Cancer Rehabilitation:: Acute and Chronic Issues, Nerve Injury, Radiation Sequelae, Surgical and Chemo-Related, Part 2

Cancer affects millions of individuals, and approximately half will develop functional impairments. Cancers that commonly, either from direct effects or from its treatments, result in functional impairments include breast, head and neck, brain, and spinal cord tumors. There is a plethora of potential impairments including pain, spasticity, dystonia, weakness, and neurogenic bowel or bladder. This article reviews the functional impairments frequently encountered in breast, head and neck, brain, and spinal cord tumors. The authors also discuss management and treatment options incorporated in comprehensive cancer rehabilitation to address these impairments to maximize and maintain function and quality of life.

Prospective evaluation of finger two-point discrimination and carpal tunnel syndrome among women with breast cancer receiving adjuvant aromatase inhibitor therapy

PURPOSE

Aromatase inhibitors (AIs) are associated with musculoskeletal symptoms and risk of developing carpal tunnel syndrome (CTS), which can impair quality of life and prompt treatment discontinuation. The incidence of CTS and clinical utility of diagnostic tests such as 2-point discrimination (2-PD) have not been prospectively examined among women receiving AIs.

METHODS

Postmenopausal women with stage 0-III hormone receptor-positive breast cancer who were enrolled in a randomized clinical trial investigating adjuvant AIs (Exemestane and Letrozole Pharmacogenetics, ELPh) underwent prospective evaluation of 2-PD with the Disc-criminator™ (sliding aesthesiometer) and completed a CTS questionnaire at baseline, 3, 6, and 12 months, following initiation of AI. Changes in mean 2-PD were analyzed with multivariable mixed effects modelling. A p value < 0.05 was considered statistically significant.

RESULTS

Of 100 women who underwent baseline 2-PD testing, CTS was identified by questionnaire in 11% at baseline prior to AI initiation. Prevalence of CTS at any time in the first year was 26%. A significant increase in worst 2-PD score was observed from baseline to 3 months (3.7 mm to 3.9 mm, respectively, p = 0.03) when adjusted for age, prior chemotherapy, randomized treatment assignment, and diabetes. There were no significant differences in treatment discontinuation due to CTS between the arms.

CONCLUSION

For women receiving adjuvant AI, 2-PD scores were significantly worse at 3 months compared to baseline. Studies are required to assess whether change in 2-PD is an adequate objective assessment for CTS with AI therapy. Early diagnosis of CTS may expedite management, improve AI adherence, and enhance breast cancer outcomes.

British Menopause Society consensus statement on the management of estrogen deficiency symptoms, arthralgia and menopause diagnosis in women treated for early breast cancer

This guidance document by the British Menopause Society provides an overview of the management of women experiencing estrogen deficiency symptoms and arthralgia following a breast cancer diagnosis. It is now recommended that breast cancer patients are referred to health care professionals with an expertise in menopause for the management of such symptoms, which in turn often involves liaison with patients' breast cancer teams. However, as many women initially present to primary health care professionals for advice, this statement is aimed to support the latter in such consultations by providing information about symptom aetiology, current management strategies and controversies and identifying useful practice points.

A combination of hydroxytyrosol, omega-3 fatty acids and curcumin improves pain and inflammation among early stage breast cancer patients receiving adjuvant hormonal therapy: results of a pilot study

PURPOSE

Breast cancer patients receiving hormonal therapies face risks of relapse, increased rates of cardiovascular events, and toxicities of therapy such as aromatase inhibitor (AI)-associated musculoskeletal symptoms (AIMSS). C-reactive protein (CRP), a marker for inflammation, is associated with breast cancer outcomes. We evaluated whether the olive-derived polyphenol hydroxytyrosol combined with omega-3 fatty acids and curcumin would reduce CRP and musculoskeletal symptoms in breast cancer patients receiving adjuvant hormonal therapies.

EXPERIMENTAL DESIGN

This prospective, multicenter, open-label, single arm, clinical trial enrolled post-menopausal breast cancer patients (n = 45) with elevated C-reactive protein (CRP) taking predominantly aromatase inhibitors to receive a combination of hydroxytyrosol, omega-3 fatty acids, and curcumin for 1 month. CRP, other inflammation-associated cytokines, and pain scores on the Brief Pain Inventory were measured before therapy, at the end of therapy and 1 month after completion of therapy.

RESULTS

CRP levels declined during the therapy [from 8.2 ± 6.4 mg/L at baseline to 5.3 ± 3.2 mg/L (p = 0.014) at 30 days of treatment], and remained decreased during the additional 1 month off therapy. Subjects with the highest baseline CRP levels had the greatest decrease with the therapy. Pain scores also decreased during the therapy. There were no significant adverse events.

CONCLUSIONS

The combination of hydroxytyrosol, omega-3 fatty acids, and curcumin reduced inflammation as indicated by a reduction in CRP and reduced pain in patients with aromatase-induced musculoskeletal symptoms. Longer studies comparing this combination to other anti-inflammatories in larger groups of patients with clinical outcome endpoints are warranted.

Aromatase Inhibitor-Associated Tendinopathy and Muscle Tendon Rupture: Report of Three Cases of This Exceedingly Rare Adverse Event

Aromatase inhibitors (AIs) are a commonly used antihormonal therapy in the treatment of breast cancer in postmenopausal women, specifically in the treatment of hormone receptor-positive breast cancer. AI-associated tendinopathy and muscle tendon rupture is exceedingly rare. Until now, only one case with AI-associated severe tendinopathy has been reported in the medical literature, and there are no recorded cases of AI-associated muscle tendon rapture. We report three cases of postmenopausal women with hormone receptor-positive breast cancer, who experienced tendinopathy or muscle tendon rupture under antihormonal treatment with letrozole. All of the three women were in the adjuvant setting, and the treatment of tendinopathy or tendon rupture consisted of AI discontinuation, initiation of corticosteroids, or surgical treatment. Diagnosis was made via MRI. Furthermore, in our cases, there were no signs of underlying systemic disease, there was no abnormal physical activity preceding the complaints, and there was no use of other drugs beside letrozole. AIs are one of the most commonly used drugs in antihormonal therapy for hormone receptor-positive breast cancer. In every case of a female patient with hormone receptor-positive breast cancer under treatment with AIs and arthralgia, an MRI should be performed in order to exclude the presence of tendinopathy or muscle tendon rupture.

Efficacy of Complementary Therapies in the Quality of Life of Breast Cancer Survivors

Breast cancer (BC) is the most common cancer diagnosed in women and the second most common cancer overall, ranking as the fifth cause of death from cancer. The chronicity of the disease produces long-term physiological and psychological manifestations, which adversely affect the quality of life of the individual. The primary treatment while managing cancer presents with various debilitating side effects. With the recent advances in treatment techniques that have improved the survival rate, patients suffer from continuing posttreatment complications. Patients seem to cope well with the stress of treatment of BC and sustain a normal life; however, the deterioration in physical well-being makes the patient functionally inefficient. Exercise has been proven to be an effective, safe, and feasible tool in combating the adverse effects of treatment, prevents complications and decreases the risk of BC-specific mortality. This review briefly presents an overview of the burden of the disease and its management strategies. Owing to the heterogeneity of the population and the multitude of therapies they receive, the response of each patient to treatment is different and so is the magnitude of adverse effects. The review discusses the late sequelae following treatment and evidence supporting the role of physical activity in their management. In conclusion, there is a need for personalized physical activity plans to be developed to suit the individual and their circumstances.

Randomized placebo-controlled pilot trial of omega 3 fatty acids for prevention of aromatase inhibitor-induced musculoskeletal pain

PURPOSE

Aromatase inhibitor (AI)-induced joint symptoms negatively impact drug adherence and quality of life in breast cancer survivors. Mechanisms underlying symptoms may include inflammation. It is hypothesized that n - 3 polyunsaturated fatty acids (PUFAs) have anti-inflammatory properties and may reduce symptoms.

METHODS

We conducted a randomized, double-blind, placebo-controlled study comparing 4.3 g/day n - 3 PUFA supplements vs placebo for 24 weeks in postmenopausal breast cancer patients starting adjuvant AIs. Primary endpoints were adherence and tolerability; secondary outcomes included inflammatory cytokines and symptoms assessed by the Brief Pain Inventory short form (BPI-SF) and Functional Assessment of Cancer Treatment-Endocrine Symptoms (FACT-ES) at 0, 12, and 24 weeks.

RESULTS

Forty-four women were randomized, of which 35 completed the study. Adherence was ≥ 88% based on these 35 patients with pill counts as well as change in red blood cell (RBC) n - 3 PUFAs. Common toxicities included grade 1 flatulence (55% of both groups) and belching (45% of n - 3 group). Mean pain severity scores (BPI-SF) did not change significantly by time or treatment arm. Quality of life, based on FACT-ES scores, significantly decreased within placebo (p = 0.04), but not the n - 3 group (p = 0.58), with a trend toward between-group differences (p = 0.06) at 12 weeks, but no significant differences at 24 weeks. RBC n - 3 levels were strongly positively correlated with FACT-ES at 12 weeks, but attenuated at 24 weeks.

CONCLUSION

High-dose n - 3 PUFA supplementation is feasible and well tolerated when administered with AIs. Additional studies are needed to evaluate efficacy in prevention of joint symptoms.

Prevalence of aromatase inhibitor-induced arthralgia in breast cancer: a systematic review and meta-analysis

BACKGROUND

Although aromatase inhibitors have proven to be an effective treatment of hormone receptor-positive breast cancer in postmenopausal women, aromatase inhibitor-induced arthralgia (AIA) is an adverse event associated with low compliance with treatment. The aim of this literature study is to assess the prevalence of AIA and to provide an overview of significant predictors for the development of AIA.

METHODS

A systematic review was conducted using PubMed, Cochrane Library and Web of Science. A meta-analysis was performed and heterogeneity has been investigated by moderator analyses. The meta-analysis was repeated with studies that were considered as best evidence, i.e. studies with an above-average score on the STROBE checklist.

RESULTS

Twenty-one studies (13,177 participants) were included. Prevalence rates ranged from 0.200 to 0.737. Meta-analysis resulted in a pooled estimate of 0.459 (95% CI = [0.397-0.520) with a high heterogeneity (I ² = 98%). Moderator analysis showed no differences regarding heterogeneity. Predictors for the development of AIA included a body mass index of 25-30 kg/m² (OR = 0.33), taxane-based chemotherapy (OR = 4.08), stage III cancer (OR = 0.32) and a duration of menopause of 5-10 years (OR = 1.10) or >10 years (OR = 0.44-3.29) (An OR <1 indicates a predictor of lower risk of AIA).

DISCUSSION

Despite the established benefits of AI, an important portion of the patients experiences AIA. More research is needed to investigate the efficacy of treatments such as exercise therapy for AIA.

Anastrozole-Induced Carpal Tunnel Syndrome: Results From the International Breast Cancer Intervention Study II Prevention Trial

PURPOSE

Carpal tunnel syndrome (CTS) occurs when the median nerve is compressed at the wrist in the carpal tunnel. It has been suggested that hormonal risk factors may be involved in the pathogenesis of CTS, and a higher incidence of CTS has been reported in randomized clinical trials with aromatase inhibitors (AIs) compared with tamoxifen.

PATIENTS AND METHODS

This was an exploratory analysis of the International Breast Cancer Intervention Study II, a double-blind randomized clinical trial in which women at increased risk of breast cancer were randomly assigned to receive anastrozole or placebo. This is the first report of risk factors for and characteristics of CTS in women taking an AI in a placebo-controlled trial.

RESULTS

Overall, 96 participants with CTS were observed: 65 (3.4%) in the anastrozole arm and 31 (1.6%) in the placebo arm (odds ratio, 2.16 [1.40 to 3.33]; P < .001). Ten participants were reported as having severe CTS, of which eight were taking anastrozole (P = .08). Eighteen women (0.9%) in the anastrozole arm and six women (0.3%) in the placebo arm reported surgical intervention, which was significantly different (odds ratio, 3.06 [1.21 to 7.72], P = .018). Six women discontinued with the allocated treatment because of the onset of CTS. Apart from treatment allocation, a high body mass index and an a prior report of musculoskeletal symptoms after trial entry were the only other risk factors for CTS identified in these postmenopausal women.

CONCLUSIONS

The use of anastrozole was associated with a higher incidence of CTS but few participants required surgery. Further investigations are warranted into the risk factors and treatment of AI-induced CTS.

Validity and reliability of the Patient-Reported Arthralgia Inventory: validation of a newly-developed survey instrument to measure arthralgia

Background

There is a need for a survey instrument to measure arthralgia (joint pain) that has been psychometrically validated in the context of existing reference instruments. We developed the 16-item Patient-Reported Arthralgia Inventory (PRAI) to measure arthralgia severity in 16 joints, in the context of a longitudinal cohort study to assess aromatase inhibitor-associated arthralgia in breast cancer survivors and arthralgia in postmenopausal women without breast cancer. We sought to evaluate the reliability and validity of the PRAI instrument in these populations, as well as to examine the relationship of patient-reported morning stiffness and arthralgia.

Methods

We administered the PRAI on paper in 294 women (94 initiating aromatase inhibitor therapy and 200 postmenopausal women without breast cancer) at weeks 0, 2, 4, 6, 8, 12, 16, and 52, as well as once in 36 women who had taken but were no longer taking aromatase inhibitor therapy.

Results

Cronbach’s alpha was 0.9 for internal consistency of the PRAI. Intraclass correlation coefficients of test-retest reliability were in the range of 0.87–0.96 over repeated PRAI administrations; arthralgia severity was higher in the non-cancer group at baseline than at subsequent assessments. Women with joint comorbidities tended to have higher PRAI scores than those without (estimated difference in mean scores: −0.3, 95% confidence interval [CI] −0.5, −0.2; P<0.001). The PRAI was highly correlated with the Functional Assessment of Cancer Therapy-Endocrine Subscale item “I have pain in my joints” (reference instrument; Spearman r range: 0.76–0.82). Greater arthralgia severity on the PRAI was also related to decreased physical function (r=−0.47, 95% CI −0.55, −0.37; P<0.001), higher pain interference (r=0.65, 95% CI 0.57–0.72; P<0.001), less active performance status (estimated difference in location (−0.6, 95% CI −0.9, −0.4; P<0.001), and increased morning stiffness duration (r=0.62, 95% CI 0.54–0.69; P<0.0001).

Conclusion

We conclude that the psychometric properties of the PRAI are satisfactory for measuring arthralgia severity.

Safety of aromatase inhibitor therapy in breast cancer

INTRODUCTION

Aromatase inhibitor (AI) therapy is the current preferred choice of endocrine therapy in postmenopausal estrogen receptor-positive breast cancer patients thanks to their improved effectiveness compared to tamoxifen. Despite the absence of increased endometrial pathology and deep venous thrombosis seen in tamoxifen-users, the safety profile of AIs consists of a variety of bothersome side effects negatively influencing daily functioning.

AREAS COVERED

Besides the well-known adverse effects on joints and bone and the vasomotor system, more neglected and latent toxicity like cognitive problems and vulvovaginal atrophy will be discussed. Concern has been raised in terms of increased risk of fractures and cardiovascular events with chronic AI use.

EXPERT OPINION

Placebo-controlled long-term studies carefully monitoring these adverse events, together with more extensive research in the etiologies, are warranted.

Risk factors for complications of open trigger finger release

BACKGROUND

Open trigger finger release is generally considered a simple low-risk procedure. Reported complication rates vary widely from 1 to 43 %, mostly based on small studies. Our goal was to determine the incidence of complications in a large consecutive series, while also identifying potential risk factors.

METHODS

All open trigger finger releases performed from 2006 to 2009 by four fellowship-trained hand surgeons at a single institution were retrospectively reviewed. There were 795 digits released in 543 patients. Complications were defined as signs or symptoms requiring further treatment and/or considered unresolved by 1 month postoperatively. Complications requiring operative intervention were regarded as major. Multivariable analysis was performed to determine possible risk factors for complications.

RESULTS

There were 95 documented complications among 795 digits (12 %). The most common complications involved persistent pain, stiffness, or swelling, persistent or recurrent triggering, or superficial infection. Most were treated nonoperatively with observation, therapy, steroid injection, or oral antibiotics. There were 19 reoperations (2.4 %), mostly including revision release, tenosynovectomy, and irrigation and debridement. Male gender, sedation, and general anesthesia were independently associated with complications, while age, diabetes, hypothyroidism, recent injection, and concurrent procedures were not associated.

CONCLUSIONS

Open trigger finger release is generally a low-risk procedure, although there is potential for complications, some requiring reoperation. Male gender, sedation, and general anesthesia may be associated with greater risk. Surgeons should be careful to thoroughly discuss the risk of both major and minor complications when counseling patients.

Acupuncture for joint symptoms related to aromatase inhibitor therapy in postmenopausal women with early-stage breast cancer: a narrative review

BACKGROUND

Aromatase inhibitor-induced musculoskeletal syndrome (AIMSS) leads to discontinuation of aromatase inhibitor therapy in a significant proportion of patients with breast cancer. Acupuncture is popular among cancer patients and has previously been shown to improve symptoms in a range of musculoskeletal complaints.

AIM

To determine the effectiveness and safety of acupuncture for the management of AIMSS in postmenopausal women with early-stage breast cancer.

METHODS

A literature search was carried out for randomised controlled trials (RCTs) on acupuncture for AIMSS in postmenopausal women with early-stage breast cancer. Characteristics of trials and outcomes were extracted from the retrieved articles, which were also assessed for risk of bias and quality of reporting.

RESULTS

Four RCTs were retrieved of sample size 32-67 (totalling 190 participants). Compliance with treatment was high and rates of adverse events were low. Of the three two-arm RCTs, two found no difference between acupuncture and sham acupuncture and one found that acupuncture was statistically superior to sham acupuncture. The fourth RCT, which incorporated three arms, found acupuncture and sham acupuncture to be statistically superior to usual care but there was no difference between true and sham acupuncture. Three trials that used non-penetrating sham as the control found no effect of acupuncture over sham, but the one trial that used superficial needle insertion found acupuncture to be superior.

CONCLUSIONS

Acupuncture is safe and results in improvement in AIMSS symptoms, but similar benefits are also elicited by non-penetrating sham acupuncture. Future research should seek to establish the durability of improvements.

Steroidal and non-steroidal third-generation aromatase inhibitors induce pain-like symptoms via TRPA1

Use of aromatase inhibitors (AIs), exemestane, letrozole and anastrozole, for breast cancer therapy is associated with severe pain symptoms, the underlying mechanism of which is unknown. The electrophilic nature of AIs suggests that they may target the transient receptor potential ankyrin 1 (TRPA1) channel, a major pathway in pain transmission and neurogenic inflammation. AIs evoke TRPA1-mediated calcium response and current in rodent nociceptors and human cells expressing the recombinant channel. In mice, AIs produce acute nociception, which is exaggerated by pre-exposure to proalgesic stimuli, and, by releasing sensory neuropeptides, neurogenic inflammation in peripheral tissues. AIs also evoke mechanical allodynia and decreased grip strength, which do not undergo desensitization on prolonged AI administration. These effects are markedly attenuated by TRPA1 pharmacological blockade or in TRPA1-deficient mice. TRPA1 is a major mediator of the proinflammatory/proalgesic actions of AIs, thus suggesting TRPA1 antagonists for the treatment of pain symptoms associated with AI use.

The JACS prospective cohort study of newly diagnosed women with breast cancer investigating joint and muscle pain, aches, and stiffness: pain and quality of life after primary surgery and before adjuvant treatment

BACKGROUND

Breast cancer affects one in eight UK women during their lifetime: many of these women now receive adjuvant chemotherapy and hormone therapy. Joint and muscle pains, aches, and stiffness are common but the natural history, aetiology and impact of these symptoms are unknown. A cohort study of newly diagnosed women with primary breast cancer was established to explore this. In this paper we present study methods and sample characteristics, describe participants' experience of musculoskeletal pain at baseline interview, and explore its impact on quality of life.

METHODS

Women with non-metastatic breast cancer were recruited following primary surgery into a multi-centre cohort study. They received questionnaires by post five times (baseline, 3, 6 , 9 and 12 months) to investigate prevalence, severity, location and correlates of musculoskeletal pain, and impact on quality-of-life. Pain was measured by the Nordic musculoskeletal questionnaire, the Brief Pain Inventory, and MSK-specific questions, and quality of life by the SF-36 and FACIT scales.

RESULTS

543 women (mean age 57 years, range 28-87, 64% postmenopausal) were recruited following surgery for primary breast cancer from breast cancer clinics in eight hospitals. Fifteen per cent of the eligible cohort was missed; 28% declined to participate. Joint or muscle aches, pains or stiffness were reported by 69% women with 28% specifically reporting joint pain/aches/stiffness. Quality of life, as measured by the FACT-B and adjusted for age, depression, surgery and analgesic use, is significantly worse in all domains in those with musculoskeletal problems than those without.

CONCLUSIONS

Our findings highlights the importance of a better understanding of these symptoms and their impact on the lives of women with primary breast cancer so that healthcare professionals are better equipped to support patients and to provide accurate information to inform treatment decisions. Further papers from this study will address these issues.

Pain related to cancer treatments and diagnostic procedures: a no man's land?

BACKGROUND

While guidelines are available for the management of cancer-related pain, little attention is given to the assessment and treatment of pain caused by treatments and diagnostic procedures in cancer patients.

METHODS

We evaluated the literature on pain related to cancer treatment and diagnostic procedures within a critical analysis.

RESULTS

The data available are sparse, suggesting that little attention has been directed at this important aspect of oncology. This points to potentially suboptimal patient management.

CONCLUSIONS

Appropriate studies are necessary in order to understand the incidence and appropriate management of pain, both during and/or after oncological treatments and diagnostic procedures. At the same time, Health Care Professionals should have heightened awareness of the causes and treatment of pain with the aim of anticipating and managing pain most appropriately for each individual patient. This is clearly an important component of holistic patient care before, during, and after oncological treatment.

Germline variants in the CYP19A1 gene are related to specific adverse events in aromatase inhibitor users: a substudy of Dutch patients in the TEAM trial

Musculoskeletal adverse events (MSAEs) and vasomotor symptoms (VMSs) are known side-effects of aromatase inhibitors, and may be related to genetic variations of the aromatase gene (CYP19A1). We investigated the relationship between these specific AEs and single nucleotide polymorphisms (SNPs) in the CYP19A1 gene in postmenopausal, hormone receptor-positive early breast cancer (BC) patients treated with adjuvant exemestane for 5 years. Dutch patients who were randomized to receive 5 years of exemestane in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial were included. A tagging-SNP approach was performed, covering 80 % of variations of the CYP19A1 gene with 30 SNPs. Logistic regression analyses were used to assess the risk of reporting VMSs or MSAEs in relation to genotypes within selected SNPs. Of 737 included patients, 281 patients reported at least one MSAE (n = 210) or VMS (n = 163). Homozygous AA genotype of rs934635 was associated with a significantly higher odds of MSAEs (multivariate odds ratio (OR) 4.66, p = 0.008) and VMSs (multivariate OR 2.78, p = 0.044). Regarding both rs1694189 and rs7176005, the homozygous variant genotypes (TT) were associated with a higher odds of VMSs, but not MSAEs (OR 1.758, p = 0.025 and OR 6.361, p = 0.021, respectively). Our exploratory analysis demonstrated that some CYP19A1 gene variations may be associated with MSAEs and/or VMSs. Specifically, patients with the homozygous variant rs934635 genotype reported more MSAEs and VMSs. Although further confirmatory studies are warranted, genomic profiling can help identify patients at an increased risk of reporting these specific AEs, potentiating further personalized BC treatment.

Aromatase inhibitors in the breast cancer clinic: focus on exemestane

Breast cancer is the most prevalent type of cancer in women and responsible for significant female cancer-related mortality worldwide. In the Western world, over 80% of breast cancers are hormone-receptor positive for which endocrine therapy is administered. The main anti-estrogen treatments in use consist of selective estrogen-receptor modulators, such as tamoxifen, and third-generation aromatase inhibitors (AIs), such as exemestane, letrozole, and anastrozole. In this review, the focus will lie on exemestane, its clinical use, and its side-effect profile. Exemestane is the only third-generation steroidal AI. Its efficacy as a first-line treatment in metastatic breast cancer has been demonstrated. Therefore, exemestane could be considered a valid first-line therapeutic option, but it also can be used in second-line or further situations. Exemestane is mostly used as part of sequential adjuvant treatment following tamoxifen, but in this setting it is also active in monotherapy. Furthermore, this AI has been studied in the neoadjuvant setting as presurgical treatment, and even as chemoprevention in high-risk healthy postmenopausal women. It may reverse side effects of tamoxifen, such as endometrial changes and thromboembolic disease but may also cause some inconvenient side effects itself. Additionally, there is a lack of total cross-resistance between exemestane and nonsteroidal AIs as far as their anti-tumoral efficacy is concerned; moreover the two classes of AIs display a nontotal overlapping toxicity profile. Taking together, exemestane can be considered as a useful treatment option at all stages of breast cancer.

Aromatase inhibition 2013: clinical state of the art and questions that remain to be solved

Following their successful implementation for the treatment of metastatic breast cancer, the 'third-generation' aromatase inhibitors (anastrozole, letrozole, and exemestane) have now become standard adjuvant endocrine treatment for postmenopausal estrogen receptor-positive breast cancers. These drugs are characterized by potent aromatase inhibition, causing >98% inhibition of estrogen synthesis in vivo. A recent meta-analysis found no difference in anti-tumor efficacy between these three compounds. As of today, aromatase inhibitor monotherapy and sequential treatment using tamoxifen followed by an aromatase inhibitor for a total of 5 years are considered equipotent treatment options. However, current trials are addressing the potential benefit of extending treatment duration beyond 5 years. Regarding side effects, aromatase inhibitors are not found associated with enhanced risk of cardiovascular disease, and enhanced bone loss is prevented by adding bisphosphonates in concert for those at danger of developing osteoporosis. However, arthralgia and carpal tunnel syndrome preclude drug administration among a few patients. While recent findings have questioned the use of aromatase inhibitors among overweight and, in particular, obese patients, this problem seems to focus on premenopausal patients treated with an aromatase inhibitor and an LH-RH analog in concert, questioning the efficacy of LH-RH analogs rather than aromatase inhibitors among overweight patients. Finally, recent findings revealing a benefit from adding the mTOR inhibitor everolimus to endocrine treatment indicate targeted therapy against defined growth factor pathways to be a way forward, by reversing acquired resistance to endocrine therapy.

Aromatase inhibitor-induced arthralgia: a review

Though aromatase inhibitors (AIs) are an essential part of estrogen receptor-positive (ER+) breast cancer therapy, many patients discontinue the medicine before their adjuvant therapy is completed because of the arthralgia which often accompanies the medicine. Up to half of women on AI therapy experience joint pain, and up to 20% will become non-compliant with the medicine because of the joint pain. Yet, very little is known about what causes AI-induced arthralgia (AIA), and there is no established, effective treatment for this difficult problem. It compromises survivors' quality of life and leads to non-compliance. This paper will discuss AIA in depth, including potential etiologies, clinical significance, risk factors, and possible management solutions. Of note, this article presents one of the first proposed algorithms which clearly lays out a treatment plan for AIA, incorporating a variety of interventions which have been proven by the available literature.

Defining the aromatase inhibitor musculoskeletal syndrome: a prospective study

OBJECTIVE

To define the musculoskeletal syndrome associated with use of aromatase inhibitors (AIs), specifically, to describe its incidence, time to onset, risk factors, and clinical presentation.

METHODS

Postmenopausal women with hormone-sensitive, nonmetastatic breast cancer starting AI therapy were enrolled in this prospective cohort study. They underwent complete rheumatologic evaluation and contrast-enhanced magnetic resonance imaging (MRI) of the hands and wrists prior to starting AI, at 3 and 6 months. The primary outcome was change in grip strength.

RESULTS

Twenty-eight (54%) of 52 women reported new or worsening musculoskeletal symptoms. Two discontinued AIs due to pain. Mean time to symptom onset was 6 weeks (range 2-18 weeks), and 75% of symptomatic patients developed symptoms by 8 weeks. Later-stage cancer and worse quality of life (QOL) pretreatment were significantly associated with symptom development. Sixty-eight percent of symptomatic subjects had involvement of the hands; however, there was no difference in the mean change in grip strength (-2.9 kg versus -1.3 kg; P = 0.6). Among symptomatic subjects, 46% had evidence of focal tenosynovitis of the hands and feet on examination. Although some symptomatic subjects had new MRI abnormalities, Rheumatoid Arthritis Magnetic Resonance Imaging Scoring did not significantly change.

CONCLUSION

The incidence of AI-associated musculoskeletal syndrome is more than 50%, with most women developing symptoms by 8 weeks. The key finding in symptomatic women was focal tenosynovitis of the hands and feet, without evidence of autoimmune disease or systemic inflammation. Later-stage cancer and poorer QOL were predictive of symptom development.

Etiology, assessment, and management of aromatase inhibitor-related musculoskeletal symptoms

Aromatase inhibitors (AIs) are recommended as adjuvant endocrine therapy for postmenopausal women with hormone-responsive breast cancer. With the widespread use of AI adjuvant endocrine therapy, a significant profile of musculoskeletal symptoms has emerged. Moderate to severe musculoskeletal symptoms have led some women to discontinue therapy, compromising the survival benefit. The etiology of AI-related musculoskeletal symptoms is poorly understood, which challenges development of effective management strategies. The purpose of this article is to describe AI-related musculoskeletal symptoms, review possible causes, provide assessment guidelines, and recommend management strategies based on the best available evidence. Little evidence exists for effective management strategies of AI-related musculoskeletal symptoms, and randomized clinical trials are needed to establish effective interventions. A thorough musculoskeletal assessment can help guide clinical decision making for the best individual management approach. Providers need to manage symptoms with the best available evidence to minimize symptom distress and maximize adherence to AI therapy.

Changes in bone biomarker concentrations and musculoskeletal symptoms among breast cancer patients initiating aromatase inhibitor therapy and women without a history of cancer

The objectives of this study were to examine: (1) changes in bone formation (osteocalcin) and bone resorption (cross-linked N-telopeptides of bone type I collagen [NTXs]) markers, as well as calcium, phosphorus, and intact parathyroid hormone, over the first 6 months of aromatase inhibitor (AI) therapy among a cohort of breast cancer patients compared with a group of unexposed women without a history of cancer; and (2) whether bone marker changes were associated with musculoskeletal pain. Eligible breast cancer patients (n = 49) and postmenopausal women without a history of cancer (n = 117) were recruited and followed for 6 months. At baseline, 3 months, and 6 months, a questionnaire was administered to assess pain and medication use, and a blood sample was drawn. Results showed that, among the breast cancer patients, calcium concentrations decreased significantly (-7.8% change; p = 0.013) and concentrations of NTXs increased significantly from baseline to 6 months (9.6% change; p = 0.012). Changes were not observed for women in the comparison group. Statistically significant differences in percent change between the breast cancer patients and the women in the comparison group were observed for calcium at 6 months (-7.8% versus 0.0%; p = 0.025), phosphorus at 6 months (-5.1% versus 16.7%; p = 0.003), NTXs at 6 months (9.6% versus -0.7%; p = 0.017), and osteocalcin at 6 months (11.5% versus -3.6%; p = 0.016). No statistically significant associations were observed between bone turnover marker changes and musculoskeletal pain among the breast cancer patients, although baseline NTXs were higher among women with onset or increase in pain compared with those reporting no pain (p = 0.08). Findings from this study suggest that AIs cause changes in bone turnover during the first 6 months of treatment; however, these changes are not associated with musculoskeletal pain. Breast cancer patients initiating AI therapy should be assessed and monitored for fracture risk using known clinical risk factors, including bone density, and managed appropriately.