Skeletal manifestations of treatment of breast cancer

Weight Change in Post-Menopausal Women with Breast Cancer during Chemotherapy-Perspectives on Nutrition, Activity and Bone Metabolism: An Interim Analysis of a 5-Year Prospective Cohort

Women with breast cancer are a growing population due to improved screening and treatment. It has been described that chemotherapy can negatively affect patients' metabolism. The aim of this study is to assess weight gain during chemotherapy treatment in an interim analysis on an ongoing prospective cohort of women with early breast cancer. To help untangle the many possible reasons for weight change, we examine blood tests, Patient-Reported Outcomes (PROs), and bone mineral density (BMD). We find that the 38 women that have measurements taken after chemotherapy have an average weight gain of 1.2 kg although not significant. Together with this, there is a significant drop in HDL cholesterol, an increase in triglycerides, and a non-significant tendency towards decreased insulin sensitivity. PROs show that although the women experience more pain and fatigue, they have higher activity levels. BMD is at an expected level according to age. All in all, we see an increased focus on physical activity and nutrition, leading to less severe metabolic changes as previously reported. However, even though more measures are taken, we still see an overall negative metabolic impact with unknown long-term implications.

Physical activity and health-related quality of life among postmenopausal women with breast cancer treated with aromatase inhibitors

PURPOSE

Breast cancer is the most common non-cutaneous cancer in women with an estimated 268,600 new cases diagnosed in 2019, joining the over 3 million women living with the disease. To reduce cancer recurrence, postmenopausal women (highest incidence and prevalence of breast cancer) who test positive for hormone receptors in their tumors are candidates for adjuvant endocrine therapy (i.e., aromatase inhibitors [AIs]). Despite the benefits of AIs in the treatment for breast cancer, many women remain at risk for complications, including osteoporosis and fractures, all of which can adversely affect health-related quality of life (HRQoL). Increased attention is being paid to the role physical activity (PA) may have in improving health outcomes in survivors of breast cancer, but few studies focus on postmenopausal women. We sought to examine (1) the percentage of women in our sample meeting (or not meeting) the American College of Sports Medicine (ACSM) PA recommendations, (2) the relationship between AI use and three types of PA (leisure time, strength training, and walking), and (3) the relationship between PA and HRQoL by AI use, controlling for covariates.

METHODS

Postmenopausal women with breast cancer (n = 170), ages 50-95 years (M = 68.7), diagnosed with stage 1-3 disease, 45% on AIs, were recruited. Demographic, HRQoL, and PA data were collected via patient self-report, while clinical data (AI use) were abstracted from patient medical records. To address study aims, we utilized descriptive statistics, chi-square analyses, and multiple linear regressions, respectively.

RESULTS

Half of the sample met the ACSM recommendations for total leisure-time PA (vigorous and moderate intensity combined), and 65.3% (n = 111) weekly walking. With regard to strength training, 36.5% of the women met these ACSM recommendations. Generally, there were positive relationships between AI use and most HRQoL domains. There were no statistically significant relationships between PA (meeting recommendations or not) and HRQoL by AI use.

CONCLUSION

The proportion of women meeting guidelines for walking activity was encouraging. It is imperative that healthcare professionals providing care to breast cancer survivors follow up regarding symptoms, side effects, and physical activity in tandem to fully understand their relationship on an individual level.

Changes in Bone Mineral Density in Women With Breast Cancer: A Prospective Cohort Study

BACKGROUND

Cancer treatment-induced bone loss is an important long-term effect among breast cancer survivors. Little is known, however, about the pattern of bone loss and the factors associated with it.

OBJECTIVE

The aim of this study was to examine annual bone health changes and factors associated with bone loss for 3 years after diagnosis among women with breast cancer.

METHODS

Ninety-nine newly diagnosed women with breast cancer (mean age, 51.1 years) were enrolled in a prospective longitudinal study. Bone mineral density (BMD) was measured with dual-energy x-ray absorptiometry at baseline and yearly for 3 years.

RESULTS

During the 3-year follow-up, the proportion of women who had osteopenia or osteoporosis increased from 33.3% to 62.5%. The BMD of the participants significantly decreased 6.8% in the lumbar spine, 4.6% in the femur neck, and 3.5% in the total hip, with bone loss the greatest in the first year. In multiple linear regression analysis, chemotherapy was significantly associated with bone loss at all sites, and premenopausal status at diagnosis was significantly related to bone loss at the lumbar spine. We found no significant relationship between health behavior status and BMD change at any site.

CONCLUSION

Women newly diagnosed with breast cancer can lose up to 6.8% of BMD during a 3-year follow-up. Chemotherapy and premenopausal status are important risk factors for bone loss.

IMPLICATIONS FOR PRACTICE

Identification of premenopausal women at diagnosis and monitoring BMD before and after chemotherapy are key for promoting bone health in women with breast cancer.

Previous History of Breast Cancer Increases Rates of Pulmonary Embolism and Costs after Total Knee Arthroplasty: An Evaluation of 185,114 Matched Patients

Risk factors for adverse events after total knee arthroplasty (TKA) relating to malignancy have not been well studied. Thus, the purpose of this study was to conduct a retrospective case-control outcome and cost analysis after TKA in this population. Patients with a history of breast cancer (BrCa) were identified based on the International Classification of Disease 9th revision codes. An age- and sex-matched cohort was also identified of patients without a history of BrCa. Complications, length of stay, comorbidity burden, and reimbursements were tracked at 90 days. Each cohort comprised 92,557 patients. Length of stay was similar between cohorts (p = 0.627). Comorbidity status and incidence of pulmonary embolism (PE), lower extremity ultrasound, and chest computed tomography (CT) use were higher in patients with a history of BrCa (p < 0.05 for all). Control patients had a lower incidence of acute myocardial infarction (0.14 vs. 0.21%; p < 0.001). Surgical complications were similar. The 90-day reimbursements were greater in patients with a history of BrCa (US$13,990 vs. US$13,033 for controls; p = 0.021). Surgeons should be aware of the increased risk of PE after TKA in patients with a history of BrCa as well as increased 90-day costs, which warrant great attention.

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

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.

Expression Quantitative Trait Locus Study of Bone Mineral Density GWAS Variants in Human Osteoclasts

Osteoporosis is a complex disease with a strong genetic component. Genomewide association studies (GWAS) have been very successful at identifying common genetic variants associated with bone parameters. A recently published study documented the results of the largest GWAS for bone mineral density (BMD) performed to date (n = 142,487), identifying 307 conditionally independent single-nucleotide polymorphisms (SNPs) as associated with estimated BMD (eBMD) at the genomewide significance level. The vast majority of these variants are non-coding SNPs. Expression quantitative trait locus (eQTL) studies using disease-specific cell types have increasingly been integrated with the results from GWAS to identify genes through which the observed GWAS associations are likely mediated. We generated a unique human osteoclast-specific eQTL data set using cells differentiated in vitro from 158 participants. We then used this resource to characterize the 307 recently identified BMD GWAS SNPs for association with nearby genes (±500 kb). After correction for multiple testing, 24 variants were found to be significantly associated with the expression of 32 genes in the osteoclast-like cells. Bioinformatics analysis suggested that these variants and those in strong linkage disequilibrium with them are enriched in regulatory regions. Several of the eQTL associations identified are relevant to genes that present strongly as having a role in bone, particularly IQGAP1, CYP19A1, CTNNB1, and COL6A3. Supporting evidence for many of the associations was obtained from publicly available eQTL data sets. We have also generated strong evidence for the presence of a regulatory region on chromosome 15q21.2 relevant to both the GLDN and CYP19A1 genes. In conclusion, we have generated a unique osteoclast-specific eQTL resource and have used this to identify 32 eQTL associations for recently identified BMD GWAS loci, which should inform functional studies of osteoclast biology. © 2018 American Society for Bone and Mineral Research.

Cancer Treatment as an Accelerated Aging Process: Assessment, Biomarkers, and Interventions

An accumulating body of evidence supports the hypothesis that cancer and/or cancer treatment is associated with accelerated aging. The majority of these data come from the pediatric literature; however, a smaller yet growing body of literature points toward similar findings in the geriatric population. This is a key survivorship issue the growing number of older adults with cancer face, along with the short- and long-term impact of cancer therapy on the aging process. This article will review clinical and biologic markers of aging in older adults with cancer, use cardiovascular disease as a model of accelerated aging, and discuss potential interventions to decrease the risk.

Cancer survivorship issues: life after treatment and implications for an aging population

The US population of cancer survivors age ≥ 65 years will continue to grow rapidly over the next few decades. This growth will be driven largely by the aging of the national population. With the diffusion of earlier detection and more effective therapies, the majority of these individuals can expect to live long term after diagnosis. This often vulnerable group of survivors poses significant challenges for both researchers and clinicians with regard to how best to document and address its unique health care needs. In this article, we briefly review the long-term and late-occurring effects of cancer and its treatment in older survivors, review information on current patterns of post-treatment care and the evolving guidelines for this care, and discuss opportunities for future research.