Quantitative ultrasound and DXA measurements in aromatase inhibitor-treated breast cancer women receiving denosumab

Insights and implications of sexual dimorphism in osteoporosis

Osteoporosis, a metabolic bone disease characterized by low bone mineral density and deterioration of bone microarchitecture, has led to a high risk of fatal osteoporotic fractures worldwide. Accumulating evidence has revealed that sexual dimorphism is a notable feature of osteoporosis, with sex-specific differences in epidemiology and pathogenesis. Specifically, females are more susceptible than males to osteoporosis, while males are more prone to disability or death from the disease. To date, sex chromosome abnormalities and steroid hormones have been proven to contribute greatly to sexual dimorphism in osteoporosis by regulating the functions of bone cells. Understanding the sex-specific differences in osteoporosis and its related complications is essential for improving treatment strategies tailored to women and men. This literature review focuses on the mechanisms underlying sexual dimorphism in osteoporosis, mainly in a population of aging patients, chronic glucocorticoid administration, and diabetes. Moreover, we highlight the implications of sexual dimorphism for developing therapeutics and preventive strategies and screening approaches tailored to women and men. Additionally, the challenges in translating bench research to bedside treatments and future directions to overcome these obstacles will be discussed.

Interrelations between clinical-psychological features and bone mineral density changes in post-menopausal women undergoing anti-osteoporotic treatment: a two-year follow-up

Introduction

Psychological features have been bidirectionally associated with osteoporosis, but it is still unclear whether patient's anxiety fluctuations during the anti-osteoporotic treatment can have an impact on bone mineral density (BMD) variation. The aim of this study was to investigate the interrelations between psychological distress features, such as anxiety, depression, health-related QoL (HRQoL) and bone health in women receiving anti-osteoporotic treatment.

Methods

192 post-menopausal osteoporotic women were treated with alendronate or risedronate according to the standard procedure. The levels of anxiety, depression, and perceived HRQoL, along with BMD, were assessed at baseline and at a 2-year follow-up.

Results

At the end of the study, the patients showed a statistically significant increase of both psychic and somatic anxiety (p<0.0001) and exhibited a worsening of depressive symptoms (p<0.0001), whereas HRQoL showed no change. BMD improved and no incident fractures occurred. BMD variation (ΔBMD) at lumbar spine was significantly associated with anxiety levels (r=0.23, p=0.021). Multiple regression analysis showed that both patients' worsening anxiety levels (β = -0.1283, SE=0.06142, p=0.04) and their treatment adherence (β=0.09, SE=0.02, p=0.0006) were independently associated with ΔBMD.

Discussion

The findings of the current follow-up study suggest that BMD in post-menopausal women undergoing anti-osteoporotic treatment was predicted by treatment adherence and anxiety change over time.

Changes in Vertebral Marrow Fat Fraction Using 3D Fat Analysis & Calculation Technique Imaging Sequence in Aromatase Inhibitor-Treated Breast Cancer Women

Aromatase inhibitor (AI) is a cornerstone drug for postmenopausal women with estrogen receptor-positive early-stage breast cancer. Fat-bone interactions within the bone marrow milieu are growing areas of scientific interest. Although AI treatment could lead to deterioration of the skeleton, the association between AI medication and subsequent marrow adiposity remains elusive. A total of 40 postmenopausal, early-staged, and hormone receptor-positive breast cancer patients who underwent treatment with adjuvant AIs and 40 matched controls were included. Marrow proton density fat fraction (PDFF) at the L1-L4 vertebral bodies using 3D Fat Analysis & Calculation Technique imaging (FACT) sequence at 3.0T, bone mineral density (BMD) by dual-energy X-ray absorptiometry, and serum bone turnover biomarkers were determined at baseline and at 6 and 12 months. We found that, in comparison to baseline, an increase of type I collagen cross-linked telopeptide was detected at 12 months (P <0.05). From baseline to 12 months, the PDFF measured using FACT was greatly increased. At 12 months, the median percent change of PDFF (4.9% vs. 0.9%, P <0.05) was significantly different between the AI treatments and controls. The same trend was observed for the marrow PDFF at 6 months relative to the respective values at baseline. Although BMD values were significantly reduced after 12 months in AI-treated women, changes in BMD vs. baseline condition were not significantly different between the AI-treated and control groups [Δ BMD -1.6% to -1.8% vs. -0.3% to -0.6%, respectively, P > 0.05]. In the AI-treated group, Δ PDFF was associated with Δ BMD at the lumbar spine (r = -0.585, P < 0.001), but not in the controls. Taken together, over a 12-month period, spinal marrow fat content assessed with FACT sequence significantly increased in postmenopausal women with hormone-receptor-positive breast cancer receiving AI treatment.

Effects of competitive physical activity on serum irisin levels and bone turnover markers

BACKGROUND

Irisin, a myokine, is a polypeptide derived from the cleavage of the extracellular domain of fibronectin domain-containing protein 5, a receptor that is present on different tissues (skeletal muscle, pericardium, myocardium, and brain), whose functions are not yet fully defined.

PURPOSE

The main aim of our study was to evaluate the effect of competitive physical activity on serum irisin levels and bone turnover markers.

METHODS

Fifteen male footballers and an equal number of subjects of the same age and gender, but with a predominantly sedentary lifestyle, had their serum levels of irisin and bone turnover markers measured. Bone mineral status was evaluated in both groups by quantitative bone ultrasound of the calcaneus. In addition, only in footballers, biochemical analyses were repeated after 3 months.

RESULTS

We did not observe significant differences in the serum levels of calcium, phosphorus, and parathyroid hormone between the two groups. The footballers had significantly higher quantitative bone ultrasound, 25-OH vitamin D, and creatinine values than the controls. There were also no significant differences in the bone alkaline phosphatase, carboxy-terminal telopeptide of type I collagen, osteoprotegerin, sclerostin or Dkk-1 values, while the irisin levels (+ 89%, p < 0.001) and RANKL were significantly higher in the footballers compared to those in the controls.

CONCLUSION

Our study shows that footballers have significantly higher serum irisin values than the general population. Irisin could be the "trait d'union" between bone health and physical activity.

Therapeutic Options in the Management of Aromatase Inhibitor-Associated Bone Loss

BACKGROUND

Breast cancer is the most commonly occurring cancer in women worldwide. Early breast cancer is a kind of invasive neoplasm that has not proliferated beyond the breast or the axillary lymph nodes. Current therapeutic strategies for breast cancer mainly include local therapies such as surgery or radiotherapy and systemic therapies like chemotherapy, endocrine, and targeted therapy.Nowadays, the adjuvant treatment for hormone receptor-positive early breast cancer in postmenopausal women remains the main effective systemic therapy which can improve disease-free survival and overall survival; it involves several endocrine treatment regimens including selective estrogen receptor modulators (SERMs), aromatase inhibitors (AIs), or a combination of them. AIs have been shown to be more effective in preventing recurrence in postmenopausal women with early breast cancer when compared with tamoxifen, thus representing the standard of care for adjuvant endocrine therapy. Although AIs are usually well-tolerated, they can have some side effects. Apart from the appearance of arthralgias or myalgias and cardiovascular events, AI therapies, reducing already low endogenous postmenopausal estradiol levels, cause increased bone loss and increase fracture risk in postmenopausal women.

OBJECTIVES

To evaluate the therapeutic options in the management of aromatase inhibitor-associated bone loss (AIBL).

METHODS

We reviewed the current literature dealing with different therapeutic options in the treatment of AIBL.

RESULTS

Clinical practice guidelines recommend a careful evaluation of skeletal health in all women with breast cancer before AI therapy initiation. Adequate calcium and vitamin D intake have also been suggested. Pharmacological attempts to minimize AI-related bone loss have focused on the use of antiresorptive agents, such as bisphosphonates and denosumab, to protect bone integrity and reduce the risk of fractures. Furthermore, clinical trials have shown that by making the bone microenvironment less susceptible to breast cancer metastasis, these drugs are able to increase disease-free survival.

CONCLUSIONS

AI, thatare the pillar of the systemic treatment for patients with hormone receptor-positive breast cancer, are associated with different side effects, and in particular osteoporosis and fractures. Both bisphosphonates and denosumab are able to prevent this negative effect.

Executive functions predict fracture risk in postmenopausal women assessed for osteoporosis

BACKGROUND

Cognitive impairment and muscle strength have been associated with bone fragility. However, the potential predictive role of executive functions on fracture risk has been poorly investigated.

AIM

We intended to explore the association between executive functions, psychological distress and physical performance with fracture risk in postmenopausal women.

METHODS

Cognitive tests explicating executive functions (i.e., Trial Making Test-B, Digit Span Backward, Digit Span Forward) and questionnaires assessing psychological distress (i.e., Back Depression Inventory and Hamilton Anxiety Scale) were administered. Physical performance was explored through the Short Physical Performance Battery and handgrip strength. The 10-year probability of major and hip fractures was assessed by Fracture Risk Assessment tool (FRAX); the bone mineral density (BMD) was evaluated by Dual-Energy X-ray Absorptiometry.

RESULTS

60 women (mean age 66 ± 7.99 yr.) were recruited. The FRAX score for major fractures was significantly associated with Trial Making Test B score (r = - 0.25) and with Digit Span Backward (r = - 0.34); the FRAX score for hip fracture was associated with handgrip strength (r = - 0.39, p = 0.002). BMD was significantly associated with Digit Span Backward (r = - 0.32) and with depression (r = - 0.33). After several adjustments, the multiple regression analysis showed that BMI (ß = 0.09, SE 0.03, p = 0.013), Beck Depression Inventory score (ß = - 0.09, SE 0.06, p = 0.04) and Digit Span Backward score (ß = 0.55, SE 0.17, p = 0.002) were independently predictive of lumbar BMD.

CONCLUSIONS

Verbal working memory, as assessed by Digit Span Test, and psychological features were associated with BMD and could contribute to fracture risk prediction in postmenopausal women.

Change in Quantitative Ultrasound-assessed Speed of Sound as a Function of Age in Women and Men and Association With the Use of Antiresorptive Agents: The Canadian Multicentre Osteoporosis Study

INTRODUCTION

Five-year changes in multisite quantitative ultrasound-assessed speed of sound (SOS in m/s) were studied in a cohort of women and men. The impacts of antiresorptive therapies and menopausal status on SOS were also assessed.

METHODOLOGY

Two SOS assessments, clinical assessments, and comprehensive questionnaires were completed 5 years apart on 509 women and 211 men. Age at first assessment was grouped into: <40 yr, 40-49 yr, 50-59 yr, 60-69 yr, 70-79 yr and 80+ yr. Mean rate of change in SOS at the distal radius and tibia were calculated for each age grouping by sex. SOS changes were stratified by antiresorptive use (yes, no) or menopausal status (premenopausal, postmenopausal, or bilateral oophorectomy).

RESULTS

Mean losses in SOS occurred over the 5 years in almost all age groupings. In women, mean losses in SOS for the <40 yr, 40-49 yr, 50-59 yr, 60-69 yr, 70-79 yr, and 80+ yr age groupings were -59, -83, -107, -92, -80 and -66 (p = 0.30; differences among age groupings) at the radius and -18, -16, -54, -1, -9 and 31 at the tibia (p < 0.05), respectively. In men, mean SOS losses were -101, -56, -69, -67, -83 and -127 at the radius (p = 0.61) and -46, -61, 0, -35, -29, and -26 at the tibia (p = 0.23). At the tibia, women prescribed antiresorptives had a mean increase in SOS (8.6 m/s) whereas untreated participants had a mean loss (-23.0; p < 0.001); there was no significant impact at the distal radius. There were no significant differences in change in SOS among menopausal groups (p > 0.26).

CONCLUSIONS

Mean SOS generally declined over 5 years in all age groupings of both sexes. The consistent mean losses in SOS over the age spans investigated are coincident with increasing fracture risk. Women on antiresorptive therapy had increased mean SOS over the 5-year assessment period at the tibia, whereas untreated women had mean losses in SOS.

Quality of life and psychological functioning in postmenopausal women undergoing aromatase inhibitor treatment for early breast cancer

INTRODUCTION

Aromatase inhibitors (AIs) dramatically increased breast cancer (BC) survival, leading to enhanced attention to their long-term consequences on psychological functioning. Conflicting data has been examined regarding the association between AIs administration and the clinical psychological features in BC survivors (BCSs).

PURPOSE

As psychological symptoms often occur in such chronic diseases, our study aimed at exploring anxious and depressive symptoms and the perceived quality of life (QoL) in BCSs assessed for osteoporosis.

METHODS

The total sample consisted of a clinical sample of 51 outpatient postmenopausal women, diagnosed with BC, and a control group composed of 51 healthy postmenopausal women. All recruited participants were evaluated through the clinical gold standard interview and completed the following self-rating scales: the Hamilton Anxiety Rating Scale, Beck Depression Inventory II edition, and 36-Item Short Form Health Survey, which were administered at baseline and after 6 months in BCSs in AIs treatment, compared with controls. Moreover, all participants were assessed for vitamin D status, bone mineral density (BMD) and subclinical vertebral fractures. Data regarding age, age at menopause, body mass index (BMI), smoking habits and alcohol consumption was collected.

RESULTS

BCSs (n = 51) showed higher anxious and depressive symptoms, and lower perceived QoL vs. controls (n = 51) (p<0.05 for all). After 6 months of treatment with AIs, BCSs showed significant reduction of anxious and depressive symptoms and a significantly higher perceived QoL for both physical and mental components, vs. controls.

CONCLUSIONS

The improvement of clinical psychological features and perceived QoL was associated with AIs treatment in women being treated with, for early breast cancer. Further studies are needed to obtain a deeper comprehension of the correlation between clinical psychological and physical features in BCSs.

Comparing the Efficacy and Safety of Denosumab with Bisphosphonates in Increasing Bone Mineral Density in Patients with Prostate Cancer and Breast Cancer on Antihormonal Treatment

Osteoporosis is a common condition prevalent in both sexes that can be primary and secondary. Secondary osteoporosis may occur in cancer patients undergoing antihormonal treatment, leading to an increased risk of fractures. Androgen deprivation therapy (ADT) in patients with prostate cancer and aromatase inhibitors (AI) in patients with breast cancer can drastically increase the risk of osteoporosis. Bisphosphonates are one of the key medications in managing these patients and are widely prescribed. A monoclonal antibody called denosumab, which is a relatively new treatment option, is also used in this population group. To conduct a detailed comparison of these groups, we performed a thorough literature search using Pubmed and Google Scholar to extract data in the form of research papers/clinical trials. A total of 18 research papers were extracted using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and other inclusion and exclusion criteria. Seven of these papers were based on randomized controlled trials (RCTs) comparing denosumab with either placebo or bisphosphonates in patients with breast cancer and prostate cancer. Two meta-analyses comparing the safety and efficacy of both these drugs in this population group were also included. Denosumab was found to significantly increase bone mineral density (BMD) for up to two years and showed better results than bisphosphonates, while both had a comparable safety profile. More trials should be conducted in patients with prostate cancer or breast cancer on ADT or AI therapy, respectively, for longer durations to assess the long-term safety of these drugs in this population.

Trabecular bone score and quantitative ultrasound measurements in the assessment of bone health in breast cancer survivors assuming aromatase inhibitors

PURPOSE

Aromatase inhibitors (AIs) represent the first-line adjuvant therapy for hormone receptor-positive breast cancer (BC) women. AIs have been associated with an increased rate of fractures. The aim of our study was to investigate trabecular bone score (TBS) and bone quantitative ultrasound (QUS) measurements as bone quality surrogates in AIs users.

METHODS

Sixty postmenopausal BC women starting AIs and forty-two controls (mean age 61.64 ± 8.33 years) were considered. Bone mineral density (BMD) at lumbar spine and femoral neck and TBS were measured by DXA; QUS-derived Amplitude-Dependent Speed of Sound (AD-SoS), Bone Transmission Time (BTT), and Ultrasound Bone Profile Index (UBPI) were assessed at phalangeal site; morphometric vertebral fractures (Vfx) by X-ray, serum bone-specific alkaline phosphatase (BSAP), and C-telopeptide of type 1 collagen (CTX) were also evaluated.

RESULTS

After 18 months, changes of TBS vs baseline were significantly different between AIs group and controls [Δ TBS - 2.2% vs - 0.4%, respectively, p = 0.001]. AD-SoS, BTT and UBPI values decreased only in AIs' group (- 3.7%, - 6.45%, -8.5%, vs baseline, respectively, p_all < 0.001). 3 Vfx occurred in AIs users and were associated with the greater TBS and AD-SoS modifications. In the AIs' group, ΔTBS was associated with ΔAD-SoS (r = 0.58, p < 0.001) and ΔUBPI (r = 0.415, p = 0.001), but not with ΔBMD. Moreover, ΔTBS was independently predicted by ΔAD-SoS, after correcting for BMD, CTX and BSAP level changes (β = 0.37, SE = 2.44, p < 0.001).

CONCLUSIONS

TBS and phalangeal QUS provide useful information related to bone quality in AI-treated BC survivors and could be considered for fracture risk evaluation.

Serum bone alkaline phosphatase is a useful marker to evaluate lumbar bone mineral density in Japanese postmenopausal osteoporotic women during denosumab treatment

A worldwide health concern, osteoporosis (OP), increases the risk of bone fracture and results in morbidity. This study examined whether the representative bone absorption marker serum tartrate-resistant acid phosphatase 5b (TRACP-5b) or bone formation marker bone alkaline phosphatase (BAP) could estimate primary OP status and denosumab efficacy in a real-world setting. We retrospectively enrolled 114 female postmenopausal primary OP patients in Japan. Values and percent changes in TRACP-5b, BAP, lumbar 1-4 bone mineral density (L-BMD), and total hip BMD (H-BMD) were assessed before treatment and at 4, 8, and 12 months of therapy to identify the correlations between the percent changes in bone metabolic markers and BMD. We also established two sets of subgroups based on the upper limits of reference values in Japan for serum: TRACP-5b (<420 mU/dL) and (≥420 mU/dL) and BAP (<14.5 µg/L) and (≥14.5 µg/L). Negative correlations were observed for the percent changes of TRACP-5b and H-BMD at 4 months (r=-0.3476) and 8 months (r=-0.3880), for the percent changes of BAP and H-BMD at 8 months (r=-0.3354), and for the percent changes of BAP and L-BMD at 12 months (r=-0.3186). We observed a significant difference between the subgroups for the percent changes of L-BMD at 8 months (p=0.013) and 12 months (p=0.004) in BAP values. These results suggest that TRACP-5b and BAP had negative correlations with BMD, and that BAP represented a useful serum marker to evaluate L-BMD during denosumab therapy for OP.